Jessica cradled the small, underweight girl while humming and swaying gently. Nyamuoch, the 20-year-old South Sudanese mother, lay nearby on a thin green hospital mattress. “I’m so happy to see her sleep,” said Jessica, a pediatric nurse from Australia who has known the mother and baby for months. “She’s been through so much.”
The air in this interior hospital room was heavy. A wounded air conditioner puffed limply, but move too much and puddles of sweat quickly formed. Still, the mood was relatively upbeat. Only three hours earlier medical personnel and curious onlookers had gathered as 5-month-old Nyanene struggled to stay alive. Her breathing radiated pain: loud, labored, gruff, desperate.
The oversize oxygen mask still covered her tiny face now, but her breaths were quieter. Jessica had skipped lunch and now took a moment to peel an orange. She offered a piece to the young mother, who shook her head.
Then, suddenly, the generator died. The light in the room dropped from green florescent to grey shadow. That wasn’t a problem. The problem was that Nyanene’s oxygen machine also shut down. Medically speaking, the baby was oxygen-dependent, and now there wasn’t any. Jessica sprang up, telling a South Sudanese medical officer named Gbang to take Nyanene’s heart rate.
“If it’s under 60 we start CPR,” Jessica said.
Gbang put the stethoscope over Nyanene’s heart. It was under 60.
Oppressive heat, unending rain
The flight from Juba to Maiwut takes two hours in a 14-passenger Twin Otter plane branded on all sides with the Red Cross’ instantly recognizable emblem. It’s a lonely flight.
While flying over Europe or the United States one sees straight four lane highways or county roads on a grid. Squares of crops. Circular irrigation patterns. At night, bright patches of light.
In South Sudan none of that exists. Unending fields of dirt, sand and splotches of trees pass below. River beds snake along, some dry, some wet. Low-lying land shows the scars of flood, with paths carved like a hundred bony skeletal fingers. Very occasionally a circle of huts appear, though no roads lead in or out.
For a while the plane shadows a dirt road. From a height of 10,000 feet it looks straight and in good order. But anyone who has travelled South Sudan knows that to actually drive that road means unending potholes and ruts; 30 kph (20 mph) is fast enough to rattle your body to a painful numbness.
The people of Maiwut live in small huts made of sticks, mud and straw. The weather does a seasonal two-step between oppressive heat and unending rain. The people living in this land face a long list of problems. Malnutrition. Malaria. Pneumonia. Sexual assault. Gun violence. A lack of roads. A lack of schools. Dirty drinking water. Precious few medical clinics.
The food situation is precarious, like in many parts of the country, which was plunged into a vicious war in December 2013 that has killed tens of thousands and displaced millions. Although the first concrete signs of peace emerged earlier this year, the most recent round of violence has returned the country to uncertainty.
As in many fragile states and conflict-affected countries, civilians pay a heavy price. Health facilities and critical services like water and electricity are often disrupted or destroyed completely. The hospital in Maiwut is basic. The only available electricity comes from diesel-powered generators that occasionally cut out, a fact of life that can prove deadly.
Gunmen launch a pre-dawn attack
“This attack came and no one knows why,” said Ojuok Puok Duel, the 40-year-old deputy commissioner of Maiwut, referring to the violence that came in late April 2016 when a neighboring South Sudanese tribe moved through the area and into the town of Gambella in Ethiopia, where they killed more than 200 people and kidnapped more than 100 children.
The gunmen attacked before dawn, shooting people in their sleep and forcing families to flee in total darkness.
“We can see they were looking for cattle and children, but they were wearing military uniforms,” Duel said. Though the attack happened in Ethiopia, it was against Nuer communities, the same ethnic group that lives in Maiwut.
The April cross-border attack triggered a new round of suffering and fear. Dozens of people wounded by bullets were brought to the ICRC hospital in Maiwut, overwhelming the medical team. The hallways filled with patients and overflow canvas tents were erected on the hospital grounds.
