. . . because even this first patient after Sofia’s departure, just this morning, worries me greatly.
He lies feverish, a halo of sweat darkening the sheets around his young body. His family watch closely; mother and two brothers from where they share his single metal bed, father from the floor where he’s spent the night. They watch his chest rising slowly under a sheen of sweat, and they sponge him often with an old cloth. And they do it with such hopeful attention that they don’t react to the dozen of us crowding around.
‘How was he during the night?’ I ask, as the father shifts their belongings for us—pot, enamel bowls, a box of matches.
‘The same,’ replies one of the health workers. Isabella, the blue-eyed Italian nurse, translates for me. ‘He had some diarrhoea this morning, otherwise nothing. His parents say no change. He is not any better.’
‘And his fever?’
The health worker flicks through the chart. ‘It was down a little during the night,’ he says. ‘But now it is back up.’
The boy remains deeply comatose, unresponsive to any stimuli. His risk of dying from cerebral malaria, the condition we think he has, is significant. If that’s what he’s suffering from. It’s a presumptive diagnosis—a likely one given the incidence of malaria out here—but without further tests we can’t be one hundred per cent sure. The blood test that we have here for falciparum malaria, a plastic strip that looks and works not unlike a home pregnancy test, was positive in his case, although that in itself doesn’t confirm the cause of his coma. Either way, we’re treating him for severe malaria; the quinine infusion was started as soon as he arrived last night. I now pull out my tropical medicine handbook to re-check our dosages, making sure we’ve not forgotten anything. We haven’t. We’re doing everything—everything that we can do out here, that is, because consider the context: this boy is in Intensivo, our ‘intensive care ward’, which isn’t too different from any ordinary brick room. Four single metal beds crowd along one wall, a hazy fibreglass window opposite. His quinine infusion hangs from a nail on an improvised wooden stand, and there will be electricity for lighting for just four hours this evening when Pascal runs the generators. There’s little else. No machines, no oxygen, no electronic equipment—just a small cupboard with essential medicines. A little misleading then to call this Intensivo, I’d have thought, but the set-up means that patients can be watched more closely; two health workers will be able to concentrate on a maximum of four patients here, as opposed to the eight or more cases in each of the other rooms. Sofia assured me that’s a big advantage. And what then of referral to a bigger hospital—like one with oxygen? No chance. The only hospital larger than ours in this province is in the regional capital, Menongue—a run-down, former ivory trading centre that’s a two-day journey by road, and where the wards are even more poorly equipped. Flights too are out of the question. The little Cessna that MSF charters to fly us out here is a five-to ten-thousand-dollar round trip, even without medical equipment or nurses on board. There’s no guarantee, either, that the family will be able to afford the cost of treatment elsewhere.
So for now we continue with the quinine. And cross our fingers, because we’re this boy’s only option for medical care. A thought that frightens me.
‘His IV bag looks new,’ I note. ‘Has it just been changed?’
The health worker nods.
‘Great. So how much quinine are we giving him through it this morning then?’
He rustles through the patient’s papers. Along with eight other health workers, all men, he’s one of the clinicos—the seniors that work at a level somewhere between a doctor and the enfermeiras, the locally trained nurses. He says nothing.
‘It’s on the drug chart,’ I say. ‘Manuel, isn’t it? Your name? Good! It’s on the drug chart from yesterday, Manuel. We wrote it at the top.’
Isabella translates, but Manuel says nothing.
‘Does anyone know how much quinine we’re giving him?’ I ask.
No one replies.
‘What about the enfermeira? The one who put up this morning’s bag? Is she here?’
Again, nothing.
‘So how can we be giving him the right dose if no one knows what the right dose is, or how much he’s getting right now?’
Silence.
Why no answer? Perhaps I’m misunderstanding the work manner here. Sofia did this, though. She asked them things. I’m also sure she said that the clinicos looked after all the infusions and other aspects of treatment, the doctor having only a supervisory role, but we really didn’t have long to spend on staffing arrangements during the handover. Seemingly endless files accounted for most of our time together—spreadsheets for drug orders, staff rosters, monthly reports, six-monthly reports, TB treatment registers, vaccine stocks and adverse outcomes reports, among others—so I’m not entirely clear as to the exact set-up on the wards. And maybe these health workers don’t understand what I’m asking, because they’d surely know how to give an infusion. Or would they? Isabella thinks so, but she’s normally in Outpatients.
