Love and Some Verses

FarewellHaving lived in such an astonishing area for all too brief a time, I take away the knowledge of some moments of staggering beauty and cruelty. It is not the whole that will stay with me; indeed it never is in our strange internal worlds of myth and memory, but rather those moments of beauty and sorrow that linger. Sitting in silence in the vanishing of the day and the sudden appearance overhead of a v of sacred ibises, winging to their roosts, still faintly touched pink by the faded sun. A striped cuckoo fledgling ruffling itself in the sand, beak wide open begging for food from its poor misguided adoptive babbler parents. Driving in the early morning through a world slowly kindled into magnificence after the obscurity of night, inflamed by an orange sun, mist rising in columns from the pools. The sand which in early morning attains those soft blue dreaming shadows and buttery highlights that normally soften and sanctify snow and so transcends its nature, to conjure wistful memory and half forgotten fairytale from the weary traveler. The deep night lit by Scorpio and Jupiter and the almost absence of the new moon and all around the sound of elephants feeding and their vague forms like waking dreams.

And then there are the few moments I have penetrated into the internal worlds of my patients and seen their sadnesses and trials. Here you are far more likely to see laughter than melancholy, and some times it seems to me that I grieve more for the harsh plights of some of my patients than they do themselves. Part of it is a cultural difference, women in particular are so disempowered as to accept their philandering husbands inflicting yet another disease or injury upon them with barely a flicker of emotion, but by far the greater part is that the grief lies in an entirely inaccessible area- barricaded off from any exposure, certainly to me. The few times I have glanced across that void sit within me, bittersweet, as moments of grace and sadness.

What of me will stay behind, counterweight to all that I have taken, moments and memory of a place far removed from that I go to? I sense even now that no matter where the perplexed and viewless streams of life bear me, I will grieve this place where I have loved, which I have loved, and carry it within me, an unrequited longing, or perhaps a benediction.

So it is farewell to all of this, to the dreaming hours that hail and mourn the sun each day, to the shadows of wheeling storks circling the skies spread-winged, in fact, to all the shadows, so much more present and wonderful than those anywhere else. The high dappled shade of mopane forest with its pools of light and flickering shadows, and the deep coolness of ebony glades, and the brief looming shadow of a raptor overhead, conjuring violent protest from the starlings. And finally, to the sun itself, that frightening, fierce, astounding orb which can whisper on the skin in the cool unsullied air of morning, or deal a merciless blow come noontime. Farewell to this, and so much more.


Decisions and Revisions

P1050866It was an early morning and the leaves were gilt with the first golden light when I received the call. A hasty drive through grasslands dotted with various large impediments, including several stationary and lugubrious giraffe, brought me to a boat idling on the Luangwa. Several large and weighty cases were piled into the boat, and across the river, unmolested by hippo or crocodile, we sped. A further winding drive from riverbed through ebony grove brought me to the room and instantly I smelt the dark cloying smell of digested blood, as if lions had killed nearby and after their first gorging, passed tarry faeces all over the place. The bed was covered in dark shadows, coffee grounds the classical description, and indeed, it was exactly as if there had been a fairly explosive incident with a cafetière. In the bed lay a man, waxy and tense with incomprehension. He had been vomiting blood since the early hours of the morning and, even more sinister, passing black bloody faeces. Climbing out of his huge bed, he had collapsed, and upon resuming consciousness, called for help.

He needed to get out of there, that much was immediately clear, and so, having set the wheels in motion for this, I bustled around checking blood pressures and heart rates and getting some IV fluids sorted. Having strung these up with the aid of a torn piece of cloth tied to the mosquito net frame, the fluids started running in at pace to replace some of the blood he had lost through the night. It was a constant battle to maintain a balance between giving him sufficient fluid to maintain some kind of circulating volume, and overloading him, flooding his lungs, and so killing him. It seemed every few minutes he veered one way or the other. The numbers were dreadful.

