Louis Kennedy reflects on working at a public trauma hospital in Johannesburg, unpicking how it operates as a ‘sociostructural space of pain’.
This piece is set at Chris Hani Baragwanath, a public trauma hospital in Soweto, Johannesburg- one of the largest trauma centres in the world. The area carries the long legacy of apartheid-era displacement and registers some of the highest rates of interpersonal violence in the country. Emergency care here unfolds within a chronically under-resourced public health system, where extreme patient numbers and staffing shortages make institutional overload a daily condition.
I. A position in the field
I spent my twenties moving between crises: refugee camps, conflict zones, Mediterranean rescue operations. Earlier this year I interned at Chris Hani Baragwanath in Johannesburg. What I encountered was not simply an overwhelmed system. It was a structure of suffering, one that required a name: I have come to call it a sociostructural space of pain.
II. First contact
The night I arrived at the guesthouse, another newcomer and I listened, round-eyed, to horror stories shared by senior staff.
“Welcome to Baradise,” said the doctor I would be shadowing, a cigarette dangling from the corner of his mouth. “Everyone here should be fired. Every single one,” he added, deadpan.
The gallows humour was familiar: the cool-down I had heard from rescue personnel on Berlin streets, the same quick banter and apparent detachment from colleagues in Lesvos and Ukraine. But something in the delivery here was different. The register was the same, but the weight behind it was not.
That first visit, meant to be brief, turned into a full 24 hours. Night fell, and once it does, you don’t drive through Soweto anymore. It was my first indication that time runs differently at Bara, that the hospital operated according to its own temporal logic.
III. Architecture as a producer of suffering
Nowhere is Bara’s particular logic more visible than in its resuscitation (resus) room.
When I first entered, I was overwhelmed not by a single impression but by the collision of many. It is a long, crowded space: fifteen stretchers aligned along the right wall, no curtains, no partitions, minimal equipment, and a steady flow of simultaneous emergencies. In the middle stands a solitary table and a computer for viewing CT scans. Across the floor: torn clothes, ripped packaging, blood, remnants of improvised procedures. Not signs of neglect, but features of a setting in which procedural closure is structurally unattainable.
Florence Nightingale’s 19th century contention that that nursing ought to signify the proper use of air, light, warmth, quiet, reads here as a list of everything systematically absent (Nightingale, 1860, p.8). The room does not fail to support care by accident, but by the accumulated weight of what has never been resourced.
Space, as Michel Foucault argued in The Birth of the Clinic, is never neutral in medicine (Foucault, 1973, p.16). The hospital does not merely contain illness, it produces a way of seeing and managing bodies that transforms patients into objects of institutional processing (Foucault,1973, p.136). In the resus room, this logic is stripped bare: pain is public. Every stretcher is a stage; every patient encounter stripped of intimacy. Stretchers align within shared lines of sight, separated, if at all, by sickly blue curtains that cannot be properly extended and do little to contain sound or smell.
IV. The management of scarcity
My first practical challenge was adjusting to extreme resource scarcity. Gloves, intravenous lines, electrocardiogram stickers, basic consumables needed to be searched for. There was no disinfectant spray, only 2×2 cm alcohol swabs. Medications had to be requested from local nurses, who would grant or deny them depending on the moment. The procedural delays were not attributable to individual negligence, but were expressions of a system in which the management of scarcity had become routinised. Pain relief here became contingent on which nurse was on shift, whether supplies were available, and the emotional and physical capacity of staff that day. The system converts care into a scarce commodity to be triaged and rationed like any other resource. Suffering, in this institutional logic, has no temporal priority.
I watched nurses move past patients in visible pain without breaking stride, and my first instinct produced the explanation that Western clinicians reliably reach for: a cultural one, something about different attitudes toward suffering. The thought formed and felt immediately wrong. The nurses moved this way not because the pain didn’t register but because registering it, at full volume, across every patient on every shift, would make it impossible to return the next morning.
Many nurses were in their fifties, carrying the historical burden of apartheid-era hierarchies: the Nursing Act of 1957 formalised racial segregation of the profession, maintaining separate registers and a governing council composed exclusively of white nurses, which meant Black nurses had no institutional voice over training standards and professional policy. The Bantu Education Act of 1953 deliberately suppressed the school level science qualifications required for nursing entry, forcing a double bind. These hierarchies were among colonoisation’s most durable instruments- not only in what they excluded, but in what they produced in those they permitted to remain. Frantz Fanon described colonialism as generating a structured negation of the colonised person’s capacity for self-determination, a negation that, when outward resistance is foreclosed, turns inward, manifesting not as passivity but as a rerouting of agency into endurance (Fanon, 1963, pp. 52-55). What I observed at Bara was not innate indifference. It was the particular affective economy of a workforce that had learned, across generations, that care extended beyond its institutional tolerance was care that would be punished or simply absorbed without acknowledgement. The system had made a functional numbness adaptive. That adaptation was still legible in how people moved through the wards in the managed distance and calibrated disengagement.
V. Where moral injury takes shape
Scarcity converts care into a commodity. What it does to the moral agency of the people administering that conversion is a separate and more insidious problem.
A patient presented with a traumatic brain bleed resulting from a mob assault, a twisted expression of vigilante justice in a society where many no longer trust the state to enforce law. Two other patients were queued for CT before him. I asked the radiology nurse whether we could prioritise him given his declining consciousness.
“Why are you so pushy?” she asked.
I tried to explain I only cared about the patient’s outcome. When I suggested returning later and starting hypertonic saline if the wait was too long, she asked why we had come at all.
We waited two hours. The bleed on the scan was walnut-sized. By the end of my 14-hour shift, the patient had not reached the operating theatre.
