Caring is unrewarding

As if Kyrgyzstan wasn't bad enough.

Canada, according to its US embassy's website, "prides itself as an open country which welcomes immigrants and visitors." What they don't tell you (it's couched in a benign sounding injunction to "consult the links below") is that their welcome is a very conditional one. Conditional upon the whims of whichever consular agent, for example, is handling your work permit application (the things required of me this year differ significantly—and inexplicably—from those required last year).

One of the conditions placed on this love of Canada is the requirement for a medical exam. Now, I don't fault them. They're intending to hire a filthy foreigner like me to work in their health-care system. I'd want to screen that foreigner thoroughly. It only makes sense.

Unfortunately, Canada has determined that a very limited number of physicians is intelligent enough, capable enough to administer their rigorous health-care screening exam (it includes such MENSA-level questions as "Why do you wear glasses?" and "How many teeth have you lost?"). In her infinte wisdom, the Dominion has decreed that, in Liberia, the sole physician designated to ask these general medical questions is a specialized surgeon. Never mind that I'm living on a hospital ship.

This was discovered, naturally, after a phone call from the consular agent informed me that, in Liberia, the sole physician desginated to ask these general medical questions is actually in Accra. Which is in Ghana. Which doesn't even border Liberia.

Small border-related gaffe averted, I called the physician's own cell phone, made an appointment directly with him, booked a taxi and headed into Monrovia.

On the Africa Mercy, we have continued to screen patients after our massive screening day in February. And during our screening, a significant number of patients come with problems that we cannot help—ulcers, uterine fibroids, runny noses, coughs, and the rest. After two days spent negotiating the Liberian health care system, I can't say I blame them.

Dante had no canto for this one.

Alfred—the man who, with the patience of St. Sebastian, drove his cab to and from the ship and waited for me while I was in the bowels of the capital city—dropped me off at the clinic. He said he did, at least. If it weren't for a small, hand-painted sign, with a rough blue arrow pointing past an unlit, dank arcade of pirated-DVD sellers, I wouldn't have believed him. But, ducking past the urchins' pleas for me to buy "Black American Slugfest V", and avoiding (not always successfully) the puddles of urine reminiscent of the 190th St. A-train station, I followed the second, hand-painted arrow to the left, past an internet cafe (well sign-posted but eminently nonexistent. Really. It just wasn't there), up the stairs, and into the waiting arms of the actual clinic.

"Hello, I have a two-o'clock appointment with Dr. ————,*" I told the receptionists. They looked at each other, wide-eyed. One motioned for me to sit down, while other said to him, in outright stage-whisper, "I haven't seen him all day!" I suppose they assumed my Liberian English wasn't up to snuff.

Turns out His Eminence was there. He was just having his lunch. So, consigned to joining the flies, the slowly-turning fan, the fecal walls, and the armed security guards, I waited. Thirty minutes later, I was escorted in to meet His Eminence.

His Eminence's first, and at this point only, question for me was whether I had the money to pay for the pleasure of this experience (and the money was not insignificant; it amounts to 18 months' salary for the average Liberian, or in US equivalence, sixty-one thousand dollars). I assured him that I did. With that, I was sent to see his resident.

His Eminence's Resident's job—the poor man—is to sit behind a desk, collect the monies, and fill out prescriptions, written on the backs of scrap paper, for chest x-rays, urinalyses, blood tests, stool samples (patently not required by the Canadian government, but no amount of arguing could convince His Eminence), and then shoo you out, lest you consume any more of his precious air conditioning.

I was sent first to radiology. Above its door flashed a big, bold, red-lit sign. The X-ray was in use, it said. Entry would be undertaken at my own risk.

I waited.

Until it became obvious that either whatever patient was behind that door had been burnt to an unrecognizable spastic puddle, or that the sign was a lie. I wagered. A small, bespectacled man, worthy of L. Frank Baum's imagination, appeared, visibly annoyed that I'd insisted on paying mind to the man behind the curtain. Emboldened, I flashed my hand-written "CXR" prescription to him and was furtively ushered in and told, in no uncertain terms, to undress.

Of course.

There were, unfortunately, no Jell-O-encrusted horses.

I regret having used up all my adjectives on the Kyrgyz medical system.

