This is a post about power.

This is a post about power. Not electrical power, nuclear powers, or power outages, but differences in power.

Recently I was privileged to host several of my fellow MUD 4 volunteers in Umphumulo.  It was great to have visitors and get to show off what I love about my site.  During their visit, we walked around the Umphumulo area, explored the church center and the old Lutheran seminary, picked guavas and avocados, and took turns cooking on my gas burner when the power went out.  Perhaps the most interesting part of the visit was our tour of Umphumulo Hospital.   As I was giving my friends a tour of the hospital campus, we ran into a couple of the doctors I’ve gotten to know over the last few months.  They told us that there was an elective C-section scheduled for later that morning.  I thought that we might be able to observe the procedure, as the operating theatre in Umphumulo is never particularly busy or crowded.  We were pretty excited about the idea, and after a little bit of asking the doctors gave us the ok. 

Around 11, our group of four Americans trooped into the tiny changing room outside the operating theatre.  After getting decked out in green scrubs covered with emblems reminding us that they belonged to the KZN Department of Health, we got ready to enter the theatre.  Unfortunately, the matron informed us that the operating rooms did in fact have a maximum capacity, and as a result only one of us could observe at a time.  We were a little disappointed, but after explaining that my friends wouldn’t have a chance to visit other than today and asking very nicely, we worked out a way to let my three guests observe together.  Several nursing students who were planning on watching the procedure offered to come back another day, and I offered to watch from outside the operating room doors. 

The procedure went perfectly, and the mother gave birth to a healthy baby girl around 11:45.  Soon after, we thanked everyone for letting us observe, changed out of our scrubs, and walked back to the church center. 

I didn’t realize this story had anything to do with power until later that afternoon.  I was telling my friend Smangele what I had been up to that morning, and she asked me a question that had never occurred to me.  Smangele simply wanted to know whether we asked the mother if we could observe the procedure.  I thought for a second.  We had permission from all sorts of people… the doctors performing the C-section, the matron in charge of the operating theatre, the nurses who had volunteered to let us observe in their place… but not the mother. 

Since I’ve been in Umphumulo, I have probably observed more than 20 C-sections.  I’ve seen watched different groups of doctors and nurses work, seen cases that went well and ones that couldn’t even get started, and gotten to know the major points of the procedure.  Yet I have never thought to ask the mother for permission to watch.  Sure, I have written permission from the chief of medicine that allows me to observe, ask questions, and help throughout the hospital.  I’ve made friends with many of the doctors and nurses, and have often been invited to observe interesting cases or procedures.  How could I do all this without the patient’s permission?

How many mothers in American hospitals would let a handful of random people—with virtually no formal medical training—observe their C-section without even asking why they were there?  It’s not exactly a modest procedure for the mother, and I can’t even say that the patient is under general anesthesia and won’t know who is observing.  C-sections aren’t the only procedures I’ve observed at the hospital here either… I imagine the young men whose circumcisions I observed weren’t exactly pleased I was in the room.   Yet I have never even been asked my name by a patient. 

Once again, my friend Smangele had an answer.  She suggested that the reason I have access to so many private moments in patients’ lives has everything to do with the dynamics of power.  Many power differentials probably had a role in creating this situation, but I want to focus on four.

The first three are the differences in power between doctors and patients, between men and women, and between Zulu speakers and English speakers.  All of these power differentials are rooted in the culture of this rural area in South Africa.  Umphumulo is a very traditional place, and the most of the adult population can only speak Zulu.  English is one of South Africa’s 11 national languages, but despite being considered the language of education and commerce isn’t widely used in rural areas.  The vast majority of people who live in and around Umphumulo are unemployed, surviving on pensions, or dependant on family members working elsewhere, so the “language of education and commerce” can easily be translated to the “language of power”.  People with jobs, education, cars, houses, and money make decisions, know how the world works, and speak English.  Doctors fall into this category for all these reasons.  American volunteers do as well, even if we only have an education and speak English.  As a result, most Zulu speaking patients rarely question the medical system they are a part of at Umphumulo Hospital, especially the doctors who make decisions about their care.  Similarly, many doctors rarely ask what their patients think about the care they receive, or even if they have questions about it.  The gender difference also plays a large part.  Rural Zulu society is dominated by men.  Men are the head of the household, the breadwinners, and the final decision makers in most Zulu families.  Women are expected to cook, clean, and raise children; traditional practices like lobola (when a groom “purchases” his bride from her family before they can be married) reinforce this patriarchy.  The feminist movement hasn’t made much ground in the rural areas of KwaZulu-Natal, despite women constitutionally having the same rights to live and work as men.  The fact that my presence has never been questioned by a mother on the operating table highlights all of these power differentials.

The fourth power differential is the white elephant in the room.  Pardon the pun, but racial issues are still surprisingly close to the surface, despite 17 years of freedom in the rainbow nation.  On second thought, maybe it’s not so surprising.  How much racial tension still exists in the US almost 150 years after the end of slavery and 40+ years after the civil rights movement?  I can’t speak for all of South Africa, but in my experience the color of my skin has played a role in earning me questioning looks, inspiring wild assumptions about my personal wealth, education, and connections, placing me in seats of honor at weddings and other functions, and allowing me to go wherever I want in Umphumulo Hospital.  Don’t get me wrong: I’m not saying that people in Umphumulo are racist.  Nor am I suggesting that my race places me in a superior position to many people in my community here.  I am simply saying that race still causes questions and assumptions that may have little to do with the truth.  Racial issues are undoubtedly woven into the three power differentials mentioned above as well, and I am not nearly competent enough to address them.  Simply put, despite very little overt racism today, the abuse of power by one race on another during apartheid cannot be waved away as easily as we might like.

What can we do about unhealthy power differentials?  Personally, I can start by making sure I have the patient’s permission to observe procedures in the future.  More broadly, we should be more observant to ways in which we unconsciously take advantage of power differentials.   Once we realize these power differentials exist, it’s easy to take steps to flatten them.  Asking questions opens channels for dialogue, and dialogue helps to both expose power differentials and empower people to level them.  That’s what volunteering (and life, I suppose) is about: becoming aware of unnoticed details that have always surrounded us and working to change these circumstances by uniting with those around us.