Sitting with this later, I kept returning to her question: “Why are you so pushy?” This was a question about position, mine specifically. I was a temporary visitor with a return flight booked, accountable to no one in this system, free to advocate without bearing the consequences. The nurse who asked it would be here tomorrow, managing the aftermath of whatever I pushed for today. It was the system’s time-logic: suffering carries no urgency; bodies move according to institutional rhythms, not clinical need. (Rowell et al., 2016, p.321). Moral injury is born not of cruelty but of enforced passivity.
VI. When language fails
Another day, a small boy, no older than four, was carried suddenly into the resus room. At first, it looked like a simple head wound. Then someone asked whether he still had a pulse. I shifted into automatic medical routines.
This was a child who had been in a road accident. When I first saw him, he was lying on a stretcher in the aftermath of stabilisation, the detritus of a chaotic attempt still around him, torn packaging on the floor, a tangle of lines. He was deeply anaesthetised, but the eyes were open, and it registered as a wrongness I couldn’t resolve: the pupils still and unfocused, pointed at the ceiling, receiving nothing.
He was wearing a t-shirt with horizontal stripes in blue, red, yellow, and cream. No shoes. There were scabs on both knees, the ordinary tattoo of a child who runs and falls and runs again. He smelled of sweet sweat, the smell of a child who has spent the day outside, moving. He was lying there without a blanket. No one had put a blanket over him. The team was somewhere else, organising the scan, and for a long time, he lay by himself in the middle of what the room had become: the remnants of the effort to save him spread across the stretcher and the floor around it, the small ears, the open eyes, the tongue slightly over the lip.
A nurse carried him away. No words. No ritual. No transition. Just removal. I never saw the family, though colleagues later said they had been somewhere nearby. I only saw the boy being zipped into a body bag.
Ivan Illich, in Medical Nemesis (1974) argued that industrial medicine has expropriated death and stripped communities of the capacity to face mortality on their own terms (Illich,1974, p. 921). Cultures historically had ritual frameworks, ceremony, grief, and family presence. The clinic replaced them with protocol; at Bara, even that was absent. What Illich called ‘cultural iatrogenesis’ (Illich, 1976, p. 34) revealed itself completely: no pause, no acknowledgment, no grief allowed to enter the room.
I had been trained to work professionally in the presence of death. The clinical role had always provided a scaffold: actions to take, steps to follow, a role to inhabit. What I had not examined was how much that scaffold was also doing existential work by deferring meaning-making as much as enabling action. As an atheist, I had no ritual framework to reach for. The professional role had been doing double work, and when it failed, what lay beneath it was not a formed understanding of death but an absence. The boy in the body bag made that absence impossible to ignore.
This was the moment the boundary between professional role and moral-self tore open.
VII. What remains
Back in Germany, a case like this would have triggered layers of institutional response: a debriefing, a Morbidity & Mortality meeting, psychological follow-up. A resonance chamber as a place to metabolise what had happened. In Johannesburg, there was none. The experience dissolved into the rhythm of the next shift.
Bara is not an aberration at the edge of global inequality. It is the place where dynamics present in every health system become undeniable, where care is stripped of the architecture and resources that allow other systems to maintain the illusion of guarantee.
The sociostructural space of pain does not only act on patients. It acts on everyone moving through it. A structure that prevents pain from becoming socially resonant does not make that pain disappear, but it privatises it. The normal mechanism of witnessing suffering is resonance: pain travels, is received, passes through another person, and in that passage becomes nameable, metabolised, bearable. When the structure blocks that circuit, through overload, spatial compression, or affective shutdown, then the signal cannot complete its journey. It accumulates unprocessed in the observer.
What it accumulates as is not straightforwardly grief or trauma, though it shares features with both. It is closer to a persistent vividness; the people encountered remain present without having been processed, their suffering fixed at the moment of witnessing. This is not a psychological complaint. It is a structural diagnosis. The sociostructural space of pain produces this effect not as a side consequence but as a logical outcome of its core condition: an environment in which suffering cannot become socially resonant. What cannot resonate cannot be metabolised. What cannot be metabolised is privatised, pushed back into the individual observer, where it accumulates without framework, without ceremony. The people working inside such spaces carry this alone. And carrying it alone, over time, is one of the ways the structure reproduces itself: it makes the witnessing of suffering a private burden, and private burdens fail to become political claims.
About the author
Louis Kennedy is a Berlin-based paramedic working in clinical emergency medicine. His field experience spans Mediterranean search and rescue, medical advisory work in Ukraine, and paramedicine in Moria, Lesvos, where he was embedded with an investigative collective and travelled to Bosnia and Herzegovina to report on Refugees on the European Border. He is currently studying international disaster response at Akkon University.
References
Fanon, F. (1963). The Wretched of the Earth (C. Farrington, Trans.). Grove Press. (Original work published 1961)
Foucault, M. (1973). The Birth of the Clinic (A. M. Sheridan Smith, Trans.). Pantheon Books. (Original work published 1963)
Illich, I. (1974). Medical nemesis. Journal of Epidemiology and Community Health, 57(12), 919–922. https://doi.org/10.1136/jech.57.12.919
Illich, I. (1976). Medical Nemesis: The Expropriation of Health. Pantheon Books.
Nightingale, F. (1860). Notes on Nursing: What It Is, and What It Is Not. D. Appleton and Company.
Rowell, C., Gustafsson, R., & Clemente, M. (2016). How institutions matter “in time”: The temporal structures of practices and their effects on practice reproduction. In J. Gehman, M. Lounsbury, & R. Greenwood (Eds.), How Institutions Matter! Research in the Sociology of Organizations, Vol. 48A, pp. 303–327. Emerald Group Publishing. https://doi.org/10.1108/S0733-558X201600048A010
