“Olumwa?” I asked in my best impersonation of a Lugandan accent. My patient pointed to her belly. She looked as if she had swallowed the moon. She was writhing uncomfortably on her bed in the maternity triage laying on the single sheet of black plastic. I scanned the room one more time to look for any physicians. The interns, called junior officers, were on strike. They had not been paid in 5 months so the strike was a drastic measure to confront the unfairness of their plight. The residents, called senior officers, were taking exams and were studying in the small hallways in Makerere University quizzing each other on clinical technique and treatments. The attendings were around, but they were few and spread out. It was just us – me, my two medical school classmates, and the midwives (called Sisters in Uganda) – who were charged with directing admissions at the maternity ward at Mulago Hospital. My patient rummaged through her mamma kit and handed me a set of sterile gloves. “Omanyi luzungu? I’m a medical student from the United States. The Sisters and I are going to take care of you today”, I told her. She nodded.
We admitted up to 70 patients a day at maternity triage. On average, approximately 50 of our laboring patients deliver vaginally and approximately 20 deliver by emergency C-section. Mulago has two operating theatres, and the medical staff must triage the most important cases: uterine ruptures trump women with cephalopelvic disproportion, but sometimes the mothers in the high-risk obstetrics ward like those with severe pre-eclampsia jump the list quickly if needed. Women in the post-natal maternity ward who have severe postpartum hemorrhage jump the list, too. With the sheer volume of patients and acute cases we see every day, not every patient can have immediate access to a theatre or a skilled attendant. Despite the best efforts of the medical staff, this lack of clinical resources and clinicians resulted in devastating stillbirths, terminations and in some cases, maternal death. This was my reality for 6 weeks.
When I returned home after my work in Uganda, I related my experiences to a friend and I used the phrase, “I got used to it.” I paused to reflect on the reflexive casualness of my response. I was referring to the shock I felt on my first day of working on the wards where I witnessed overcrowded hallways, women laboring in bathroom stalls and sitting on long lines for the operating theatre, and one maternal death from an uncontrollable postpartum hemorrhage. During my time in Uganda, I treated rural women with HIV who struggled to get access to triple-drug therapy HIV medications, pregnant women who presented with vaginal bleeding after their spouses physically abused them, and elderly women who lived with chronic pelvic pain after years of untreated infection from rape. Experiences such as these are not uncommon in developing countries where one hospital alone can magnify global inequalities and injustices. In 2015, the World Health Organization reported that the risk of a woman in a developing country dying from maternal-related cause is about 33 times higher compared to women in developed countries. In sub-Saharan Africa, 1 in 41 women die in childbirth or related complications. Before my work at Mulago Hospital, these numbers were only abstractions. My experience in Uganda humanized the reality that hid behind the statistics. I witnessed the tireless efforts of the medical staff do the best they possibly can, given the painfully challenging circumstances. Frankly, I knew this was injustice. Did this mean I had now habituated to it?
The phrase “I got used to it” suggested a complacency. It was as if the limited resources, congestion, and the absence of physicians made the reality of injustice somehow more psychologically palatable. But was it ethically palatable as well? Complacency is dangerous. It creates both an expectation and an excuse for the social, economic and institutional causes of human disease. It redefines injustice as a default condition in some parts of the world and not others. It regularizes global inequality. Essentially, this is structural violence because it neutralizes an otherwise grotesque reality: the comforts and conveniences of the developed worlds are achieved (to some extent) at the expense of developing world. We tolerate the injustices because it is embedded within the ordinary, and because we are far removed to witness its lived experience.
When I feel inertial pull toward complacency, I remember the question I asked my patients most often during my work in Uganda: Olumwa? This translates from Lungandan into “Where does it hurt?” As humans, we know what it feels like to hurt, and the universality of pain reminds me that people and communities all over the world are unjustly suffering. We should all hurt for that. My global health work has forced me to grapple with questions of responsibility, accountability and ethics. There is no compass to guide us toward perfectly informed social actions that overall alleviate the injustice and inequality that denies health access and quality care certain individuals and not others. But we can and must try.