‘So who’s supposed to be checking how much quinine we’re giving him?’ I ask.
Again no one answers.
‘Someone must know. Please—this is not easy to set up, this drip. Someone’s done it, and very well. They must know the dose.’
An awkwardness is growing but I’m not trying to embarrass anyone. I just need to know that this child is getting the right treatments. Malaria is one of the few tropical illnesses I have reasonable experience with—the clinic in Thailand was rife with it—and the issue now is that quinine is extremely toxic if given in too-high doses. Too little, and the malaria will progress.
‘You are checking it, Novo Doctor,’ says Sergio, the head clinico here. He’s a short man with closely clipped hair and unusually soft facial features in comparison to those of other locals. O Novo Doctor—The New Doctor—is what people have been calling me since my arrival.
‘You are checking the infusion,’ he says.
‘Sorry?’
He chats with Isabella for a moment.
‘He says that of course you should be checking this,’ she translates, ‘because you are the doctor. He says that this is your responsibility. He says that surely this is why MSF sent you, and that you should know this.’
‘Hang on, tell him I’m not pointing fingers. Tell him that I’m just trying to work out who does what on the wards. And tell him that I’m still a little confused, because if the enfermeiras give the drugs, and the doctor supervises treatment, what exactly is the role of the clinicos?’
It’s an honest question that’s immediately misconstrued. Sergio shakes his head and speaks with the others.
‘I think something’s getting a little lost in the translation,’ Isabella says, winking to me. She adjusts the infusion herself. ‘I’m not quite sure, but I think we may be stepping on toes here. Let’s just move on for now, hey?’
We do. We review the two other patients in the room—an infant with pneumonia, and a woman receiving a blood transfusion for post-partum anaemia—and step outside.
• • •
The hospital itself is a series of freestanding, single-storey buildings, dotted around a football pitch–size compound. Some parts are well planned, others an afterthought. Although clean and neat—the exterior of each structure is painted in either soft blues, pale yellows or dusty pinks, a welcome splash of colour against the dreary landscape—it’s likely only a few storms away from collapse.
Walls are sturdy brick, but doors are flimsy and roofing’s a problem, the latter a greying, silver patchwork of metal sheeting fixed to a rickety wood-pole frame. Much of the basic structure had been here when MSF first arrived but had required extensive rehabilitation—a task duly carried out, albeit under the assumption that the project was short term. Four years later, it’s still seeing three hundred patients admitted to its wards each month, another two thousand filtering through the outpatient rooms. The current plan is for MSF to close it at the end of the year and hand responsibilities for health care over to the town’s Administration, who’re working on a new hospital about a kilometre up the main road.
We step from Intensivo into the rear courtyard. A low sun and calls of Toto! greet us; our onomatopoeic resident is up. Clothed in bright red jumper and black pants, he’s surveying the passing world from his tent, here in the sandy centre of this quadrangle of inpatient buildings. The location appears to suit him well. His white canvas home, along with the identical one beside it—shared permanent residence of a blind albino woman who’s riddled with skin cancers, and her demented mother—couldn’t possibly be better positioned for people-watching.
Immediately ahead of Toto are the general adult and children’s wards, a long, yellow building in front of which people congregate in the afternoons. Looming behind him are Intensivo and Outpatients—a single block of rooms that partially separates this space from the hospital’s front courtyard, and around which new patients will shortly be queuing. To Toto’s left, smoke curls gently from the tin-walled kitchen hut, beside which the malnutrition ward stretches, while to his right, a young mother feeds her infant on the steps of the maternity and delivery wards. All of which places Toto at the epicentre of hospital life. A fact he seems quite happy with, peering ceaselessly from his floppy white door.
The clinicos chat with him—
‘Morning, Toto. Oh, yes, we are good. And how are you? Very good. Oh yes—it is cold.’
—carrying out something between imaginary conversation and normal dialogue as Toto’s are called back in appropriately varying tones. There’s calling from our right side, too, where Portuguese with a heavy German accent can be heard against the backdrop of periodic moaning: Andrea and the Angolan midwives are coaching a woman through labour. But we pass their pink building, step around Toto, and enter the first room in the long, yellow block at the back of the hospital. The general paediatric ward. And it’s now that I brace myself for the inevitable: a punch to the sensory cortex. A wake-up call more powerful than a hundred coffees, and an odour so pungent it literally takes my breath away. The smell of unwashed humanity confined to too small a space.
