Woe to the patient who is unattended

Third world hospitals rely on relatives to care for and feed the patients.  As a result staff from Cornerstone have to be delegated to remain with our children.  I recently spent a week at the bedside of one of our children who was admitted to hospital with appendicitis.  I am not sure if I am the first ever white person to care for a patient in Nimule Hospital, but I was certainly a cause of some surprise.

Nimule Hospital is run by Save the Children, an internationally respected charity.  On a banner outside the hospital are a large numbers of logos from other aid foundations and governments, including the UK.  In spite of this apparent support, I suspect that it is similar to many hospitals in the third world.  As I know from previous experience, there is no x-ray machine and no specialisms apart from HIV/AIDS.  There are only two doctors, both non-specialist.  The doctors also act as surgeons.  There are very few nurses.  The ward we stayed on has three shifts of only one nurse at a time.  The nurse is responsible for more than one ward. 

Standards of hygiene are poor.  Each ward has an allocated latrine, which is kept padlocked.  At one point while we were staying there, the key was mislaid and nobody was able to use the latrine at all.  Some were forced to squat at the edge of the compound.  Fortunately as Cornerstone is very close by, I was able to walk back and use the toilet there.  Even when the latrine is operational, it is filthy.  There are no hand-washing facilities, or even water.  Family members prepare food squatting outside.  We took turns to go back to Cornerstone to shower, change our clothes and fetch food.  We sponge-washed our patient on the ward.

I am told that the hospital was originally composed of tents.  Now, it has improved to the extent that the wards are made of metal, with boards of wood on the outside and corrugated iron roofs.  As a result they are unbearably hot during the majority of the day.  Trees are planted outside, with some stone benches and space for mats to sit or lie on.  There are more than 20 beds on the ward where we stayed, but six of them were out of use as they had no mattresses or mosquito nets.  Relatives sleep either on vacant beds, on mats on the floor or two to a bed with the patient.  As it is a women’s ward, most patients had a baby with them. 

The next door ward is a feeding centre for malnourished children.  The children were pathetic to watch, sipping their porridge.  They were often unable to finish it, so their mothers drank the remainder.

As the week went by, injured children started to take up beds in our ward, as the paediatric ward was completely full.  Some of these children’s parents were very lacking in caring skills.  My heart bled for two little children, one severely burnt and the other with a fractured leg.  As the children howled in agony, their mothers simply sat and said, ‘khalas’ (Arabic for ‘enough’).  No attempts at distraction or any signs of love at all.  I am sure this is symptomatic of the brutalisation of South Sudanese society by the traumas of decades of war.  I have been told before now how parents don’t dare to get too close to their children for fear of the hurt of losing them.

The nights were very difficult, although by the end of the week I was becoming acclimatised.  The electricity comes on at dusk and is not switched off until the morning, so we had to sleep with bright lights blazing.  There is no concept of privacy.  Some families chatted and laughed all night, as babies and injured children cried.  Some families came complete with menfolk, so it was difficult to undress.

One day, as we were sitting outside in the shade, I noticed some smoke next to the wall of our ward.  I went to investigate and found that the electric cable running from the ward to the operating theatre was on fire.  I sent one of our older children, who was visiting, running for help.  A man came with an extinguisher.  Thankfully not too much damage was done, but it could have been serious.

Our child had had appendicitis twice before.  On both previous occasions she was simply sent home with medication.  This time however, the hospital decided to operate.

The first thing that went wrong was that the member of staff who was with her before I came on duty, made the mistake of giving her a drink of tea when she was supposed to be ‘nil by mouth’.  That caused the operation to be postponed by 24 hours.  In the meantime the poor girl was on a glucose drip to keep her going.  Her veins kept collapsing so that she suffered many hours of pricking with needles in attempts to find fresh veins.  She is not a stoical child, so the whole experience was difficult for everyone concerned.

Finally we got to the operating theatre.  After about an hour a nurse came out and told me that they had no general anaesthetic.  She asked me to buy some.  I phoned our clinic, who fortunately had some in stock.  They rushed it over to us.

When our child came out of the theatre, it was our job as ‘family’ to wheel the heavy stretcher trolley to the ward, across very bumpy unpaved ground.  I thanked Heaven that she was unconscious.  Hospital porters have not been invented yet.

Back on the ward, the nurse brought us the news that the medical store was unmanned as the store keeper was ‘not around’.  Apparently he had been gone for days.  Therefore Cornerstone would need to provide all her medications.  To continue the theme of my previous post, what a blessing that we have our own clinic.  Pity those who can’t afford the drugs or haven’t the manpower to get them.