“It was complete chaos,” said Igor Macala, a 55-five-year-old trauma surgeon from the Czech Republic. “40 or 50 people arrived together, patients and relatives.” The team enacted its triage protocol, separating the wounded into four categories. The most severe category of patient are actually the ones the team can’t save.
One man had a bullet hole through the head. Still breathing, yes, but no hope of survival. The next category was for those in extreme need but who could be saved, such as Nyaduel Gony, a gunshot victim who was nine months pregnant.
An unborn life on the line
It was still dark, around 5 a.m., when the gunfire began, she recounted. Nyaduel’s four children quickly ran away, but the pregnant woman and her elderly mother couldn’t outrun the attack. She estimates she and her mother stumbled forward for 30 minutes before the gunmen’s bullets found them. Both were shot in the back.
“I was afraid that we were all going to die. I couldn’t see the attackers but I know they are not our people,” Nyaduel said from the hospital, where she lay on bright pink sheets.
“They want to kill us first and then they get our cattle and then our children. My husband was shot twice.”
The bullet entered Nyaduel’s lower left back and came out the front, on the left side of her pregnant belly. Intestines poured out. Her mother, shot in the left shoulder, lay wounded nearby. But they couldn’t talk or comfort each other, lest they draw the attention of the gunmen.
One hundred and twenty minutes they lay there. More than enough time for Nyaduel to believe she would die. But the gunmen finally left, and other villagers arrived and organized a way for Nyaduel to travel the 100 kilometers to Maiwut.
“She was the most serious case we had,” said Igor, the trauma surgeon.
There was no time to use an ultrasound machine to determine if the baby were still alive. Igor entered surgery not knowing if a baby would be born.
The pre-surgery survey “should be professional, without emotion, because it will create big problems for you and the team,” Igor said. “You cannot be cynical but you need balance. You cannot give up but you also can’t say this is horrible and, oh, this poor child.”
Igor performed a C-section, but the child was dead. “Unfortunately she lost the baby but she was extremely lucky. The bullet came through the whole abdomen but the uterus was still okay. She was extremely lucky because she survived.”
Surgery in a stifling heat
Daytime rains turn the ICRC office grounds into mini ponds. At the hospital, the floors turn to mud and cleaners wage a day-long battle to keep them clean. When it’s not raining it’s oppressively hot.
Ibrahim Zehran, an anesthetist from Jordan, moves his mosquito dome out of his tukul — a locally made mud hut — which now feels like a sauna, to sleep in a community room.
Manuel Lopez, a general surgeon from Cuba, says his room is fine.
“But you know my secret? When I go to bed I get two blocks of ice from the freezer and put one behind my neck and one on my chest.”
In the operating theatre, the air is just as hot and stifling. Surgeons Igor and Manuel dig their fingers into a 10-centimeter gap in the upper arm of a gunshot victim, assessing the boneless space. The hospital doesn’t have an X-ray machine.
Both men wear blue full body smocks that seal in their body heat. The surgeons ask repeatedly for a South Sudanese medical assistant to wipe the stream of sweat pouring off their heads. It’s the day after a cooling rain and Earth’s furnace is again roaring. The air conditioning unit in this room has been broken for months, and attempts to fix it have failed.
Igor guides his general surgeon colleague through a new procedure: hand drilling metal supports into the patient’s broken bone fragments. The external metal brace will guide the bones to grow back together. Igor steps back and swats a cricket off the wall.
Forty-five minutes later Igor gives his colleague a thumbs up. Both surgeons have sweat through their shirts and pants, and Manuel says he thinks he has lost two kilograms.
“If we continue like this all afternoon we will feel very tired. We have to bring one or two liters of water and drink between operations. It’s very tough,” Manuel said, adding that cooler temperatures would help the patient, too. “He is also losing a lot of fluid.”
Igor calls air conditioning a luxury. “When there is no water and light, that’s when there’s a real problem.”
Scorpions, vipers, and cobras
Nightfall brings the bugs. Mercifully there are no mosquitoes this early in May. But the crickets are vicious and the flying termites pervasive. At the ICRC compound, the bugs cover the dining room’s parquet floor, from where they plan their sneak attacks, jumping on to people’s heads and going down shirts.
