BEING A DOCTOR IN RURAL AFRICA

Rural Kenya in winter is colder than one would expect, even when
you are from Wisconsin. There is no snowfall, but the high humidity and
the cool air after sunset seeps away any warmth that has not been
instilled by alcohol. There are no streetlights, so after 5pm, when the
sun slips behind the tea plantation-pocked hills, it is impenetrably
dark. The hospital where I am working is effectively isolated from the
rest of the world. The phone works rarely, and the internet connection
exists only in theory. Deep within the countryside, there are no stray
noises apart from the occasional cow wandering through hospital
grounds. The dim silence is unnerving enough to make me wonder why I
wanted to volunteer here.

The town of Maua is a crowded and dirty place in the Meru district,
about 130 miles from Nairobi. It is a wide spot in the road flanked by
a dense concentration of shacks containing businesses, barbers,
groceries, restaurants, and junk shops, with piles of burning
garbage scattered throughout. The most numerous of these are bottle
stores, known to westerners as pubs. Men fill the bottle stores, and
their bingeing spills out into the muddy streets. Drunken
arguments in Swahili sound pretty much the same as their English
equivalents, veering rapidly between love and belligerence. During the
day people sell random items from blankets by the road. Some are
useful, like cheap radios, clothing, and machetes; some useless, like
used batteries charged with a single volt for resale to the unaware.
The machetes are made from the leaf springs of larger cars, so they are heavy and easily able to divide skin and bone. For the hefty price
of US$2, you can have your very own, stamped with the words
“Specially Made for Children”. My hospital specializes in tendon repair
and internal fixation for near-amputations. We average six of these per
day in a town of perhaps ten thousand. Usually the victim, often a child, has been caught
trespassing in a miraa field.

Miraa is the primary industry. It’s an amphetamine in the form of
a
green stalk that has been denuded of its drug free leaves. A clump of
fifty can be
yours for 500 kenyan shillings, enough to do a week’s shopping for a
family of four. All the men in this town chew miraa, their eyes a blank
slate of suppressed anger. The women do not chew miraa, nor drink.
Women do the cleaning, the farming, and child rearing. The men tend the
cattle by tradition, although there have been no cattle in Maua for
decades. All day and night, giant trucks speed through the town,
hauling miraa and occasionally flattening a child or errant goat.

Maua is a small cauldron of discontent and dreams unrealized, much
like small towns in the United States. HIV made its slow burn through
here long ago, leaving an infection rate of about one in ten. Commerce
is slow, progress nonexistent in a place where inertia has trumped the
flow of history. The people of this area do not appear to mind the
gradual decline of rural Kenya over the past two decades. Optimism and
skepticism are irrelevant when it is one’s appointed task to simply
endure. At least, this is the way it seems to a tourist like me.

I am working at a mission hospital, which is better in quality than
the government funded Meru District Hospital. We have some laboratory
test and X-ray capability, which is uncommon in this area. The
hospital’s resources are stretched thin, wards perpetually stuffed,
every bed filled with two people and mats on the floor for the more
stable patients. At night, the ill and destitute
sleep in almost complete silence, stirring to swat the occasional
mosquito. The overworked physicians are getting some much needed sleep,
as medical students like me are around to staff the casualty during the
night. I am here to learn medicine as my trade, with idealism as my
ballast.

Some nights I am bored to the tits, reading Swahili vocabulary and
trying to sleep. This night, however, starts off with a mother bringing
in her child, perhaps two years old, and obviously dead. The body is
stiff, eyes staring sightlessly, pupils dilated to the diameter of the
iris. No heartbeat, no spontaneous respirations. Its belly is swollen
with kwashiorkor, a protein deficiency of malnutrition. There is money
in this town, but it does not go to food.

I inform the mother through a translator that the child is quite
dead. They take her to another room to grieve, and summon the priest on
call. The priests generally don’t sleep very well. An urgent phone call
comes in – a child is dying in the pediatric ward. I sprint over to the
ward to see if my inexperienced presence will be helpful. This child
has severe malaria and, as a result, only one fifth of his blood supply.
Malaria can be an aggressive disease in those least able to fight back,
and this child just made it to the hospital too late for the treatment
to help. His agonized breathing stops and his heartbeat soon follows.
The children in the other beds look in my general direction, faces a
mixture of fear and curiosity. I avoid their searching glances, as I
know some of them will die before sunrise.

Several patients are waiting for me in casualty. The first two have
minor complaints, and are quickly sent on their way. The third is a
woman sitting quietly, and not complaining of anything beyond abdominal
pain. A pregnancy test is sent. I return to her room to inform her
she is pregnant and find her nearly unconscious on the floor,
whimpering. A needle plunged into her abdomen yields blood suggesting a
large hemorrhage from a misplaced pregnancy that has ruptured her
reproductive organs. The OB-Gyn surgeon is summoned, and the patient is wheeled
to surgery with a bag of malaria-infested blood for transfusion. It is
disconcerting when someone looks perfectly fine one moment
and the next are on the edge of the mortal plane. For some reason,
African patients have this in common, showing few signs of illness
until on the verge of death. There is no explanation for this, other
than perhaps a lifetime of pain and abuse tempering individuals to
withstand almost anything. Materials so tempered become hard, but brittle.

doctorafrica

It is only 1am and I am beyond tired. The previous morning was
spent scrubbed in for several hours of surgery to debride a leg wound a
farmer gave to himself with the dirty end of a farm implement. He had
walked to the hospital from several miles away with a large abscess
that proceeded to blow open during his hike. People here will walk for
miles to reach a hospital. A week prior I helped fix a leg fracture
that a woman walked upon for at least two miles, dragging herself
the last several hundred feet.