The X-ray machine was one that would have done Roentgen proud. It was old. Like, last-century old. Like, Mary Shelley old. It looked something like this:



Only in a further state of disrepair.

And I never got to use it. I was saved by a frantic knock and an acknowledgment, by His Eminence's Resident's secretary, that the images produced in that room would not meet the Dominion's standards. I needed to get my lab tests first, and then head to the Catholic Hospital.

It took another half hour to be acknowledged by the lab personnel—a half hour that could have been spent sterilizing their equipment, for example. Ah, but no. Akon's coming to town in two weeks. We must prepare! I was graced, instead, with the dulcet tones of the lab staff singing, "Nobody want to see us together, but it don't matter no! Cause I got you, babe!"

Dante had no idea.

"Your name?" "Your age?" "Where you live?" "Married?" (why this particular question matters for a stool sample still escapes me.) And, wearing the same pair of gloves with which he's wiped his nose, opened the door, handled lab samples, shaken hands with multiple friends, danced to over-produced Liberian-American hip-hop, and rifled through a collection of old medicine bottles on the floor, the lab tech took my blood. With a sterile needle. Because that covers a multitude.

He sent me on my way with an old Tylenol bottle into which I needed to pee, and a folded up piece of paper holding a used lollipop stick.

The consternation on my face was probably obvious because, without prompting, he gently explained, "You make stool. Then take this"—pointing to the lollipop stick—"and take stool from toilet and put it in here"—pointing to the folded piece of paper. Thus instructed, I was shown the way to the toilet.

It was a hole in the ground in the middle of a brackish miasma of flies, odorants, sweat, and mosquitoes, surrounded by a slippery patina of the remnants of old occupants, backlit on once-white tiles. And it belonged to the family whose house abutted the clinic. I'm not kidding. They ignored me as I walked by.

Those same gloves accepted my frankincense and myrrh. And, finally freed of my requirements, I found Alfred and we raced to the Catholic Hospital (motto: Caring is Unrewarding. I am not making that up).



"Sorry. We're closed."

No, really. Closed! A hospital. "It is night shift. No more X-rays."

It was 3:40. Evidently, the night shift starts mid-day. "You can check in the ER. Maybe they can do an X-ray for you."

To the ER I went. It was empty. A lone, short man emerged from a curtain (Baum struck, once again), and I made my plaintive request. "Who told you we could do an X-ray?" he asked. After I answered, he escorted me back to the front desk. And they started fighting with each other, the receptionist and the short man.

"I didn't tell him. He wanted an X-ray!"
"He said you told him"
"I told you I didn't."

And on, until the short man put his arm on my shoulder, in a very unrewardingly caring way, and said, "Let me explain to you clearly" (clearly! Ok. I'm listening). "We don't do X-rays. It's night shift."

Ah! Thank you, sir. God help the man who actually needs one.

Flummoxed, I crumpled in the car on the way back to the ship, past cries of other street urchins. Kohminerah! Kohmineruatah! (This, by the way, means "Cold mineral water." It comes in sandwich bags, hand-tied.) I got my X-ray done on the ship.

I won't regale you with the details of day 2. With waiting in the same feces-infested room for five hours, beneath the gleeful smiles of the two receptionists, watching bad Nigerian television (you guys missed a riveting episode of Husband My Foot 2, I'm sorry to say), and having His Eminence emerge, at the top of the fifth hour, with widened eyes, a start, and an "Oh! I forgot about you!" Or with the threat—in all seriousness—of bodily harm by the bespectacled X-ray tech if I peeled any more paint off the wall. (I was bored. What can I say?) Or with His Eminence's exceedingly thorough medical exam.

By the time I got back to the ship on Wednesday night, after nine hours of attempting to fulfill the Dominion's requirements for her conditional love and acceptance, I wondered whether Accra wouldn't have been a better choice.

*There are only 40 doctors in Liberia. I'm not about to take a chance.

Restoration

Sometimes, words simply distract.

This is Amachin. The hands are those of Dr. Gary Parker, Chief Medical Officer on the Africa Mercy.

Multicultural crash-test dummies

There are eighteen bridges on the road to Robertsport. The twelfth has become a close friend.