At least five times that day I was certain that he was about to die, beyond a continual pervasive pessimism about the likely result. Nevertheless, on went the routine, fluids, check heart rate, check blood pressure, slow down, speed up, listen to the chest. The gurgling would get worse and then better, and occasionally he would wake up and say a few words, before slumping back into his pillows. He took what drugs I had; some anti acid medication, and some pain relief, and somehow carried on. At one point he got up to have another bout of bloody faeces and leaning on me with his bag of normal saline held over my shoulder, he wobbled to the toilet only to collapse unconscious on the floor, chin bleeding. I was unable to lift him, and the maintenance worker who was my assistant had briefly left to run some errand.

The time dragged by with every minute bringing us closer to his death. I sat outside the open door on the veranda in the ebony glade and listened to breath after breath bubbling up and cursed myself for giving too much fluid, the next minute checking his blood pressure and finding him to be barely maintaining enough circulating volume to keep his organs alive. So up and down with the infusion- faster and slower and faster and slower ad infinitum. Meanwhile he passed two more large bloody faeces and grew steadily paler and waxier until even his conjunctiva had no apparent colour and his face seemed no longer animated by any life force.

My only hope was that we would get him on a plane and so to Johannesburg where he could get blood and have an endoscopy to find the bleeding source. The time continued to pass. There was no information; the lodge staff were continually engaged on the phone speaking to this or that insurer. Vital signs were emailed across continents repeatedly, the numbers of a vanishing life. The plane was still not authorised. It later emerged that the two insurance companies involved spent the day arguing over who should pay for the flight that would wing him to safely, neither one willing to accept responsibility and authorise the plane. By now five hours had gone by since I had arrived, and we were only closer to a horrible death. I knelt outside, lost in despair at my inability to do anything, and overwhelming anger at the insurance companies, who by their fractious squabbling over money were allowing a man’s life to seep away.

He started groaning and moving wildly, grasping at the air, at someone who was not there and could not provide solace. I stood beside him, convinced this was it, brought him painkillers in the hope that perhaps they would provide comfort, and again, he slumped and continued, despite the odds, to live.

Word came, finally, that a plane was authorised and was coming with a medical team to evacuate him. Finally some hope, and the fear that perhaps when in sight of redemption, he would fail at last. But no, he continued gurgling and I continued in my post, now outside for a little respite from the desperate noise, now back, unrelieved. The plane proved a false dawn, some paltry excuse about not being able to carry bleeding patients. A few more hours of anxiety and fading hope and another beacon, another plane, with a doctor on board. So, into the back of a car by stretcher and over potholed road and river, bag of fluid swinging wildly from the roof, bucket strategically situated by the man into which he soon vomited a further litre of blood. Crouched beside him in the back I started a further bag of fluid; slicing the melted plastic open with a knife and tying it to the roof to swing there for a further few bumpy kilometres.

On our arrival to the airport we were greeted by the district medical officer, an august and elderly personage who failed to live up to the usual Zambian standards of politeness by refusing to shake my hand. Rather puzzled by this I took in his cohort of masked colleagues and it suddenly dawned on me that the lapse of manners and the undercurrent of bumptiously enthusiastic officialdom was due to the suspicion that I was bringing in a case of Ebola. An ungainly journey through various halls of bureaucracy later we ended up in the quarantine room- all neatly kitted out with hospital beds which had obviously not seen use in many moons, where we were subject to a long and repetitive inquisition. Finally, having been convinced by dint of repetition that this was not a haemorrhagic fever, the district medical officer deigned to give a nod of approval to my treatment plan, and seconds later, we were alone again, deep in the dusty halls of Mfuwe airport, still awaiting the ever-delaying arrival of the plane. Several false alarms later, the plane finally arrived, and with a certain amount of manhandling, the patient was loaded on the plane accompanied by a Zimbabwean doctor and nurse, still waxy skinned and shocked, but somehow hanging on to the threads of life. They took off as the sun disappeared, just as the airport closed for business, almost 12 hours after I had entered that bloodstained room.