Sixty or more people lie in this dim hall of a room this morning. Two dozen patients and their attendant relatives, all on or beside the two dozen beds along the walls. Mothers have shut tight the windows and doors overnight in an attempt to stave off the bitter cold, instead locking in the stale air of the crowd—many of whom are suffering from vomiting and diarrhoea. The air is thick, utterly nauseating. Sergio orders the windows to be opened.
People stir as we enter. Some are eating, others chatting, many lying listlessly, but mothers are all up, and breasts of all shapes and sizes have been urged from beneath layers of clothing to feed hungry mouths. Most children appear delighted with the novelty of a new, different Branco (white person) in their midst—this short, untanned, shaved-headed specimen—although not in all cases. A handful are frankly upset. Glances their way prompt only fearful moans, with one young boy opting for a more decisive bolt out the door.
‘Little Pedro Neto,’ begins the clinico, as we gather around the first bed. ‘He is one year old, from the village of Seixta-Feira. He arrived yesterday. His diagnosis is malaria moderada’—moderate, as opposed to severe like the patient in Intensivo—‘and diarrhoea.’
There’s not much to see of little Pedro from here. Light seeps weakly through the few windows, and most of Pedro’s face is hidden anyway by a colourful, oversized beanie, his body wrapped in several layers of baggy garments. His carer begins to undress him as we talk, and what’s left a couple of minutes later is a pile of garments twice the size of the skinny body they covered. In fact, the dress in general is distinctly more Scandinavian than African in here. Staff too wear thick, warm tops over their lab coats, again in that mishmash of styles that seems to be the rule, with many in woollen hats as well. Patients and carers are often not as warmly dressed. Most wear Western clothes nearing the end of their days: pants that have been repaired and re-sewn, then re-worn and re-repaired with other pieces of fabric; shirts—torn and glued, now stitched to other bits of old shirt; and nylon ski-jackets, fluorescent and gaudy and completely out of place in the African savannah. Footwear is a luxury many do without.
We examine Little Pedro, who appears delighted with all the attention he’s getting. No new problems overnight, says Carlos, who’s looking after this ward today. Pedro’s fever is down and his feeding up, so he’ll likely be discharged tomorrow, after the last of his three days of curative artemisinin injections.
‘And his mother?’ I ask. ‘Will she come here before then?’
Carlos looks confused.
‘The mother,’ I say. ‘A mãe. Where is she?’
Quizzical looks are exchanged among the staff.
‘That is the mother, Novo Doctor,’ says Carlos.
‘Seriously? It can’t be—she looks far too young! That’s surely his sister, no?’
‘It definitely is the mother,’ says one of the enfermeiras. ‘I know her family.’
‘Really? How old is she?’
‘Fifteen,’ the answer.
But I’m right to ask the question. Many children are indeed being looked after by their older siblings here—brothers and sisters aged eleven or twelve—because the mother has stayed at home to look after others. I soon learn to stop asking the same question for the other end of the reproductive spectrum, though. ‘Tell the grandmother . . .’ I begin on two occasions, only to be corrected that the heavily wrinkled, aged-looking woman in front of me is in fact the mother—and a mother in her mid-thirties at that. It appears that marriage followed closely by motherhood in one’s mid to late teens, all the while tilling fields, grinding grain and ferrying endless loads under a tropical sun, is a potent accelerant of the ageing process.
For hours we continue like this: I ask questions, Isabella translates, confused looks shoot back. I stop to jot down things to address, and after two hours there’s still more than half a hospital to see. But the paediatric cases at least appear straightforward. Chest infections, malaria, diarrhoea—or any combination of the three—account for most admissions, and almost all children appear to be responding well. Where treatment is being given appropriately, that is. What is particularly unusual though is that all those with diarrhoea, essentially the entire ward, have been prescribed an antifungal drug. A relatively safe medication, albeit a strange and entirely unnecessary one.
‘We always use it for diarrhoea,’ the clinicos explain. ‘In Mavinga. Always.’
