You are angry. I understand.

You are angry because a hospital administrator changed the name of your department without asking you. Because an insurance company denied your patient’s medication for the third time this week. Because a nurse practitioner is now doing your job at half the cost, and nobody consulted you about that either. You feel like a pawn on a chessboard, moved around by forces you cannot see and did not vote for.

I hear you. And I want you to know — you are not wrong to be angry.

But I want to tell you what physician autonomy looks like from where I stand, because I think it will change the shape of your anger. Not diminish it. Change it.

I am an intern doctor in Juba, South Sudan. I rotate between Al Sabah Children’s Hospital and Juba Teaching Hospital. I was trained at the Latin American School of Medicine in Havana, Cuba, graduating in 2023, and I am the first physician from my village of Logwerle. I speak four languages — English, Spanish, South Sudanese Arabic, and Bari, my mother tongue. I work without a salary — intern doctors in South Sudan are not paid. I work because there is no one else.

There are no advanced ICUs where I work. When a neonate needs oxygen, we share the nasal prongs between babies, because there are not enough. When a baby needs phototherapy for jaundice, I rotate them on and off the device, because there are not enough machines. I keep a mental schedule in my head — this baby gets twenty minutes, then I switch.

Last week I watched a neonate’s heart rate drop. Bradycardia. Cold peripheries. Everything pointing to shock. I knew exactly what this baby needed. Epinephrine. The algorithm was clear in my head — I have read UpToDate on this, on my iPhone 13, which I share with colleagues because they cannot afford a smartphone and the internet is unreliable and we are all unsalaried and doing this anyway.

There was no epinephrine. There was no emergency medication of any kind. I stood at that incubator and did what I could with what existed, which was my hands, my training, my presence, and nothing else.

This is not a story designed to make you feel guilty. Guilt is not useful to either of us. This is a story about what physician autonomy actually means when you strip away everything else.

In your world, autonomy means the right to make clinical decisions without corporate interference. That is a real and legitimate fight, and I support you in it.

In my world, autonomy means something more elemental. It means the right to have the tools that match the decision. It means that knowing what to do and being able to do it should not be two entirely separate privileges. It means that a physician in Juba and a physician in Los Angeles, separated by ten thousand miles and ten thousand resources, are still doing the same thing — standing between a patient and death, and using everything they have.

The difference is what “everything” means.

South Sudan has 12.4 million people. It has no residency training programs. Not one. If I want to specialize — and I do, desperately — I have to leave my country. I want to train in internal medicine, and eventually specialize in oncology. Universities in East Africa offer these programs. The University of Nairobi. Makerere University in Uganda. The cost is approximately $3,500 per semester. That is not an unreasonable sum by global standards. But I am unsalaried. I have no savings. I cannot pay.

And so the question of who gets to become a specialist is not decided by aptitude or ambition or dedication. It is decided by money. And in a country where doctors work without pay, money is the one thing we do not have.

I want to be the first specialist in my community — a community of 40,000 people with no specialist of any kind. That should not be an extraordinary ambition in 2026. And yet it is. Because South Sudan has no chemotherapy. No radiation therapy. No children’s cancer centers. A child diagnosed with leukemia in Juba must travel to a neighboring country for treatment — if the family can afford to go, if there is time, if the disease has not already won.

We live in a world with its first trillionaire. We live in a world that can sequence a genome in hours and deliver a drug to a doorstep overnight. And yet there are 12.4 million people in my country for whom none of that exists. There is no global equity. There is global medicine, and then there is what the rest of us do with what is left.

I have an abstract being presented at an international conference in Barcelona this September. It describes how to recognize pediatric leukemia using only a complete blood count, because flow cytometry does not exist where I practice. I worked out a framework for doing more with less, because less is all there is. Getting to Barcelona is its own battle — there is no institutional budget to send me, and no salary to draw from. But the work exists. The patients made sure of it.

Dr. Pack wrote in his mission statement that he wants to reach physicians in India, China, Bolivia, the Central African Republic — that he suspects their ingenuity is remarkable, and that there is as much to learn from them as they from us. I believe he is right. Not because resource-limited medicine is romantic. It is not. It is exhausting and heartbreaking and sometimes it costs lives that should not be lost.

But necessity is a teacher that no medical school can replicate. And the physician who has learned to think without a safety net has something to offer the physician who is fighting to keep theirs.

We are not so different, you and I. We both became doctors because we wanted to help. We both face systems — or the absence of them — that make that harder than it should be. We are both, in our own way, trying to do the most fundamental thing medicine has always asked of us.

Show up. Think clearly. Do not abandon the patient.

That is the autonomy worth fighting for. Together.

Buga Charles George Kenyi is a medical intern at Al Sabah Children's Hospital and Juba Teaching Hospital in Juba, South Sudan