1939

Seventy years ago, when Benin was still Abomey, a Q-tip-shaped parcel of land wedged within French West Africa; when the memory of Portuguese slave ships was fresh and the mention of Dahomey warriors still struck fear; when Mohandas Gandhi was fasting, Adolf Hitler was attacking, Judy Garland was following yellow bricks, and John Steinbeck was writing about angry grapes—seventy years ago, when the world was declaring war on itself for the first time, Gbayi* got sick.

It may have been measles—it often is. The thing is, unlike others who got what he got, he survived, but the victory was unfortunately Pyrrhic: not long after, his lips fell off.

No, seriously. I've written about noma before, but it never ceases to amaze me. See, we all carry around in our mouths somewhere on the order of 800 species of bacteria, but, besides feeding on the detritus you leave behind when you don't brush your teeth (and lining the pockets of Procter & Gamble executives), these bugs do very little of dramatic import.

Except in noma.

In noma, an immune system weakened by a recently-fought-off infection becomes unable to contain the bacteria, and they're left alone, free to devour more than food.

Why they attack some patients and remain docile in others, I don't know. But seventy years ago, when the French were still guillotining people and Clark Gable was going with the wind, they ate Gbayi's upper lip. And part of his nose.

Gbayi is now 77 years old. Age has rendered him unable to walk—he was carried to the stadium on his son's back—and, seven decades later, his hands perpetually hover around his mouth, as if by doing so they can prevent the shame that has shadowed him since Einstein was researching atomic bombs.

And Gbayi was only one of over 2000 stories we saw in two days at the Hall des Arts, Loisir, et Sports this week (loisir, for sure: half the chairs in the stadium were brown—sometimes garish red—leather armchairs, incongruously defying the remaining wood-and-metal seats; they, I assume, are where the important people sit). Over the course of two days, patients who had begun lining up in the middle of the week wended their way through the sports stadium toward the surgical schedulers, who would give them a date for their surgery. Not everyone made it there, but we said yes far more often than we said no.

Massive tumors and goiters the size of watermelons, clubbed feet and contracted arms, burned faces and bowed legs, hernias, hydroceles, and fistulas—each accompanied by a story like Gbayi's.

Physical deformity, a lawyer once wrote, calls forth our charity. The need, as always, is greater than any group of humans can help. But that is perpetually a good reminder.

The first patients arrive on Monday. Pictures will be forthcoming, but, in the meantime, here's a six-minute video from the day (Gbayi shows up near the end):

*Not his real name

Sparks

Forgive me bloggers, for I have sinned. It has been 11 days since my last post.

And I can’t promise that this one will be altogether all that uplifting. I had to say no to two patients on Friday; saying no is the hardest part of this job.

Ballah
Ballah* is a sixty-five-year-old woman who, for the past six weeks, has noticed a swelling of her jaw. It’s a painful swelling, interfering with her eating, and causing her to lose weight (or, as our interaction went, I’ can peeyⁿ me. I caⁿ ee’ freely. Ohhh, I be reducing. Because of the worry... I’m going to miss Liberian English). She had been prescribed antibiotics for the jaw swelling, and had been sent to our dental clinic for further work-up.

God bless our dental clinic. They are the front-lines. Firmly ensconced at Redemption Hospital, a former MSF hospital turned over last year to the Liberian government, our dentists, dental assistants, dental coordinators, dental sterilizers, and a vanguard of translators occupy the former pediatric ICU (which sounds significantly better stocked than it actually is. It's a room. With fans. And numbers on the wall).

They see everyone. Jaw swellings. Ma-too’-be-hurtin’s. My-breasts-be-too-bigs. And Vicki, the indomitable whirlwind of a woman who runs the clinic, brings them in or sends them away with a gentleness and a care that rivals many.

