Systems and Powers: #COVID-19UGANDA day 134

Monday, Wednesday, and Friday we spend the first 30+ minutes (OK who are we kidding it is often an hour) of our hospital day in an outdoor, socially spaced, all-staff morning report. Twice in the last few weeks we've spent an extra all-day meeting for government and partner planning on health, education, care for children. Every day we have people coming to talk to us, or we are interacting as we work and move. And IN EVERY SINGLE CASE we are the only people from beyond the borders of Uganda in the conversations, which means we are always listening and learning and processing and comparing. We are always running a little behind the curve of a dynamic system of beliefs, habits, values, history, proverbs, language, culture. Then many evenings we are viewing through the window of CNN or newspapers back into our birth culture, watching testimony before Congress, or reporting on protests or the pandemic. This week there has been a slew of live-coverage from Congress. Again we are outsiders by location, slightly out of step and behind the dynamic curves of popular opinion. But in both cases, I would say our off-balance not-belonging can be a strength as well as a weakness. Because we can bring a fresh view.

So when Attorney General Barr said that he did not believe there was systemic racism operative in our criminal justice system, I immediately applied that to the kind of systems-thinking we try to do in medicine in Africa.

When problems arise, the human tendency is to look for the person to blame. Bad outcome of treatment? Well, whose fault was it?

But while it is important to hold people accountable to do their jobs, most of the real progress in improving care and reaching goals comes from thinking about the system that is functioning to produce the results that we see. For instance, here are some of the problems we have been present for discussions of this week:

• A child dies of severe anaemia from Sickle Cell, because there is no blood in the blood bank to transfuse them.
• Teenage pregnancies are on the rise during lockdown, and we're all realising that many girls are safer in school than at home.
• An infant is still born because the nurse called the doctor to do a C-section, but he did not answer his phone, and so she waited for the next shift in the morning.
• Rats are eating the hospital register books and plaguing the operating theatre because they are attracted to placentas left in buckets.
• A two-year-old comes in with an abdominal stab wound inflicted by his own father who was high on a substance and mentally ill.
• Alcohol and marijuana are in our markets because the parliament gets income from this business.
• Artesunate, a key malaria drug, is out of stock because people believe it is so powerful that they sneak into maternity ward and copy the name and file number of patients so they can go to the dispensary and fraudulently take it.
• Before all schools were closed, teacher absenteeism was rampant because they take loans which they cannot repay on their salary so are constantly working other jobs.
• Government staff do not respect their supervisors because their salaries come via bank transfer not tied to performance.
• Coronavirus deaths are now three in the country (extremely low, but the beginning of the wave) because people have stopped wearing masks and distancing.
• Families complain to the police when their daughters are enticed into sexual relationships as teenagers or even younger, but as soon as the threat of action generates a financial settlement from the seducer they drop the case.
• Medicines are out of stock because the national supply chain is months behind schedule.
• A friend has to move out of his paternal home because his alcoholic brother keeps beating up the friend's wife when he is at work, and the family cannot send this alcoholic brother away.
• Another friend calls a community meeting because the neighbours have blamed a death on the statement "you should take her to the hospital; if you don't she might die" , attributing that statement rather than the delayed care as the cause of disaster.
• A neighbour limps in with snakebites because the local house construction has many gaps.
• The school gets a 2.4 million shilling water bill (almost $700, or more than 30x normal) because of a shoddy repair five years ago that has now allowed thousands of liters to silently leak into the ground. 
• We are on our last tin of therapeutic milk, because our district relies on UNICEF supplies that do not reflect the reality of the need.
• Food production is inadequate for our district, because people planted so much land in cocoa over the last two decades to make some cash, at a ratio that benefits the buyers and leaves the small holders with hunger.
• A baby dies because his exhausted mother is over 40 and on her tenth delivery and she just can't summon the strength to push him out.
• A rape case is not followed up because the family can't pay the extortion required to get all the forms filed with police and medical reports.
• With primary elections approaching, people are warily testing the winds to figure out who will win, because the voting is done publicly by lining up for your candidate. So what is meant to quell rumours of ballot box stuffing becomes, in peoples' hearts, a fear that they will be punished for supporting the wrong person (whoops, your name was deleted from the payroll, spend a few months with no salary to try and sort that out).
• The further from town a school or health center is, the less likely it is to be fully staffed, because as people move up in education and responsibility they want to live more centrally with access to shops and power.

It is exhausting to generate a quick list of items we have been presented with in just a week, let alone months and years. I am not making any of these up, and I know I'm not remembering many. Pretty much any of those issues could be traced to an individual who cut a corner, took a bribe, failed to show up, made a bad decision, committed a crime. But the fact that they happen, over and over, is bigger than any one individual. They are part of systemic injustices that have brought pain and suffering into Bundibugyo for centuries. The Bible speaks of the world (the fallen state of everything from the coronavirus to flooding), the flesh (our own sinful desire to promote ourselves at the expense of others), and the devil (principalities and powers in the unseen realms bent on evil and destruction). These are seen in the objectification of women, the colonial systems of administration, the removal of resources, the corruption in allocation of services, the extreme fear of the spiritual powers, the personal conflicts, lack of agency, lack of trust. None of the solutions are simple. We can exterminate a few rats or buy some milk or boxes of medicine or pay for some court cases . . but the real solutions require generational changes in values and habits. They require hearts for serving others, access to adequate food and information, dependable safety nets. 

Which is, of course, why we are here for the long haul. In the meeting of the district committee on orphans and vulnerable children (OVC's), I noticed that amongst the two-dozen people in the room were two young adults who had received OVC scholarships at Christ School. OVC's who were now planning for the care of OVC's. This kind of change takes time, lots of it. But it is happening. The people of this district are resilient and committed, patient enough to listen to a dozen sides and opinions, willing to sacrifice and wait, willing to pitch in and change.

So Mr. Barr, let us respectfully disagree.  The broken world, self-absorbed human hearts, and evil intentions, permeate every part of our globe. Our problems in America are not just a handful of agitators or trigger-happy outliers. Change in the USA and in Uganda both require some deep works of the heart, some careful attention to policies, some just allocation of resources.

Today I finished my read through the book of Isaiah. The prophet is writing at a time of danger and upheaval, and I imagine his audience felt something like we do in 2020. And much of what he has to say relates to big-picture, large-scale, national systemic transformations. Yes there is talk of individual piety, it is never either-or, always both-and. But let's not forget that God works through people for peace to cascade in like a river that carries life to all.