Robertsport—or Rawspoh, as it's pronounced by most Liberians we met—is a once-beautiful town, on a still-beautiful beach, about ten miles south of the border with Sierra Leone, and a three-and-a-half-hour, hundred-mile drive north of Monrovia. Three and a half hours, that is, if it's pulled off without complication. This being Liberia, however, little occurs without complication.

That thought, though, was far from our minds as we piled into five Liberian cabs, with seventeen other Mercy Shippers, on Friday morning, for what promised to be a relaxing overnight camp-on-the-beach affair. I've mentioned it before: the only resemblance between cabs in Liberia and cabs in, say, New York City, is their color. And possibly the mental state, and addiction to speed, of those who drive them. That thought, too, was absent.

Most Liberian cabs are emblazoned with lightning-bolt decals, branded with particularly pithy sayings—God's Time Is Best Time, or Thank God Garbala, for example—and graced by pictures of Madonna (and not the one that precedes "and child", either). We avoided The Blonde One, picked My Love For You Count No Wrong, shook hands with Suri, her owner, and clambered aboard.



The first two-thirds of the road to Robertsport is actually paved, and littered with UN checkpoints, stray chickens, and shops named after theologic apothegms of more depth than many of today's churches. God Knows Why Cellphone Repair. The Lord's Chosen Cement Factory. God's First Money Exchange (is that a possessive or a contraction?). We breezed past them all, and, immediately after the invitingly dirty (and jarringly plural) Mother and Child Guests House, we made an abrupt left onto a dirt road.


That's where the bridges began. Suri maneuvered Count No Wrong with agility belying his misfortune of having a celebrity kid named after him. Count No Wrong responded to his suggestions without complaint. Her love for us was living up to her name. When the tire on another cab (aptly named Why Me?) blew, Count No Wrong sailed on by without a hitch. (The spare was provided by The Lord Is On My Side. All cabs carry a spare tire—heaven forbid, though, the tire actually fit the cab that carries it).

Emboldened by his success at avoiding the first major hitch, and with no small amount of encouragement from us, Suri sped Count No Wrong to the head of the pack. This had the added benefit of placing us clear out of the plumes of red dust that trailed each cab. We were going to arrive in Robertsport clean, wind-swept, and hitch-free.

Bridge 12 had other plans for us. Each of the eighteen Pakistani-built bridges on the road to Robertsport is of rickety wooden construction, wide enough for one car to pass, and that only slowly. Appropriately, Suri slowed down for Bridge 12.


It is unfortunate that the plume of red dust that trailed us, and the cars it enveloped, didn't.

The sound is hard to describe. It's loud, brusque, and jolting, an explosive, black, metallic clap. Our bodies pivoted on our necks, backwards, then immediately forward, like so many wide-eyed, multicultural crash-test dummies. And then our car lurched forward. And to the left. And time became elastic. And the bridge's wooden barricade filled our windscreen. And then it didn't, pushed under the wheels of the car.

And then we fell off the edge.

Down into the gully, flattening tall grasses, shrubs, and nascent trees. I could hear someone's voice saying, "Jesus keep us safe." I could hear the voice in my head saying, "Wow. This might actually be how we die." Nobody turned. No one screamed. Another voice in another person's head said, "I don't care what happens. Just please don't let it hurt."

And then we stopped. Landed. Halted by one final tree.




And there was silence. Nobody spoke. Nobody breathed. Finally, a voice from outside the car, from above us, "Is everyone OK?"

Time snapped back with a huff, regimentedly shuffling away from us with nary a look over his shoulder. Slowly, we started asking each other the same question. Was everyone OK?

Everyone was. Necks were sore (though not nearly as sore as they were about to get over the next forty-eight hours). One of us had sustained a blow to the back of the head from an errant guitar case. But, barring the scrapes, bruises, and bewilderment, we were unscathed.

And here is where the life of the NGO worker gets surreal. Not five hundred yards down the road was a detachment of the self-same Pakistani battalion that had built the bridge which nearly destroyed us. It takes a certain person, it seems, to work for an NGO, and Pakistani UN soldiers are no different. Normal human beings with a streak of the insane.

The first thing they did was to make sure we were OK. The next was to whip out their cell phones and start taking pictures.