It is not often that we as doctors spend a whole day in the company of a patient who is dying. In fact, we rarely spend a long time with a single patient under any circumstances. This enforced captivity with all the vicarious distress of the constant struggle for life, the gurgling and rattling and the silences which haunted my day, all of it was awful. What if I am killing him, what if I am not doing enough, what else can I do? There is no other who walks beside you, would that there were! The helplessness of having no solution but to keep attempting to prolong a guttering life was hard to face. And then, after having had the first plane and salvation rudely dragged away from under our feet, it suddenly seemed that perhaps we had done the wrong thing by trying to trust to the medical evacuation services, perhaps we should have just treated him as a local and shipped him to the nearest hospital, but then, they so rarely have blood. Perhaps we should have borrowed one of the light aircraft in the valley and flown him out ourselves to Lusaka. It was hard to see the right path. In the end it seemed that we did right, the next day the news that he was in the intensive care unit in Johannesburg, awaiting surgery. Yet there were a thousand endings to that day, and most of them would have taken place in a morgue in Chipata. The day ends, as it started, with hope.

Red Dust Road

Cranes 2Near the market, stacked with neat little piles of tomatoes, there runs a road. Pockmarked tar for the first few hundred metres, it runs amid speckled grasslands dotted with giraffe dozing in the early morning. The road soon goes to sand, sloping up and away from the village and in the transforming light of daybreak and dusk seems to fall away into a world of myth and possibility. It never fails to lift my weary spirits, cowed by a day of too close proximity to suffering.

Along the road, sand made gold with early light, walks a line of women- nine, ten of them; slender and upright, each with a bright chitenge wrapped around her waist, arm curving upwards to stabilise the bundled boughs resting upon her head, the other held out to the side, axe carefully tied into the bundle. Gracefully they move in convoy down the long road amid the mopane forest, and past the lagoons. Sometimes you will pass them standing in conversation, each to each, impossibly weighty burdens for the minute cast aside, heads turned as one towards the ponderous advance of a herd of elephants, as antelope unite before a foe. The danger passing on, they once again take up their loads, and tread their long and weary progress home. The men who proceed down the same road for wood tend to do so on bicycles, and so avoid the heavy homeward journey, though they have their own struggles- fully loaded bicycles are not easy to push through sand.

If, enraptured by the silky light, you continue, you will find that the road wends its way through ever taller mopane forest; at first elephant-trimmed into the semblance of an ancient apple orchard abandoned to the wild, and later grown to adulthood unrestricted by the rough predations of elephant-kind. Here sooty stems emerge from a haze of blonde grasses and the odd majestically corpulent baobab stands aloof from its lesser companions. It is oddly quiet this forest, and in the light of late afternoon, greenish gold light filtering through, only a few hornbills and the ever present sparrow-weavers intrude to stir the drowsy motes of light. The arching branches and immaculate undergrowth give it the air of some ancient place of worship, sanctified by some long lost agency and left to while away the centuries undisturbed. The occasional party of impala wander through, and emerge, blinking, on the road, as if they too have made a long and solemn journey from some far away world, softly luminous in the honeyed light before nightfall. Human agency is the mysterious force which creates this drowsy kingdom, any animals making this paradise lost their home are taken by snare or weapon, and no dead wood is allowed to lie long before being loaded on a bicycle to fuel someone’s cook fire.

Further along, if you take a certain turning, and continue until you feel you must be hopelessly lost, you reach a clearing of vivid green, and there, on the right day, at the right time, will be hundreds of crowned cranes, head down on the hunt for frogs, or nodding rhythmically to one another in courtship. As you venture closer, some of them fly over the heads of their companions, long white wings outstretched, gold crowned heads extended. At a certain point in the year, you might catch them all in courtship displays, for though faithful to one mate, every year they go through their ritual dances to reaffirm their affections.

Deep into the wood the road continues, and I have not yet reached the end. Perhaps I never will.