Later that day, the doctor called me to speak to him.  He told me that our girl’s appendix was in too bad a state to operate.  It had fused with bladder, bowel and intestines due to hardened pus.  The doctor had not been able to remove it without damaging other organs.  He therefore cleaned and applied antibiotics before closing the incision.  She will need another operation after a course of antibiotics.  Poor girl. 

In the meantime she came to in a delusional and unfocused state.  Twenty of her friends from Cornerstone had arrived, eager to see her.  She looked at them and said, ‘Who are all these people?’  The children at the home all see themselves as brothers and sisters, so they were very hurt.  Some cried. 

Fortunately she improved steadily from the next day and was discharged a week after the operation. 

I suspect that all African hospitals are like Nimule Hospital to some degree, hence the huge difficulties faced in countries with the Ebola epidemic.  Let us hope Ebola doesn’t reach us.  I don’t think Nimule Hospital has the capacity for an emergency of that type.

Look what I missed!

Cornerstone is on the foot slopes of a range of mountains called the Imatong Mountains.  They form a border with Uganda with the River Nile winding through them on its way north.  When I consulted my Sudan guidebook before I came here, it informed me that these mountains are still largely unmapped.  However, the part nearest to Nimule is a designated national park with a large herd of elephants who migrate to and fro between the park and Uganda, crossing the Nile on their way.  There is also a very dramatic series of waterfalls called the Fulaa Falls.  ‘Fulaa’ means Living Water.  It is also the name of the charity that supports Cornerstone.

View of the Imatong Mountains (Google image)

Given the state of the country, Nimule National Park is not yet on the international tourist map.  Although things are peaceful here, there are still land mines from the civil war.  There are also bandits.  So any trip there must be made with great caution.

I searched the internet to find decent information, but there is very little.  Here is someone else's blog description. 

Pastor Abdullah told me one day that he was planning to take the children on a trip to the national park and to see the falls.  To do this he wheedled free entry from the rangers.  He booked the use of a truck to transport all the children.  He also asked for a military escort in case of trouble.  To my great disappointment I was unable to go because I was still too weak following malaria.  The children promised to tell me all about it.

This was a major event as it is extremely rare for the children go on an outing.  They had a wonderful day out.  They took a goat with them and cooked roast goat as a picnic beside the falls.  One little girl told me that they saw monkeys and a white family with twins!  Both equally amazing.  The falls impressed them all very much too.

The icing on the cake for the staff was that the truck was pursued from Nimule by a car containing a very important government figure from Juba.  When they arrived at the park, he hurried over to ask if the children came from Cornerstone Children’s Home.  When told that they did, he said that he had seen a film about the home last year on TV and had wanted to find them.  He then produced a large amount of money and handed it over as a donation.

Our clinic

This week has been my baptism in malaria.  It is surprising that it has taken over a year to strike me as malaria is the most common illness here, akin to the common cold in Britain, but considerably more serious.  It is a much bigger killer than Ebola.  The week before, a twenty year old relative of our matron died of it, which gives a flavour that it is not just the old or sick who are in danger.

Before I arrived last year I was told that the home was trying to start a really good clinic for our children and also for the outside community.  This has been a major struggle because of lack of funding.  When I came there was one nurse operating from a small room, with some drugs and the facilities to put people on a drip, but very little beyond that.  Sometimes she had to send children to the hospital, which is also very poor.  The practical advantage of the clinic at that time was mainly to avoid having to free up a member of staff to stay with the child in hospital.  The reality of third world hospitals is lack of nursing provision.  If a family member does not accompany the patient, there will be nobody to provide food, bathing or nursing care.  You can die of neglect in hospital.

Advertising poster

During the last few months the home has managed to expand its clinic staffing to include a laboratory technician and an additional nurse.  As word has spread, there has been an increase in members of the local community using the clinic.  Prices are kept artificially low to encourage people to take the service seriously, but not to drive people away.

The other great improvement, is in regular monitoring of our children’s health.  They all now have individual medical record books.  I have been told that their overall health is already improving.

Our lab technician is working hard to look for ways to get reliable electricity, buy a fridge and stock the many medications and vaccines which require refrigeration.  If this can be achieved, we will have the only clinic in the town which can do this.  Currently people have to make a four hour road trip into Uganda along very poor roads to a good, but still third world, hospital.