They spoke little English, but one of our travelling companions (who was raised in Fiji but lives in Canada), spoke Hindi (naturally). And because—red-faced politicking notwithstanding—Hindi and Urdu are simply dialects of the same langauge, when he began speaking to them in Hindi, they congratulated him on his Urdu. Between them, they determined that the car would stay there until the police found it. The now-carless would pile onto the back of the UN truck.



This is how we found ourselves sitting atop large bamboo rods, packed hip-to-shoulder with six men and their automatic weapons, listening to one sing a song, softly, into the wind and dust, driven through the African bush to the air-conditioned compound of the Pakistani UN battalion (Motto: Twenty-six, Brave and Brisk. I'm not making that up).

What happened during the remainder of the trip—the offer, by the UN commanding officer, of one of his own vehicles to take us the rest of the way to Robertsport, the pristine beach, the waves that taught me what drowning actually feels like, the torrential downpour that bested our tent, the campfire, the boiled cassava, the sunset, the crabs, and the flat tire on the way back (this time, there was no spare; don't ask)—pales in comparison.

The remaining pictures are here.

Believe

Have you ever had a patient dance for you? Seriously—have you ever walked into your exam room and had your next patient break out into spontaneous fits of jive? Or, have you ever sat on a doctor's examining table and decided that what she really needed was a little soft-shoe number?

I wrote last week about the fact that medicine in Africa can be frustrating. But it can also be a trip. We may never leave.

Meet Marie. Marie had a large left-sided goiter, and two weeks ago she came on-board for her hemithyroidectomy. Her story should have been relatively humdrum, but that's because I'm coming from years of training in detachment. She was someone we would treat, and then she'd go home, and we'd congratulate ourselves on how big a goiter we were able to take out. And we'd send show-and-tell pictures to our doctor friends—look what we just did! And we'd hope for the requisite affirmatory pats on the back. And in all this, we'd never get involved in Marie's actual story—why she wanted this thing out, what it meant for her to have a mass in her neck, and what it felt for her even to be offered the possibility of having it removed.

Little do you expect the pat on the back to take the form of a careening conga.

See, what I didn't realize is how stigmatizing goiter is. In my mind, goiter is almost synonymous with Africa. It's endemic. It's something you read about. Everyone, of a certain age, has it. So, of course, that same everyone is used to seeing their mothers, sisters, grandmothers with goiters, right?

Marie proved me wrong. For her entire time on the ship, she barely met my eyes. Or anyone else's. The stigma of goiter, it turns out, is the stigma of the unclean, the demon-possessed.


Her surgery was hitchless, but her post-op course was complicated by significant, often unarticulated fear. Was coughing OK? Could she turn her neck? Would the stitches come out? And then came her first post-operative visit. After years of averting her eyes from the overly-curious gazes of her neighbors, she had a hard enough time meeting ours. She had to be reminded. But when I asked her if I could take her picture, she broke out into an ear-to-ear grin, wider even than her incision, and she started dancing. Right there on the examining table. No amount of pleading would get her to sit still.

I can only believe in a God who dances, wrote Friedrich Nietzsche. So, here she is, a woman reintroduced into society. And my first dancing post-op picture.*

*Apologies for the obtrusive black bar.

You can understand me, yea?

If English can have dialects, surely Liberian English counts as one. Part of my daily job as the hospital ward physician is to chat with all the patients that are being admitted to make sure that there are no contraindications to surgery. Taking a patient's history is always done in a very regimented fashion in medicine, as the internist starts with the chief complaint and moves down through a patient's past medical history in order to get to an assessment and plan. In my first couple of days on the ward, I fumbled my words as I tried to communicate. After a couple of crash courses from the translators, however, I am beginning to get the gist of things. These are the things I tell the patients daily:



Welcome. My name is Dr. Peggy, and I will ask you some questions to make sure your body alright for surgery.

What sicknesses do you have in your body? (What medical problems do you have?)

How many bellies have you had? (How many children have you had?)

Any bellies spoiled? (Any miscarriages?)

Have you ever had any work done on you? (Any surgeries in the past?)

Any medicine can itch you or treat your body bad? (Any allergies to any medications?)

Are you taking any tablets right now? (Are you on any medications?)

You can smoke? You can drink? (Do you smoke? Do you drink?)

Any sicknesses in your family? (Any family history of diseases?)

You can reduce? You dry now? (Have you lost weight?)