A Darkling Plain

darkSome days it feels as if my frame can barely encompass the overwhelming tension held inside of me. Yesterday was such a day. It had all the ingredients necessary for disaster; the swiss cheese holes that management-types are so keen on discussing were neatly lined up to allow whatsoever catastrophe to occur: the nurse meant to be in clinic tied up with a delivery; a huge waiting room full of people; my translator occupied cleaning an infected gunshot wound, and a cry brings me to the first emergency. The girl was 16, and in the last stages of exhaustion, barely able to breathe, with oxygen saturations dipping, and heart thrumming along at a tremendous rate; cue that ordinary kick of adrenaline, and the possibilities and probabilities whirring through my head.

Sign and story were unfaithful. She couldn’t speak; too busy gasping for another breath. She was asthmatic, according to a teacher, and had been well until that morning. Her chest did not give much away, too much choking and coughing, and perhaps she was too far gone to give any clues, or perhaps I was too panicked to hear them.

Now, to give you an impression of our available resources in the clinic for such a case- we have no oxygen, no inhalers, no nebulisers, nothing necessary to provide an airway. She swallowed some salbutamol tablets, and I started an IV infusion of a rather nasty drug which is all we have for acute asthma. Meanwhile, the exercise books we use as patient records piled up awaiting my attention. The gunshot wound festered in my consulting room.

The girl was not feverish, and had no symptoms as far as we knew, other than the terrible choking and gasping for air; I did not even consider another cause for her symptoms. Luckily, someone was around who had experience (if not training), and tested the girl for malaria despite the seeming lack of any indication to do so. Of course she was positive, and suddenly it all appeared in a different light.

Malaria can give an appalling acidosis if severe enough, and cause patients to hyperventilate. I had however never seen a malarial patient in quite such severe respiratory distress. The IV quinine began to run in and gradually her breathing settled, but she only became more confused and delirious. Deteriorating, she was eventually ferried off to hospital in the ‘Voluntary Male Circumcision Campaign’ jeep, the ambulance being otherwise engaged. So, having narrowly avoided (entirely due to the efforts of an untrained volunteer) letting a young girl die, on went the day. The notes were by now towering on my desk, and I must admit to telling a teenager who came into the room complaining of ‘ah, madam, I am not sure’ to get out and come back when he was sure.

A floppy seven year old tottered in, a parody of ill health, eyes half closed and falling to the ground every few steps. I carried him to the paediatric ward, and IV line in hand, pricked his finger for a malaria test. He had been left unwell in his house for several days, and looked as if he was done for. Another IV infusion of quinine started. Another case of severe malaria followed, this time deteriorating despite treatment and again confined to the ward and IV quinine.

Two people came in vomiting blood, and by now there was little ward space left and outside was a mass of sweaty humanity. The child was only worsening, fever now well into the forties, and barely rousable, he lay on the bed. Awaiting the ambulance (after some bargaining with a local health committee who were in attendance, but refused to take the child to hospital- it seems management is the same everywhere) more and more patients came through my door, some with trivialities, some with stress or grief disguised as ‘palpitations’, and the occasional light relief of a pickaxe wound to stitch. The day ended, as they have a habit of doing, one of the more difficult I have had here.

Sometimes the weight of the decisions taken, and all the compromises and misunderstandings seem insurmountable. And yet in sadness there are always consolations, a woodpecker taps on a branch and the next day comes, a Bateleur soars over the plain in his usual wobbly way and all goes reasonably to plan, and a brief bit of success cheers me on my way through a week in which I can barely catch my breath. A young man whom I had sent to hospital the previous week with a provisional diagnosis of leprosy did indeed turn out to have leprosy, and will now be cured of it- even the most grievous days have their successes.