Next up is a perhaps three year old child who has malnutrition and
looks dead. He isn’t moving. Upon a closer look, he is just
avoiding movement or making sounds, his eyes wide with fear, mouth
agape. Trying to move his neck elicits a weak cry. Meningitis looks
like this, and kills in a matter of hours. After I put in an IV and
start the antibiotics, it is off to the pediatric ward with him. His
chances of survival are about half, with a good chance of residual
brain damage. The next five hours are utter torture, with dead
children, surgical emergencies, and women in labor. The patients
waiting to be seen in casualty pile up endlessly.

The last child brought in sometime before sunrise had some sort of
pneumonia, but my thoughts end there when she stops breathing in front
of me. Standard therapy is to intubate the child and ventilate her
after a few attempts at rescue breaths. The rescue breaths are
unsuccessful, and so I reach for the intubation equipment. The power fails, leaving me to flail about in the
dark. Power outages and surges are common here, but the timing of this one could
not be worse. I retrieve the tube and a headlamp and turn to find the
child vomiting – her airway would now be compromised.

I call for “Suction!” in a dramatic manner. The nurse retrieves a
medieval looking machine out of a cabinet that provides suction via
foot pump, and promptly leaves me alone with the child. The process of
intubation is fairly difficult, particularly for a medical student with
little experience. It’s made much more difficult by trying to operate
a foot pump, suctioning vomit out of a child’s throat by the dim light
of a headlamp and looking for the vocal cord target whilst a mother is
looking on expectantly. After what seems an entire football half, and
four failed attempts, the child is intubated, and ventilated. She
is also dead at this point. There are times you can look a family
member in the eye and inform them that their child is dead, but this is
not one of them. I give the bad news to the floor while the nurse
(now back in the room) translates. I return to the casualty room with
what is left of my confidence to find yet another apparently dead body
waiting for
me.

A family of five struggles to hoist this forty year old man onto
the examination bed, and he is unresponsive. At first, I am resigned to
going through the motions to confirm death, but he has a faint heart
beat, and shallow breathing. They could tell me little about him except
he is taking a medication of some sort. He is quite fat, which is
unusual for this area. I inject him with sugar on a whim, and within
two seconds, he is off the bed and thrashing violently. After the next
shot he is merely confused. The unknown medication he was taking must
have been for diabetes, and his prescribing doctor must have overdone the dose. I
take some comfort in knowing that Lazarus would recover after a few
days. A success story ends my evening. Now, it is time to begin the work
day proper.

The morning sun does little to invigorate me as I trudge to the
pediatric ward to begin my rounds. My mind swims with the faces of
those left behind in the night. Real or imagined accusations seem to be
in every pair of eyes I meet in the hallway. I would later learn to
avoid reflecting immediately on disastrous shifts like this. As it
turns out, regret has a very long half life, and is more than willing
to wait until you have had a decent amount of sleep.

The hospital begins its daily hum, the theatre is beginning its
daily surgical schedule, and the casualty fills with its usual endless
line of illness. Outside the hospital grounds, Maua begins its day just
as it always has. The petrol station already has miraa trucks queuing
up for the road ahead. The bottle stores and businesses open their
doors, and blankets are spread by the roadside to hawk miscellaneous
wares. The town is saddled with more than its share of misery, yet
balanced by an inexplicable fortitude that seems to be uniquely
African. Unique, at least, to someone who has a great deal to learn
about the vast regions of the world in which survival is a daily
struggle.

Looking back with the benefit of a few years experience, I am not
convinced that my work in Kenya made the slightest difference. In an
area of intensive poverty, not much can. Perhaps a rare correct
diagnosis, maybe even a few saved lives, possibilities that grant me a
great deal of undeserved credit. Local life expectancy is 49, and
likely any victory I can claim has since been swallowed whole by the HIV
epidemic, starvation, and environmental disasters. The idea of
improving community health is a feeble one compared to unfair,
international trade agreements and the corrupt rulers who pocket
international aid. My good deeds give these systems that much
more latitude.

From the outside, Africa does not stand a chance. The only
continent to fail to progress in the last century, its people seem
destined to a long slog through history. Western Africa has been
wracked by unrest fomented by outsiders. Central Africa is home to the
world’s longest running and bloodiest war. Southern Africa remains the
epicenter of the greatest plague ever. Even wealthy South Africa, with
the world’s most liberal constitution, is overrun with bizarre and
violent crime, and rape is the unofficial national pastime. Yet, there was a
time I believed in saving Africa.

Having shed the catharsis of volunteer work, I later return to
Africa with an entirely different perspective. Africa requires no
sympathy, and certainly no white knight savior. The continent as a
whole would enter a new economic renaissance if it were left
alone, without foreign interference. The way I see it, I am simply
trying to return the area where I work back to a normal state of
affairs.

Credit for any victory here is due only to those surviving on the
edge of existence, powered by faith. I use this word with no
religious overtones, as it means simply belief without evidence. There
is no other word for how a child can watch its parents die of AIDS, and
yet retain the ability to smile, looking forward to sunnier days.

6
SHARES
About Alex K.

Alex is an actual medical doctor. Really. At a hospital and everything. We don’t know what he’s doing here, but he writes good reviews.