It was lovely to be able to remain in my own bed.  As my malaria was not responding to treatment at first, they were even able to set up a drip in my room and give me stronger treatment.  Travelling while so ill would have been unbearable.

Roll on the day we achieve electricity and a fridge for the clinic.

One year down the line

I have woken up to the fact that it is almost one year since I arrived in Nimule.  Time has flown by.  Much has changed in that time, very much for the better.

When I arrived I was appalled by what I found both in the home and in the school.  I had been asked by Pastor Samuel, the chair of the American charity Fulaa which founded both home and school, to report on any concerns.  I did so.  This caused great antagonism here.  Coupled with that, some of the staff very strongly disapproved of Catholics and made their views felt strongly and very rudely.  Their treatment of the children was very lacking in love and care.  However, things have gradually changed at the home.  Yes, things are very basic in material terms, but there has been a big shift in attitude so that the children really feel loved and cared for now.  At the last government inspection in April we were one of very few children’s homes to pass.  Our matron was recently told that our home was judged the best in the whole of Eastern Equatoria.  By contrast, the other local orphanage is being forced to close because of their appalling neglect of the children.  They tried to stop the inspectors from entering but had to be forced (literally, by armed soldiers) to admit them. 

I have seen the proof of how good the home now is through watching the reception of several new children recently.  All four children settled into life here quickly and happily, immediately making new friends and becoming part of the family.  This is in spite of the terrible events that brought them here.  The first three are a brother and two sisters whose parents were murdered in the fighting further north in Bor.  The last arrival is a nine year old boy whose mother brought him south from Sudan and then abandoned him.  He had been surviving as a street child in Torit (the state capital) by polishing shoes.  All happily playing, laughing and trying to catch up on their missed education.

What is euphemistically called ‘the situation’ broke in mid-December, causing us all to worry that we might need to escape across the border to Uganda.  Thankfully, so far our fears have turned out to be misplaced.  Most of Equatoria (we are in Eastern Equatoria State) has been peaceful throughout.  The only exception has been Juba, which is the capital both of the country and of Central Equatoria State.

I spent six weeks in Kampala from May to June while my new passport was issued.  I had really resented the interruption to my work in Nimule but in fact there were benefits.  I met and stayed with a lovely lay religious community called the Grail where I was able to recharge my batteries, physically and spiritually.  The head of the community is a writer of adult and child fiction.  Her books aim to give a message of social and religious reform.  She gave me a present of two of her children’s books to take back.  The children here love them.  Books are very scarce in South Sudan, so there is little motivation to read.  These books are particularly good because they are from a similar culture which the children can easily identify with.  I have a standing invitation to go back to stay with them again.

The children welcomed me back very emotionally and lovingly when I finally returned.  I found to my surprise that the staff at the home had completely changed their attitude to me in my absence so that they were also very welcoming.  Their very prejudiced attitude towards Catholics has changed too so that I no longer suffer from their adversarial religious statements.  In fact I am regularly invited to read and preach at morning devotions and run a Bible study session every Saturday with the full support of staff.

I continued to have problems at the school but now had Pastor Abdullah (the director of the home and also director of education at the school) on my side.  That was a great relief.  The school has been a tougher nut than the home, but even there, a breakthrough has finally happened.  We had staff training for the teachers at the end of term from a very prestigious school in Kampala.  This was organised by Pastor Abdullah, who has a child at that school.  It was a huge success.  At first the teachers were very resentful, but they were completely won over by day two. 

We are now looking forward to the start of term in mid-September with a whole new approach.  No caning, teachers to set an example of arriving early, teachers in each class all day, a homework policy, a whole school approach to reading using a very lively phonics method (Jolly Phonics), a method of teaching handwriting, the abolition of the staff room….  It will be a very different school if all goes well.  The big draw for the teachers is the promise that if we can really turn the school around, word will spread and the school will become a centre of learning locally.  They have been promised that they will be head-hunted by other schools!  For me, the importance of this change is that it will show other local schools an example so that higher standards of education will gradually spread everywhere.

The teachers came away positive and ready to put their new training, both academic and disciplinary, into place.  There are difficulties to be overcome, such as the lack of much needed resources, such as desks and photocopier, but we are finally getting there..

Throughout everything I have had the support of American missionaries who are based on the other side of town.  I visit them regularly.  They and the local Catholic parish priest have been a steadying influence when I have been having particularly difficult times.  They have been able to raise funds for extra fruit and vegetables for the home and pass on their children's outgrown clothes too.