‘Why?’ I ask.
‘Because we give it, and they get better. That’s how it is.’
‘But have we seen what happens if we don’t give it?’
‘Why would we do that?’ asks Carlos. ‘It works.’
‘But what infection are we treating with it?’
Sergio sighs loudly. ‘So many questions, Novo Doctor!’ he muses.
‘Sorry, Sergio—I’m just trying to understand all this.’
‘And yet you have so many new ideas for us?’ he says, a clear change in his tone.
‘Not at all. I’m just trying to make sure I understand everything. No point me being here if I don’t know what we’re doing, yes?’
He turns to the others. ‘And this is only the first week for Novo Doctor,’ he notes. ‘The very first day! Is every round to be like this, I wonder? Are we to be questioned about everything?’
I’d been cautioned about this. They warned me during my briefings in Geneva to avoid the compulsion to rush in and change things, or at least to wait until I had a good understanding of the context before doing so.
I back-pedal. I tell Sergio that he’s right, but that I’m not blaming or accusing anyone. ‘Many things here are different for me, Sergio. A lot of this is new and confusing, so I please need for you to explain it to me as we go, okay?’
Isabella translates. Chuckles ripple through the room as Sergio adds something quietly.
‘What’s he saying?’ I ask.
‘You’re not going to like this,’ she replies. ‘He’s saying that of course you’re confused. He says this is because you don’t speak their language.’
Vacillating somewhere between embarrassment and anger, I take her up on her suggestion of a short break.
• • •
By late morning the sun casts a welcome warmth over the compound. People move outside. Roosters wander in at the front entrance, but our guard shoos the goats away. Security is tight. And the hospital’s really starting to come to life now; kids play while women hang colourful squares of laundry along available hospital fence, and a more substantial pall of smoke billows from the kitchen in preparation for lunch. Bath time, too: a young girl’s being washed outside the malnutrition ward in a plastic tub, her head a turban of soapy bubbles.
I prefer it out here.
It’s now our second break from the ward rounds, a couple of hours since we finished in paediatrics. Since then, I’ve fielded two requests for annual leave, marvelled at the leopard-attack survivor’s progress on the men’s ward, winced at the low rumble of a distant detonation by the de-mining team, and been called to the laboratory to ponder a finding.
‘You see it?’ asked our lab tech, a lanky, middle-aged Angolan. He works in a small room near the front entrance, equipped with only a single microscope and small shelf of supplies.
‘See what?’
‘The oval thing,’ he prompted.
‘Oval?’
‘Yes.’
‘Where?’
‘All over. There are many of them.’
What I did see was a kaleidoscope of colours, shapes, and fibres of plant matter, glowing in the sunlight reflected by the microscope’s mirror. Could’ve been modern art, for all I could tell. ‘What’s the sample?’ I asked.
‘Stool.’
‘Ah.’
‘Do you see the egg with the hook?’
‘Um . . .’
‘It is Schistosoma, I think.’
‘Oh.’
‘Do you agree, Novo Doctor? Do you agree that it is this?’
I agreed only to get my pathology book from the office and return after lunch.
For the moment I take a seat with Isabella, below the only tree in the compound, just near the dispensary, and contemplate this growing list of newly discovered roles. It’s pleasant out here, a world away from the austerity of the wards, but it’s not providing the desired respite. Because even this front courtyard, entered via the crooked gate to our right, a No Guns sign tacked above, is unlike anything I’ve seen. Traditional village, grim medical centre, happy child play-centre, last hope for the desperately poor—it’s all of these, everything in between.
Ahead, a few dozen people sit under a large cloth awning, waiting for consultations with one of the four Outpatients clinicos. There’ll be a hundred such people today. Every other day, too. At the front of this open-air waiting room, two toddlers are suspended loosely in linen harnesses that hang from scales. It looks fun. Just like a big swing, as if hanging there would be enjoyable, but these two aren’t buying it. Not in the least. They’re screaming loudly in protest; screaming at the rows of people on the log-roll benches in front of them—people with coughs, tumours, leprosy, leg injuries, malaria, and a man with a spine that’s bent at improbable angles who’s propping himself up with an old tree branch. Screaming at a young man who’s clutching his belly with abdominal pain, a symptom that may be caused by schistosomiasis from the river in town, or may be due to any of the other thousand viruses, parasites and bacteria that thrive in this part of the world and that are going to necessitate my doing some serious reading. Screaming too at the boys kicking a half-inflated football near the gate and at the dozen people waiting for malaria tests; and at the two of us, Isabella and me, as their mothers and those on the benches chuckle at the pair’s disapproval.
