Comfortable and Furious

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 $2.00, 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 testing 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.

It is only 1 A.M 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 were unsuccessful, and so I reached 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 retrieved 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 heartbeat, 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.







4 responses to “Being a doctor in rural Africa”

  1. don Avatar

    Thank you for this. I’ll remember it, the next time I think I’m having a tough day.

    1. Goat Avatar

      You certainly have this right. I met Alex a long time ago, and he is a dedicated physican to do what he has done in Africa. Africa is a basket case, and has been exploited by Colonialism for centuries. Now, they just tear themselves apart with tribal and cival wars. I just don’t know what to think about the future of this magnificent continent.

  2. Bear Avatar

    Great article!

    1. Goat Avatar

      I totally agree.

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