The icing on the cake for me on a personal level is that I have been invited to be godmother to a baby at the local Catholic Church.  I really look forward to being a part of the community outside the home and school as a result. 

I am planning a celebration for the children on the anniversary of my arrival here.  My missionary friends have promised to make a large cake for the occasion, which will be a major treat for the children.  I am trying to keep this a secret from them.

I am so glad I came to Nimule.  I am hoping that my children will visit at some stage in the coming year.

Best wishes to you all, 

Rebecca

Our new arrivals

I am not in the habit of writing about individual children at the home because I think it is a breach of confidentiality.  Children often come to me and talk about their lives, not expecting their stories to be broadcast.  However, we have just received three new children whose story really should be told.  In any case, there is a need for sponsors for these children.  Their names are Luka (9), Foni (6) and Nana (3).

Luka, Foni and Nana

Their story reflects both the terrible civil war situation in other parts of South Sudan and also the very common family situations which cause children to end up uncared for, either as street children, neglected children or in a home such as Cornerstone.

Most people, including me, are uncomfortable with the idea of children’s homes or orphanages.  It can be very difficult for institutionalised children to manage once they leave.  Therefore we tend to think children are better off in a family or with a loving foster family.  It is a much more natural environment.  

However, in South Sudan this is rarely possible.  Many marriages are polygamous and it is culturally acceptable for stepparents to discriminate against those who are not their own offspring.  The wicked stepmother is alive and well, and lives in South Sudan.  Conversely, where divorce takes place and the mother remarries, her children are rarely accepted by her new husband.  In spite of what I had always heard before coming to Africa, the tribe does not often behave like an extended family.

Last week at morning devotions, we were told the following simple facts:  Three new children would be coming to live with us, aged 9, 6 and 3.  They come from Bor, where the fighting is intense.  Their parents have both been killed and the children were rescued from their home, which had been set on fire.  They speak only their own tribal language.  The eldest boy is in a very emotional and traumatised state, repeatedly asking for his mother.  The children were all asked to be very kind and patient with them when they arrived.  

I now know the whole story.  The father was the first to die.  Then, sometime later, soldiers shot the mother while she was trying to escape, carrying the youngest child.  The older two hid in their hut, which was then torched.  Amazingly, none of the children were hurt.  The youngest stayed next to her mother’s body.  A Good Samaritan rescued them all and put them in a truck of people fleeing the fighting.  The truck dropped everyone in the middle of nowhere.  Another truck came and agreed to take them all to Nimule.  Nobody took any responsibility for the children.  When they arrived, they left the children at the police station.

 In the meantime their uncle, who is a soldier, discovered that his brother and sister-in-law were dead and assumed that the children must also have been killed.  Fortunately somebody told him about the rescue, although nobody knew where the truck had taken the children.  The uncle frantically tried to track them down and discovered that they were in Nimule.  He and his family came to Nimule to find them.  As the uncle had to go back to Bor he left his wife and children to care for the orphaned children.  This turned out to be a very bad move.  His wife, in true wicked stepmother style, had no intention of caring for the children.  She simply did not feed them.  Another Good Samaritan alerted the police, who contacted Pastor Juma, the pastor at Cornerstone.  Fortunately Pastor Juma speaks some of the children’s language so he was able to converse with them.  The eldest broke down in tears when he said that they hadn’t eaten for two days.  He kept asking for his mother even though he knew she was dead.  Pastor Juma contacted the uncle and asked him to return to Nimule to sign an agreement for the children to live at Cornerstone.  He arrived at the weekend and was relieved to find a home for the children.

The children arrived at their new home on Sunday after staying a few days elsewhere while the uncle arrived and the agreement paperwork was sorted out.  

I had been very worried in advance about how the home would cope with these traumatised children and how the new children would cope with being at Cornerstone.  I prayed about it a lot and asked friends to pray too.  My fears proved to be completely unjustified.  I was at church when they arrived, but heard from the matron that they had looked terrified when they arrived in the home’s office and said goodbye to their uncle.  

Nana and her two new friends run to school
on her first day at nursery

Then some of the ‘old hands’ were asked to show the children around and look after them.  Literally minutes later they were all playing happily with children their own age in spite of the language barrier and their recent experiences.  It was a joy to watch them.  To see them play, you would never imagine the hardships they have been through.  They are incredibly resilient children.