Unhappy little parachutists, caught momentarily in the weighing-tree.
‘You were saying?’ I ask Isabella. She’s been trying to reassure me about things this morning, telling me I’ll pick up the Portuguese. I’m going to have to; she leaves in a few days.
‘With all that banter between you and Sergio,’ she smiles, ‘you’ll get plenty of conversation practice.’
I ask her if I said something wrong on the rounds.
‘Don’t worry about it,’ she says. ‘Sergio gave the previous doctor a hard time as well, especially when she started. He’s got quite the reputation around here. I think he’s just trying to—what’s a nice word?—assert himself, to establish his standing in the hospital. And that whole quinine issue was unnecessary. He normally does keep an eye on those things. That was sloppy on their part. But I think he just doesn’t like being questioned, especially because you are new. Just give it back to him, though. Sofia did! She really clashed with him for a while.’
As we talk, three older women waiting at Outpatients walk over to us. ‘How many children does he have?’ the shorter of them wants to know of me, and then—‘Eh! At his age! Why on earth not?’ So I try to explain that this is normal for a twenty-nine year old where I come from, but the Inpatients clinicos wave to us; and as we join them and enter the women’s ward all levity provided by recent moments is shattered and I feel ill, actually physically ill, because on the first bed is a woman soaked in urine, skeletal, barely—
Is she even alive? I watch her for a moment. She is. Just. Her face is a grimace, an unmoving paper-thin mask draped over the severe architecture of her skull. Her eyes, open and unblinking, seem untroubled by the flies gathering at their margin.
‘She’s been sick for many months,’ says the clinico, speaking with the husband. ‘He just brought her here. She had bad pain in her belly, and she cannot eat. Now the pain is everywhere.’
Her two children sit quietly beside her on the bed, and her husband leans over to gently wipe the flies from those big eyes. It’s the saddest sight I’ve seen. I ask if I can examine her and her eyes turn to me, and the husband gives his permission so we gently pull up her dress and cover her lower half with a blanket. There’s no need to really even touch her, though. An obvious mass, a firm fist of tissue, is visible low down in her belly, bulging from the deep concavity between her hipbones. Several smaller knuckles of tissue can be felt nearby, too. It’s surely cancer. But whatever the exact condition, she’s in the final stages. We can try to keep her comfortable, little more.
I cover up her belly and the husband grabs my hand, smiling warmly. The clinicos translate his words from Tchokwe, a local language. ‘He says that he’s grateful to us for helping her,’ says Isabella. ‘He says he knows that here she will become strong again. He knows we will fix her here. His family wait for this day.’
He can’t really believe this. I ask him to come outside with us so we can speak in private, and in the far corner of the yard I explain that we will help her as best we can. ‘But sir,’ I add, ‘she is already very weak. We can’t ignore this.’
He nods, eyes downcast.
I explain that hers is not an illness we can cure. I wait for the translations, give him a few moments, then tell him that I think it’s cancer. He’s not heard of it before. He studies Isabella’s face intently as she clarifies, the clinicos interjecting with explanations in his language. I feel awful telling him all this but he needs to understand. She’s certainly going to die in the next few days; he needs to be prepared. His children meanwhile hold on to his legs, watching me with big smiles as I talk, fascinated by this white person who’s chatting with their father in the yard.
‘It’s a very serious illness, sir,’ I continue. ‘A very strong illness. And I don’t think that here, in Mavinga, we can possibly fix this. But I promise you that she will be comfortable while she is here.’
He speaks with the clinicos and shakes his head. His face softens and he grabs my hand between his, looks at me with eyes that scream hope. ‘That is why we brought her here,’ he says. ‘We know you can help her. God has led us here, and God will show you. She will get better—she will be strong!’
What to say? Maybe I’m not saying the right things. I ask Isabella how they approach such things here, but she agrees: tell him we’ll keep her comfortable. No false promises. So I try to explain that her recovery is out of our hands, but he excuses himself while the others begin to translate. ‘I must be with her,’ he says, and walks back inside.