Your skin can feel hot? (Any fevers?)

Your chest can pain you? (Any chest pain?)

You can breave freely? (Any shortness of breath?)

Any runny stomach? (Do you have diarrhea?)



And the list goes on. I find myself slurring my words and dropping my consonants as I work my way from A ward to D ward, inquiring about Henry's "poo poo" or asking if Naymah's headache has "cooled down". One day I will find myself saying "Thanks God," when someone asks me, "How are you doing?" Then I will have truly mastered Liberian English.

Beneficent trepidation

And, wrote Vladimir Nabokov,

I became aware of the world's tenderness, the profound beneficence of all that surrounded me, the blissful bond between me and all of creation; and I realized that joy...breathed around me everywhere, in the speeding street sounds, in the hem of a comically lifted skirt, in the metallic yet tender drone of the wind, in the autumn clouds bloated with rain. I realized that the world does not represent...a predaceous sequence of chance events, but shimmering bliss, beneficent trepidation, a gift bestowed on us and unappreciated.

Medicine in Africa is different. Frustrating, even, in some ways. Wounds break down that aren't supposed to, for reasons that make no sense except for the chronic malnutrition, anemia, and dust-and-mud homes patients go back to. Patients board the ship with inexplicable fevers, with two-year-long leg swellings that are either an infectious disease you've never heard of or a tumor you've never seen before. Every day you confront deficiencies in yourself.

But medicine in Africa can also be beneficent trepidation.

Vesicovaginal surgeries began this week. If you've never heard of a vesicovaginal fistula, don't worry. Neither had I until about a year ago. Here's some background.

A woman born in Sweden today has a lifetime risk for dying in childbirth of 1 in 29,800. In the US, it's 1 in 2500; in Liberia, that risk is 1 in 16.* Six percent of all the women that we meet here in this country will die, at some point, from bearing children.

As distressing as those numbers are, though, it's not the women that die after childbirth that have the saddest stories. It's those that live. Obstructed labor—in which the baby gets stuck at the pelvic outlet, in which the baby's head is simply too big to fit through the mother's pelvic bone—occurs with alarming frequency. It's estimated that as many as 5% of all labors require some sort of obstetric help. Unfortunately, in the absence of that obstetric help, the baby struggles, trying to get out; obstructed labors last anywhere from three to ten days, up to 240 unanaesthetized hours. Eventually, the baby dies.

Unfortunately, in the interim, every single uterine contraction has effectively strangled the thin tissue that separates the vaginal vault from the bladder or from the rectum (you'll pardon the explicit language). Deprived of its blood supply, that tissue dies. And, a few days after delivering a dead child—sometimes in multiple pieces—the mother starts noticing a persistent leak. Urine is no longer contained in the bladder; it follows the path of least resistance, down her leg, onto her dress, and into the world around her.

She begins to smell, through no fault of her own. A swarming aura of urine and feces surrounds her. Social and psychological isolation is the logical outcome. So, in the middle of villages that sit hours away from the nearest road, these women are abandoned by their husbands, their mothers, their families, and secreted away into makeshift shelters, where they spend the remainder of their lives.

Two hundred years ago, the problem was so prevalent throughout the world that a flashy, swish Fistula Hospital existed right in the middle of Manhattan, on the site of the current St. Bartholomew's Church, right next door to some of the highest-priced Manhattan real estate. But, in the intervening two centuries, modern obstetrics developed, and obstructed labor became a thing of the past. With it went the vesicovaginal fistula and its attendant shame.

Not so in Africa. Prevalence estimates for vesicovaginal fistula vary widely, but they run in the hundreds of thousands. And, with a simple procedure, they can be repaired.

Our first VVF ladies are on the wards right now, recovering from the first week of surgery. It takes two weeks or so to recover, and that's not a bad thing. It gives us a chance to get to know them, to get to show them acceptance after years of marginalization, to show them love without any disgust, without any upturned noses. And when they recover, there's an outright party. Each VVF patient is given a new dress, symbolic of her new re-entry into normal society, and sent off amidst the pulse of drums and the harmonies of West African voices. It's with a bit of trepidation that those of us who've never seen VVF surgeries stepped into this week. But it's with the hope of beneficence.