The school agreed to let them start straightaway even before the school fees are paid, so today the children attended our school for the first time.  The eldest was tested as he said he had been to school in Bor.  He performed very well and was placed in Primary Four where he is the youngest child.  His younger sisters have never been to school before and were placed in the nursery.

Now all that remains is for Fulaa Lifeline (the home’s supporting charity) to find sponsors for these children to pay for their living expenses.  

Independence Day

9^th July was South Sudan’s third Independence Day.  It was a very muted affair at least in Nimule.  The current situation in South Sudan is no cause for celebration. 

The evening before, I was teaching some children in my room.  At the end of our session, they told me that if they did not sing the National Anthem correctly the police would shoot them.  They took this threat very seriously and were really scared.  I did my best to make a joke of it for them.  I asked them to sing the national anthem to me.  All the children know it really well as they sing it at school assembly every morning.  They sang it for me and I applauded them and assured them that they were excellent singers (which they are).

After I went to bed I got cold feet thinking about it.  Most probably it was the thoughtless threat of someone who wanted them to do their best.  However, elsewhere in the country, the police or soldiers have proved themselves quite capable of shooting innocent people, including children.  

On the day itself I was invited to lunch with my friends on the other side of Nimule.  I hopped on a boda and we set off.  We could see a long line of jeeps with huge national flags slowly going down the road with people also walking in the procession.  Before we had reached the centre of town we were stopped by the police and told that because of the Independence Day procession the road was closed to other vehicles.  The boda driver took me by a very different route along foot-wide footpaths through long grass and small villages of huts where the children were hugely excited at the sight of me on the boda.

I had a nice lunch and chatted with my friends before being driven back along the main road.  As we passed the football ground where the Independence Day speeches and main celebration were being held, it was very evident that large numbers had stayed away.  I don’t think there were more than 400 people there in all and plenty of soldiers in jeeps.  We passed the market which is usually a hive of activity with lots of roadside stalls.  Even on Christmas Day it is busy.  Yesterday it was completely empty.  Everyone was at home taking a day off work and keeping a low profile.  Maybe they, like the children, also thought things could take a bad turn.

I was expecting the next day to be a normal school day.  I don’t learn by experience, do I?  I arrived at the school to find school children playing football but the staff room locked and no teachers.  Finally the headmistress arrived at around 10 o’clock.  She told me that Radio Miriya (the national radio station) had announced an extension to the public holiday at 9 o’clock that morning.  This does not explain why the school wasn’t open at 8am.  Yet another day with no teaching.

Football versus school - no contest!

Football fever is in the air.  The children at the home are able to watch the World Cup courtesy of some visitors who paid for a satellite subscription for them.  This week the fever has hit the school.  Instead of going to lessons, most students have spent the school day playing football.  The teachers sit and watch.  When I asked what was going on I was told that there is an inter-schools football competition soon and the children need to practise.  The headteacher even said that football was of equal importance to education.  I was speechless.

A few children still go and sit in their classrooms, so I have been teaching them.  Nice as it is for me to have such small classes, it means I can’t follow the curriculum because I will leave so many children behind. 

This week I introduced very simple dictation and word search puzzles to my much reduced English class.  Today I read them a story, which was a great hit.  The book was one of the children’s books given to me by my hosts in Kampala as a goodbye present.  I am also working with small groups who had similarly low marks in last term’s exams.  This is going very well in terms of increasing their confidence, but the poor children have a very long way to go.  Some can’t read even basic words such as ‘a’, ‘and’ etc.

For maths I have mostly been doing revision exercises, although this morning I introduced Suduku as a bit of light relief.  This afternoon we did a round-the-class times-table test which went very well.  Last term multiplication was a serious weakness, so I was very pleased to see progress in this area.  It is a challenge to find interesting off-curriculum maths for them as I am not a real maths teacher.

It will be catch-up time when the football finishes.  However I have been warned by a Ugandan teacher that next term the obstacle will be drama and singing, which will again take precedence over lessons.  No wonder the exam results here are so poor. 

Football is not the only barrier to education the children face.  Last week many children were sent home for not wearing socks and covered shoes.  One bare-footed mother came to the school the next day to complain that she could not afford shoes either for herself or her children.  She saw me and asked if she could have my sandals.  I was feeling so totally outraged by the headmistress’ mocking attitude to this parent that I took my sandals off and gave them to the woman.

On Tuesday about two thirds of the school were sent home for non-payment of school fees.  Football did not stand in the way of this punishment!  Clearly school fees and smart footwear take precedence over football, with education at the end of the list of priorities.