The ICRC team in Maiwut is a global mosaic. They come from Japan, Australia, China, Jordan, Senegal, the Czech Republic, Australia, Switzerland, Italy, Kenya and South Sudan. There is the love of community here, when people pitch in together to make a dinner eaten alfresco under a squat acacia tree.
For the most part the team seems comfortable and happy. There are morbid jokes about how this advanced medical team has no anti-venom despite living in a land with scorpions, vipers, cobras and green mambas. Malaria is rampant. Wine is a treasured and occasional luxury, but the meager town market sells Ethiopian beer.
The satellite internet connection is decent. The red song birds and bright blue salamanders give the leafy office grounds an aura of happy. So does the molting baby ostrich, who strides shyly across the raised dirt walking paths.
The medical team reports to the hospital every day to help patients suffering the effects of malnutrition, malaria and violence — all facts of life in South Sudan. Their presence saves many lives. But sometimes the lack of resources is too much to overcome, like when the electricity cuts out.
A fighter of a little girl
“If it’s under 60 we start CPR,” Jessica says. Gbang puts the stethoscope over Nyanene’s heart. It’s under 60.
Jessica holds an air bag in her hands and pumps breaths into the child’s body. Gbang presses his two thumbs deep into the baby’s chest, pumping its heart. “We’re going 15 minutes before we call it, okay?” Jessica says, then adds quietly to Gbang in the calmest, most peaceful voice one could possibly muster at a moment like this: “That’s really good. You’re doing a really good job.”
Can we get the generator back on? A call is made but the dark remains. Can you check the heart rate? What’s the heart rate? Can you close the door please? Jessica relieves Gbang and starts pressing her thumbs into Nyanene’s chest.
We’re going for 15 minutes, Jessica repeats. This baby, the one Jessica knows as hungry for life, isn’t responding. The mother, Nyamuoch, also sits on the bed, within arm’s length of her child, but she sits removed in a far-away trance. Nine minutes after cutting out the fluorescent lights flicker on, but the oxygen machine is useless now. Mucus pours out of Nyanene’s mouth and Jessica wipes it away.
The clock ticks over to 2:20 p.m. Fifteen minutes have passed. Birgitte Gundersen, a veteran of emergency room trauma nearly 25 years Jessica’s senior, says quietly, “You can stop.” Jessica collects herself for a beat, then turns to her left and touches the mother’s leg. Nyamuoch, a cloth already over her face, puts her head back and wails.
Jessica maintains a brave face but it’s obvious she’s crushed. She leaves quickly.
Outside the hospital gates she unloads anger and sadness. “You know the only reason that baby died is because the generator stopped working,” she said, her voice cracking and tears falling.
“I mean she was going to die anyway, but this killed her faster.” We talk about the idea of geographical fate. It’s unfair, Jessica says, that Nyanene was born into a land with no food. The five-month-old child was the size of a healthy newborn. It’s unfair that the generator failed. It’s unfair that it took nine minutes to come back on.
“Why her? Anyone but her. I have spent so much time with her,” Jessica says.
“This baby should have been dead months ago. But it had so much spirit. It fought and fought and fought.”
That evening the rains returned. As late afternoon turned into dark early evening, an ICRC Land Cruiser drove Nyamuoch toward her mud and straw home in Pagak. A white blanket with a fading pink and blue teddy bear sewed on the front covered Nyanene. An ICRC staff member in the front seat held the child; Nyamuoch sat in the back.
The rain pounded on the windshield, and the vehicle nearly got stuck in deep mud. Nyamuoch’s home was too far from even the muddy side road to drive her all the way home. The car stopped at an aunt’s house. The older woman came out.
Surely this was not the first time she had seen a dead infant, not in this country. The aunt took Nyanene, cradling her as you would a living, breathing, fighter-of-a-little-girl, and set off with the childless 20-year-old across a field of mud as sheets of rain poured down.