Monday, September 19, 2011

The Other Side of the Story

For reasons that I am not sure even I understand, I have been very reluctant to write about the patients that I have encountered here in Malawi.  I think I feel like it is voyeuristic, in a way.  All Americans have cable and internet.  We all know about the poverty and desperation that exists in the world.  We all choose to change the channel or avert our eyes, focusing instead on the minutiae of our comfortable, excessive lives.  You do not need me to tell these stories. I wrote the following after a particularly hard day, in order to help purge myself of the overwhelming sadness that I felt at the futility of the day's efforts. Please do not write to tell me about the difference I can make here. I am learning to find my sanity in small successes. Write to tell me what you have given up, how you are sacrificing so that these babies and mothers will suffer less. Give me hope.

There shouldn’t be such a difference between the world these mothers live in, and the one that I come from. In the states my patient's mothers worry about exposure to mold and delayed vaccine schedules. Here the they worry about having enough food for their babies, and watch them die from treatable and vaccine-preventable diseases. Today was my first day attending in the hospital.  It is like a war zone. Multiple times over the course of the day the low-level chaos of the hospital corridors would be interrupted suddenly by the sound of a mother wailing incoherently at the death of her child, a guttural deep-throated wail that transcends language and culture in its raw anguish.
The first time I heard this sound was when I was bent over the wrist of listless, dehydrated 2 year old, whose fontanelle (soft spot) was sunken to the point of being taut, sweating while trying for the 3rd time to place an IV.  He had developed profuse watery diarrhea overnight, and had grown lethargic, although he sucked greedily on the 5 cc syringe full of oral rehydration solution his mother had stayed awake dutifully all night long, giving every 5 minutes. We attempted multiple times to put a catheter into his veins to give him IV fluids, but were unsuccessful, despite his minimal effort at fending us off as we tried.  We requested help from the nurses, and were told that they were at lunch.  We requested help from one of the nurses at Baylor, and were told that they were on their way, although they preferred that the hospital nurse be consulted first, so as not to offend anyone.  Finally, as I watched this pathetic child cry weakly in front of me, I decided to put a large-bore needle into his lower leg to give him fluids. This is a procedure I imagine to be incredibly painful, as the needle is literally drilled into the bone marrow in order to give life-saving fluids, and is something I had only ever done in comatose patients.  This little boy, although pitiful, still felt pain.  With a visiting resident from the States assisting me, we held his little leg down and put the needle in,  waiting for a sickening pop as it pushed into the inside of the bone.  I tried not to hear his cries, and told him again and again how sorry I was.  For the next hour we pushed fluid into his tiny leg, having to push so hard against the syringe to get the fluid into the bone that our hands shook. The needle, made for drawing blood from an adult, stuck three inches from his shin at a right angle, but he barely reached for it.  And outside of the small, airless treatment room, littered with IV wrappers and cotton balls, blood on the floor and bugs in the sink, I could hear the childless mother crying.
The second time I was in the NRU, which is a refeeding unit, where children with kwashiorkor and marasmus come to be refed.  I was trying hard to determine the history of the malnourished child in front of me from the mother, who is what we doctors call a “poor historian”.  Suddenly a woman appeared in the doorway and emitted a howl of pure grief, then fell backwards, limp, into an empty crib.  It was clear, although she spoke Chichewa, that this was her child’s bed, and that she had returned from the treatment room where her child had died.  The women around her, whom I assumed to be aunties and a grandma, began to wail, and rock back and forth holding each other, as they sat on the floor in front of the sobbing young mother. In front of me was a baby who looked like the pictures of children in Somalia being shown on CNN recently. He is 20 months old and weighs what some newborns do, 10 lbs. His eyes were huge and watery, and the skin across his scalp was tight. His arms and legs looked like sticks. His young mother had been bent down in front of him feeding him fortified milk with a spoon from a plastic sippy cup, but they looked up when the mother of the dead child came into the ward.  All conversation stopped briefly as we, all women, listened to and absorbed her pain. Her cries echoed through the corridors as she gathered her child’s belonging, and was half-carried out by her family. And then, slowly, the chaos of the ward resumed.                 
She lay in the arms of the other woman in the hallway outside the ward, for what seemed like an hour, and cried.  I did not see her leave.