Ballah, she sent to the ship. Unfortunately, Ballah’s jaw swelling was inoperable. See, it wasn’t a simple swelling that was paining her. It wasn’t worry that was causing her to reduce. Ballah had a carcinoma of her gums, a volcanic eruption of uncontrolled tissue growth that had eroded through the bone of her jaw and out her skin, completely replacing normal tissue across about 75% of her mouth. Back home, Ballah would have required a pretty massive operation, and, after an entire day on the operating table, would still have had a significantly greater chance of succumbing to her tumor than of surviving. We would have thrown the proverbial sink at her—surgery, radiation, chemotherapy—to give her that chance.

But, here, there is a bizarre economy. In a situation in which radiation and chemotherapy are not available, in a world in which heroic measures fail more often than not, in a culture in which surgery for palliation is not understood, what is the right way to deal with Ballah? And with the other patients who would, by necessity, not be able to get surgery if Ballah did?

It’s an economy I still struggle with.

Joseph
Joseph’s* story is not much different. Fifty-five years old, retired, with a six-year history of an eye tumor, pushing his left eye forward and causing pain. It was a small thing, externally. Not one of those tumors you look at and immediately start calculating how many nerves you’re going to have to sacrifice getting it out.

Its appearance belied its actual size. A CT scan revealed a large tumor in his frontal sinus, with extension directly into his brain. And the economy reasserted itself. We have no neurosurgeons on-board. What we have is the ability to do a few, basic neurosurgical things, should they be necessary. But nothing more.

Joseph, too, succumbed to the economy. And, having experienced the Liberian health-care system first-hand, I know what we were sending him away to. It makes saying no exceedingly difficult.

But, let me tell you the story of Precious:

Precious
Precious* is Liberia. Her problems are the problems of the health care system of a developing nation. See, on February 5, Precious tripped on her way home from school. She scraped her knee and her elbow. She probably cried. She probably ran home to her mother. She probably got a hug. At home, she could have featured in any number of brightly-lit, quotidian Tylenol commercials. But not in Liberia. Here, there are no manicured front lawns with sun-dappled trees and a stay-at-home mother smilingly washing dishes over a white formica countertop. No soft-focus filters here.

Precious’s mother—a woman who commands amazing respect for the amount she has given up to care for her daughter—brought the girl to the big white hospital ship that had just, that day, arrived in Monrovia. Patients weren’t being seen for another two weeks, and, regardless, Precious wasn’t the sort of patient we could have given anything to. But mom tried. And she was sent off to one of the local hospitals to treat the cellulitis that had set into her daughter's knee.

There, Precious received appropriate antibiotics. Except that she was allergic to them, unbeknownst to anyone. Her face swelled up. Her knee and elbow got no better. And then, slowly, the facial swelling turned into outright death. The tissues on her face succumbed to a condition—unique to the malnourished developing world—called noma. Or, in its more grotesque nomenclature, cancrum oris. Noma is an opportunistic infection that attacks a slightly depressed immune system (usually after measles; sometimes after other infections), almost exclusively in the undernourished child. The bacteria that live in all of our mouths decide it’s time to feast. And feast they do.

Precious was—relatively—lucky. She lost her lips. They turned black and fell off. I’m not making that up.

But she could have lost more—others have lost lips, noses, and eyes. Her mother did not give up. Precious had been befriended by one of the receptionists on the ship, who visited her at the hospital daily. Three months later, during which time her mother had not once been home, not once left her daughter’s side, the infection had been successfully controlled and the noma had run its course.

Precious was brought on-board for reconstruction of her lips. It’s a long, four- or five-month ordeal, with six or seven stages (for those of you facile with lip reconstruction, this is like nothing you’ve ever seen before). She has finished stage I. And, for the first time in three months, mom has been home to sleep in her own bed.

What happened to Precious would never have happened at home. At home, kids eat too much. At home, they get vaccinated against measles. At home, when they scrape their knees, mom drops her dishes, runs out under those sun-dappled leaves, concern dancing in her eyes, antibiotic ointment in hand. At home, we make feel-good commercials about the very thing that has permanently scarred a little girl like Precious.

Man is born into trouble, wrote the ancients, as surely as the sparks fly upward.