By the way—if you're at all interested in finding out more about vesicovaginal fistulas, a great documentary, A Walk to Beautiful, opened in theaters in NY and LA two weeks ago. It will also be playing on PBS on May 13. It's amazing.

*WHO, UNICEF, UNFPA, Maternal Mortality in 2000,

http://www.who.int/reproductive-health/publications/maternal_mortality_2000/mme.pdf

Screening day pictures

None of the pictures are ours; cameras were not allowed on the day. The remainder of the pictures are here.

Death becomes no one

I hate the fact that the last few posts haven't been all that hopeful or full of healing. Maybe I should change the title of this blog to, as one friend has said, Hope, Healing, and Helping Little Boys Slip Quietly Away.

Two children died on the ship this weekend. Forgive me for waiting a few days to post this...it's taken a while to process it all. Death becomes no one. And most especially not little kids.

Sadie was a four-year-old boy who was brought on-board by his father on Tuesday. For two weeks, Sadie's jaw had been swelling. Rapidly. It had gotten to the point that he couldn't lie back without beginning to close off his airway, without difficulty breathing. He either had a bad dental infection, or a tumor, and likely the latter. We took him to the operating room for a biopsy.

Sometimes the simple things aren't. For reasons that have still eluded us, he arrested on the table. For other reasons that have still eluded me, he survived the arrest (don't get me wrong—of the myriad arrests I've been to in my time, this one had the distinction of being the most calm, the most ordered, the most well-run arrest I have ever seen. There's something about hearing, as your entire world stops and the thunderous funnel of emergency envelopes your thinking, the anaesthesiologist's involuntary prayer. "Lord, help us with this kid.")

Still intubated, Sadie was brought into the ICU. The biopsy confirmed Burkitt's lymphoma, and, through some amazingly heroic efforts in a city you're not supposed to venture into at night, cyclophosphamide was obtained. In 48 hours, his tumor was gone. His jaw was frankly normal.

And that's why, when we finally withdrew care, the blow was that much harder. He simply never came back from the arrest.

A day after Sadie's arrival, Benjamin came in. Fourteen years old and sick for a week with what started out as simple sinusitis, Benjamin had developed abscesses in all the wrong places. His forehead, his eye, and, ultimately, his brain. Collections of evil humors bent on ending his short childhood. They, too, won.

When Benjamin first arrived on the dock, he was barely responsive to his name. He had to be carried onto the ship. And by the time he had made it to the operating room, he'd even lost that ability to respond. We dutifully drained his abscesses, knowing that it was all we could offer. It wasn't enough. The day before we withdrew care on Sadie, we withdrew care on Benjamin.

And two boys slipped quietly away.

I realize that in writing this post, I do a disservice. I do a disservice to the couple of hundred patients who have received surgery in the last two weeks alone, who have gone home complication-free and, more importantly, with an ability to walk back into society.

I do a disservice to the other three patients who have come in on the verge of death but haven't gone down that road. I do a disservice to the healing and the hope that the four hundred people on this ship offer.

But death... she's never easy.

Synecdoche

Many people who have written about Monrovia have written about the Ducor Hotel. It's an easy target, but its ease doesn't detract from its synecdoche. The Ducor Palace Hotel is the three-decade-long trajectory of Monrovia.

As far as I can piece together from the Nigerian UN soldiers patrolling the hotel, a Liberian security guard (mostly guarding his spot in the shade), Google, and our friend Megan, the hotel was built by a Libyan company in the 1970s, at the peak of Monrovia's stint as a top-choice travel destination, and has passed through multiple owners, including the Intercontinental group of hotels. At its prime in the 1980s, a night at the hotel would set you back between $150 and $200 (that's around $400 in today's currency). And then the war started.

During the war, the hotel shouldered a number of disparate roles: as temporary headquarters of the President, the government's forces, the rebel's forces, and finally—until May of last year—as a refugee camp for up to 2500 of the internally displaced.

Since May, it's become a concrete shell, home only to a few kids whose school meets on the second floor, a church, and a requisite UN presence. And the daily influx, it seems, of amateur photographers from any of the NGOs in this country, equipped with cameras worth more than they should be, and a keen awareness of the unjust dichotomy they create.

From the lens of one of those cameras, a few pictures:

The remainder are here.
A few pictures of the Ducor in its glory are here.