Morning and a Monologue

LeopardLet me try and lead you further into life here, the spectacular presentness of living things. It sounds odd, because where is that not true, but here, sitting at my usual station, hair dripping from a cold shower, accompanied by a frog who shares my taste for this prospect, tea cooling as I contemplate the day; I am surrounded. Ants stream past my feet; a fallen mopane tree grows stealthily onto the veranda; cape turtle doves call ‘work harder, work harder’; an emerald spotted wood dove nods past, her iridescent fingerprints of colour glancing as she turns this way and that; an impala delicately picks his way through the bush, gleaming flanks catching the still early light; and sometimes, on a lucky day, an elephant silently emerges into the clearing and I am transfixed, barely breathing as he ponderously strolls past.

Sometimes it feels so mythical an aspect that if it were not for the deflated tractor sitting askew to one side, I must soon hear a noise of horns and hunting heralding Diana after an antelope, or perhaps a centaur solemnly parting the branches into the clearing. As it is it is hardly less magical. A vervet monkey sometimes comes and sits by my chair, regarding me, tilt-headed, with that peculiar mix of unconcern and ownership that they tend to affect. If I am foolish enough to venture inside he will promptly come and steal my breakfast, leaving bowl and cup as relics of a riot splintered over the floor.

Inside my sleepy little cottage, scorpions lurk undiscovered, and much time is spent in the shaking of clothes and the lifting of pillows, in order to avoid a sting that by all accounts one can do little to remedy, other than to take to bed with a large bottle of whisky and a muddle of painkillers and hope for oblivion, at least until the venom has worn off.

Occasionally a bat joins me for the night, and swoops around somehow managing not to get tangled in my hair, harvesting the various flying insects tempted in by the light. Cocooned in white netting, I am insulated from most of the night’s intruders, until moonlight streams in on full moon nights and wakes me to the hue and cry occasioned by a local leopard. Later, the regular squeak of a hippo’s teeth on grass will lull me back to sleep.

And then again to the morning, when light filters in pied by the leaves and it seems impossible to remain abed with all the birdsong and everything drenched in golden light. But I digress, and patients are waiting, so off I go into a new day, and so, I suspect, should you.

These Vanishing Endings

vanishing endingsOne of the hardest things to deal with here is the attitude to death, or more accurately, the attitude to preventing death. There is a fatalism here which one can understand, given the limited options people have when confronted with disease or injury. However, this attitude seems to have extended far past any merit it may have in enabling people to deal with disasters philosophically, and must be responsible for countless deaths and disabilities in people who would have been retrievable, had they been attended to early in their illness. Of course, it is only one barrier to care, and there are many others of equal or greater importance, but in my experience it is the most distressing, being so unnecessary.

The instances of children that are carried in deadweight in their mothers’ arms, far too late in the course of their illness are understandable at least in an intellectual context (if not an emotional one) in the light of all the barriers to care, education and money being the greater and more obvious of these. The attitude of my colleagues at the clinic upon being called to treat an emergency is however less easy to understand. In all the disparate emergencies I have attended the lack of urgency in treating patients has been staggering. Recently one of my malarial patients, a 21 year-old man, stopped breathing whilst I was starting treatment for what was probably cerebral malaria. The nurse who came in to assist me did not seem to understand that this was an emergency despite my panicked cries for help, and ambled back in what felt like a lifetime, bag-mask in hand with which to ventilate him. Luckily he had fairly shortly started breathing again, and survived, at least as far as the hospital. When patients are admitted to our little wards, care is often not initiated because ‘the patient looks hungry’. I have not quite managed to get a satisfying explanation for this novel theory of care yet. Sometimes ‘the patient looks hungry’ means that care will not start until the next day, and given the speed with which some of the malarial patients deteriorate, (to give an obvious example) this may mean the difference between life and death.

Another striking illustration of this fatalistic attitude came upon my hearing of the death of the woman who exsanguinated. The sister in charge of the clinic, (who resembles nothing so much as a distempered bullfrog) smiled at me, and baldly stated ‘now you know our culture’. Not being able to share my sorrow for the patient we had failed, and for those like her, does not make this job easier. Of course, the nursing staff is inadequately educated, and doing what is essentially a doctor’s job under extremely difficult circumstances, aided by a series of volunteers who have no formal education, and who too often end up doing the job of the nurses themselves. So on consideration it should not be surprising that this is the case. Perhaps these attitudes are merely a protective mechanism against the realization of our helplessness when set against the onslaught of death and disease. Even in the relatively middle class families here, many children die, and whole families are thrust into the care of their aunts and uncles when orphaned by HIV. Such a large weight of sadness must to some extent engender an enforced contempt for the sanctity of life.