Thursday, September 1, 2011

African Safari: An Uninvited Guest

There are certainly challenges to life here in Malawi. The electricity always goes out just as we are about to leave for Date Night. Our bowels have all suffered. It is not uncommon for the entire city to suddenly be out of one of the main ingredients for that night's supper. However, there are also certainly many benefits to living here. I truly believe that the work we are doing helps improve the quality and length of life for our patients every day. My children have the opportunity to attend a school filled with people from all different cultures, where one of Eamonn's afternoon activities each week is to go to a nearby orphanage and play with babies who have lost their families. Plus, we get to go on safari on any random weekend.
We chose to leave for our first safari at 5 am this past Saturday, packing our sleeping children and near-incoherent nanny into our "new" truck, a weathered 10-seat white Pajero with benches that line the very back. The road out of town was populated with industrious people carrying buckets on their heads, burning garbage, and riding bikes. The air was cool, and the mist in front of us layered over the horizon so that it appeared as though we were driving toward the ocean. The sun rose slowly on our left, majestic and orange, burning through the
haze and illuminating the silhouetted hills that pushed through the thick fog. As we left the city we passed small villages of only a few mud and thatch houses, wells where women pumped
the day's water into bright colored plastic pails, and ox-drawn carriages filled with vegetables. Saturday is market day, and each of the villagers was bringing their goods to the nearest town, where hundreds of people gathered in groups along the roadside, selling neatly stacked piles of cabbages and tomatoes, onions, potatoes, even clothing. One local delicacy, which I finally stopped to photograph, is mice-on-a-stick. Apparently when the fields are burned in preparation for the next planting season all of the mice flee and are caught by young boys, who then skewer and (?) barbeque them to be sold, stacked on long sticks that they wave at passerbys on the main road.
We entered the Liwonde National Park about 3 hours after we left home, paid our entry fee (about $2 per person), and started the drive to the campsite and lodge. The road, while pitted, narrow and dusty, was not much worse then some parts of Lilongwe. The foliage was grey and sparse, and we passed over several completely dry riverbeds. We unrolled the windows
briefly to help spot animals, and were almost immediately accosted by large, biting (but
thankfully slow and stupid) flies that entered in droves. We began keeping count of how many each of us killed, but finally decided to roll up the windows and turn on the "a/c" when the body count reached double-digits. Eamonn kept track of the animals we spotted as we continued on, and by the time we arrived at the campsite an hour later we had seen many, including impala and baboons, although the big ones we'd been really looking for had still eluded us.
Mvuu lodge is a beautiful and rustic open-air pavilion made of hard wood and thatch, and beyond the main building the Shire river floats lazily by. We could hear the grunting of hippos in the distance as we set up our tent. The manager gave us a lengthy speech about the need to be alert, as we were truly camping in the bush, and informed us that if we were to encounter an elephant at any time, we should go back into our tents quietly and wait for it to leave. I could see my poor anxious Eamonn's pale face go a shade whiter as he spoke, and I had to spend several minutes after he left reassuring him that this was very safe and that no, no
one had died at this camp, or I would certainly have read about it in the Lonely Planet. The kids put on their bathing suits and we headed to the pool, which, it turned out, was teeming with life. So, instead of swimming, the children spent the next hour catching water bugs in plastic bottles from the water's edge. We went on another game drive before dinner, and lengthened the list of animals we'd spotted, including a herd of elephants standing in a thicket of trees eating quietly.
At one point during the drive I felt the urgent need for a bathroom, as my body had not yet completely recovered it's normal bowel function. We had come to a dead end in the road which appeared to culminate in a small village. I lay, sweating and in pain, in the front seat, while a girl of about 6 ran alongside the truck, her scabbed knees pumping beneath her tattered dress, with the joyful shout of "Aaazuuunguuu!!!" announcing our presence.
This, roughly translated from Chichewa, means "Whiiiiiite peeeeople!!!!", and we were soon overcome by a flashmob of barefoot children attempting English phrases and eagerly trying to peer into the car to see and touch the family. I stumbled, after a frantic attempt to communicate my needs to the children, to a small, three-sided brick structure with a plastic flap for privacy, enclosing a pit latrine in the dirt. Several feet below I noticed a gentle stream flowing, and held my nose in preparation for using the facilities. It was then that I noticed that the movement below me was not that of a flowing body of water, but a teeming mass of maggots. I will leave the rest of this portion of the adventure to the reader's imagination...
We returned to the camp, made dinner over our camping stove, and had just finished eating when we heard drumming from the other side of the grounds. When we investigated we found several men singing and dancing around a fire, telling stories of African village life through their music, as explained to us by the guides.  Although it was captivating, the children were exhausted, so we headed back to the tent, holding hands and using my head lamp for light in the pitch-black night. 
As we approached the tent and Dave went ahead to unzip it, I looked up to the left of our site, about 5 feet from our front door, and saw my light reflected in the unblinking eyes of an enormous (must've been 10 feet tall) elephant. He gazed at me blithely and continued chewing. I held tight to my kids' hands and said, in my best "I am an ED doctor and I am in total control " voice: "OK. Elephant.  Everyone take a step back." Aine let out a brief shriek, Malawi began to whimper, and Eamonn burst into tears, but they all calmly stepped backwards, putting our beast of an automobile between us and the actual beast. We sought out a guard, who shined an enormous flashlight at the creature and banged on a tree with a large stick, and the elephant lumbered away.  Needless to say, it took many minutes of negotiating to convince anyone to sleep in the tent that night. I myself did not sleep well, as I was still having belly issues, and was far too afraid to leave the tent to use the bathroom.
The next morning we went on a boat safari, and spent two hours cruising the riverside with a guide, spotting hippos, crocodiles, and herds of elephants, in numbers too high to count.
Later that day Eamonn apologized, clearly ashamed, for having been so afraid the night before. I explained to him the difference between being fearless and being courageous, and assured him that he had in fact shown great courage by spending the night camping in the bush, despite his fear. Adventures like the one we'd had teach us lessons in a way that we could not have learned them at home, I told him, and are one of the benefits of living in Africa. Plus, they make really great stories.