I stay where I am. I’m not entirely clear if I’ve done the right thing. I’d have said the same at home, but one doesn’t see people in this advanced state who don’t already have a diagnosis, or at least some understanding of the nature of their illness. One of the senior clinicos steps forward as I talk with Isabella.
‘I can operate,’ he says.
‘Sorry?’
‘I can operate on her,’ he repeats. Roberto’s his name. He’s a lean Angolan man, a good four inches taller than me. Sofia’s told me much about him. He’s the closest thing we have to a surgeon here—a health worker, trained in field hospitals by military surgeons during the war, who’s proficient with limb amputations and less so with emergency laparotomies. But it was stressed to me that he’s not a doctor. And it was made clear that he’d likely pressure me to operate, but that he was to perform only emergency surgeries—and only with my permission. Looking now at his imposing frame, telling him what he can and can’t do seems somewhat hypothetical.
‘I can take out the mass,’ says Roberto.
‘That whole thing?’
‘Yes. This afternoon. Or tomorrow. When you’re ready.’
I look at Isabella. ‘Is he serious?’ I ask. She looks at me uneasily, shakes her head and looks back at Roberto. His expression suggests he very much is.
‘The husband wants us to help her, yes?’ he says. ‘So what then is your plan?’
‘I’m not sure if there’s much we can do, Roberto. There’s no way she will survive an anaesthetic in her condition—not in America, not in my country, definitely not here. She’s far too weak. And that cancer, or whatever her illness is—it’s surely spread. We won’t be able to cure her.’
‘She is not in your country!’ says Sergio, stepping forward. ‘Or in America. She is in Mavinga. Do not compare us.’
I’m speechless. Do these guys really think an operation is feasible?
‘And this nice family,’ says Roberto. ‘She has young children—did you not see them? How can you just do nothing? She will certainly die without this surgery. And yes, with the surgery she may die too, this is a possibility, but how can we not do something? How can you not at least try? Let us talk with the husband—let us see what he wants. But I tell you now, he will ask us to operate.’
I’m lost. No one back home would consider such a plan. Surely! Is this how they do things here? Maybe the husband would rather she died during surgery being given a last fighting chance; perhaps to just palliate patients out here is to admit defeat, regarded as weak. Un-African, even. Is it an insult to the husband if we don’t operate, given that he’s carried her here with their two children in tow? I have no idea. I’ll call the medical advisor in Geneva this afternoon, but right now there’s still other wards to see—not least those malnourished children. I tell the clinicos my plan and turn to head back to the wards.
‘Novo Doctor!’ Roberto calls out, walking towards me. I stop and turn back. He looks like a military commander as he strides towards me. A man’s man, for sure. Am I really about to get involved in a stand-off with the local staff? On day one? And how am I meant to be the ‘boss’ out here, anyway? These guys are mostly ten to thirty years older than me, yet technically I’m the more qualified. I’d not expected any of this. I’d rather imagined arriving and just getting on with seeing patients, and that on at least some level people would be grateful for my having come here; that I’d learn from them, they from me, and in the process we’d all work as a happy team . . .
But this—?
‘Yes, Roberto?’
‘We are not finished talking,’ he says, piercing brown eyes staring through me. ‘You must not forget something very important,’ he warns, voice calm, his face one of annoyance. ‘Do not forget that you are very young, and I am sure have no experience in Africa.’
‘Roberto—’
‘Am I correct?’
I can think of nothing to say. I look away, watch patients queuing with bowls in hand for a serving of maize and beans from the kitchen nearby.
‘We are from here,’ he continues sternly. ‘This is our home, and these are our people. Our patients. We all have worked here a long time. For years, even during the war. Long before MSF came here, we were looking after patients. And you? You have been here what—not even a week? You have only just arrived! You know nothing about us, about our medicine—nothing even of our language! You need to remember these things, Novo Doctor. Remember all of them when you are in this hospital, trying to tell us how we should manage our people, what drugs we should use, when we can operate on them. And when you do—when you understand and respect these things—maybe then we can work together properly.’
I stand, frozen, in the middle of the yard. He walks off with the others.
I’ve got no idea where to begin.