The paradox is that death itself, after the fact, is taken very seriously, at least for a brief period. Stems of trees punctuate the road where the dead person lived, and driving past, one is supposed to proceed funereally slow, and cyclists will dismount and walk past. Funerals themselves are astonishing displays of public grief that go on for hours, with hoards of people crammed sitting straight legged and straight backed on the floor. During these drawn out affairs, amid the ululating, much is made of telling the story of the death, and showing that everything that could have been done was done. As I have mentioned previously, one can largely die of two causes here, Chifuwe (cough) and Not Enough Blood, so no wonder people are concerned when they come into clinic with a mild cough, and demand a pharmacopia of drugs.

It is of course easy to judge a culture from outside, whilst ignoring the inadequacies and hypocrisies of ones own. I have long thought that we over combat death in the Western world. Sometimes a dignified death is better than a few more weeks of drug-marred life. Perhaps a balance between the fatalism of Zambian society and the can-do excess of the Western world might help in both places.

A Sober Interlude

MushroomsThursday every other week brings the mobile HIV clinic who occupy the maternity side of the clinic and who work systematically through an astonishing number of men, women and children assessing peoples medication, wellbeing and prescribing ongoing antiretroviral treatment. The whole of that side of the clinic is a hoard of people and bicycles. The arrangements are basic; four or five patients to a cramped clinic room with a doctor and three health workers. Sitting shoulder to shoulder doesn’t allow a great deal of confidentiality nor any but the most cursory examination. Despite (or indeed, perhaps because of) these difficulties they blaze through the masses and people go away counseled and treated and hopefully safe for another three months until by the late afternoon the patients are gone, and all that is left is the odd half chewed mealie.

In contrast to my experience working in Swaziland ten years ago, the acceptance and awareness of HIV is astonishing here. In the paediatric ward at Mbabane hospital in Swaziland, the word HIV was not mentioned, other than by one renegade doctor, who would whisper it as an aside every time another dying toddler came into the ward. Here, whilst people do not volunteer their status, they do not baulk at being asked, and most people seem to get tested at least reasonably regularly. Indeed, if you ask about medical history, people assume that you are just asking their HIV status. I suppose the advent of accessible treatment has lessened the stigma enormously.

There is still some way to go. Today in clinic I saw a woman brought in who was delirious from malaria. Along with the malaria test I did a blood test for HIV, as she looked so very unwell. She tested positive. It later transpired that her husband had been tested long before and knew he had HIV, but had not informed his wife. A more heartless attitude is hard to imagine, particularly now that treatment is available free of charge to everyone here. Unsurprisingly by this time she was so immunosuppressed she was vulnerable to all sorts of normally benign bugs, and in desperately poor health.

Whether the severity of her malaria owed anything to her AIDS diagnosis is unclear. The effect of HIV on malaria has been insufficiently studied, but it seems that there is in interaction both ways- i.e. not only does HIV increase the clinical severity of malaria, particularly in women who are pregnant or in those with severe immune suppression, but malaria parasitaemia may also increase transmission of HIV, though the mechanism is not yet understood.

Occasionally testing people leads to unexpected (and rather undesirable) outcomes, such as in the case of a young chap I saw recently in clinic who I was treating for a veritable cornucopia of sexually transmitted diseases. Having somewhat reluctantly consented to having an HIV test, he returned some time later with a negative result, dancing around the room in delight, grabbing enormous numbers of condoms from our stash, claiming in dismay that there were not enough, and finally marching out of the clinic with undisguised intent. I fear we may well be seeing a little epidemic of STDs in the near future…