Civil War

It is routinely amazing to compare the perspectives between Americans and Sierra Leonians. It's easy to come here and say:
'Wow, half of Waterloo doesn't have electricity?'
'Can you believe that people can buy injection Ceftriaxone and IV malaria meds in the street? Isn't that dangerous?'
'Look at all these cars that look to be on the edge of just falling apart!'
'Sometimes they eat plain rice for 2 meals a day!'

But if you catch a Sierra Leonian in a good mood, they can easily talk about all the improvements: cellphones, good roads, less people are dying because drugs are more available, electricity is more reliable. Oh, and the civil war and Ebola are over.

Both of those events still weigh frequently on the mind of the people. There's a region of houses called 'camp,' because that's where the refugee camps used to be. Mr. Abu knows many of our patients because, "They lived near us in the camps." Even when I'm talking about histories of disease, people talk about before or after Ebola and before and after the war to describe time. Time is squishy here, so Ebola is roughly 2014-2016 and War from 1991-2003.

About a month ago I was hanging around and chatting in Danquah's office. He is the hospital chaplain and district evangelist. The district pastor and some other people were also there. I don't even remember how we got started talking about the war, but it was story after story of atrocity. I'll keep it brief and don't worry, the conclusion is surprisingly redemptive.

A squad of soldiers walks up to you and demands you take off your shirt. Then they ask, do you want a long sleeve or a short sleeve shirt? If you don't answer, you get shot. If you say long sleeve, they cut off your hands at the wrist. Short sleeve, and you're off mid humerus.
They find a pregnant woman. An argument breaks out, is it a boy or a girl? They place bets and find out in the most barbaric way possible.
If they meet someone with dirty hands, they bring them to a kitchen with boiling oil. They demand that you wash your hands, or be shot.

But the crux of the stories in the office wasn't evil, it was restoration. After the war, I was told that the government made a huge effort to take all the guns, provide amnesty, and provide work and trust to the majority of the rebels. Because they had integration, a purpose, and were spread throughout society, things have remained peaceful. I was told that I've interacted with many rebels and never known it.

With these memories so fresh for almost all the adults, it sometimes manifests as judgement on the younger generation. They will see children using sticks as guns and swords and scoff, 'Ah, these Pikin (children) don't know anything about war!' This wasn't explicitly told to me, but it was implied that sometimes adults forcefully break up children's war games.

When I compare my perceptions and focus on Sierra Leonian poverty with their perceptions of progress and hope I am humbled. When I feel like life is difficult here, I'm immediately shamed anytime I leave my front door. This contrast has also forced me to compare cultural values.

This whole blog post spawned after listening to a song written in the 1960's about childhood in America. Its discussion centers around war toys and culture. I grew up in the deep American south with trucks, guns, and camo. It's nostalgic and pleasant to me. But in Africa, I'm reminded daily that every culture has both something to learn and something to share. For now, I'm only learning.




Tom Paxton "Buy A Gun For Your Son" 1965
https://www.youtube.com/watch?v=WphNO24h9nA&t=0s

Daily Routine

We’ve started to settle into a routine, which is nice. But it’s also busy. Once you know how a day usually runs, it’s easier to pack more and more into it.

6-6:30 AM: The night guard asks to be let out of the gate.

The door is secured from the inside, so nobody can leave without being escorted and having the door closed from behind. Actually, when I leave the house and Rachel is cooking, I lock her in.

We eat breakfast, commonly pancakes or eggs (we eat SO many eggs), read worship and emails. We rarely shower in the morning. Not having a water heater makes it too cold to shower.

7:50 AM: The day guard asks to be let in. Rachel and I walk to the hospital.

It only takes about 5 minutes and I really enjoy the walk. The air is cool, there are swarms of children in uniforms, people commuting to work on motorcycles, and there’s a small girl who screams across a field “HEELLOO!” Greetings are important, so everyone should be greeted as soon as possible. On the way to the hospital we always greet the canteen owner, Linda, the various hygienists who are cleaning the hospital, as well as patients and their families who are sitting in the common areas.

8:00 AM: Meet with the CHOs (Community Health Officers).

The CHO’s are similar to the concept of NPs or PAs in the States. They have medical training designed to be used in underserved or rural areas, or to augment and assist the work of physicians. At AHS, they serve in every department: outpatient, mobile clinics, and they round on patients admitted to the ward both days and nights.

During our meeting we discuss all the new patients overnight, all the calls on the patients overnight, and any interesting cases. They teach me about things that are rare in the States: Quinine, Schistosomiasis, witch guns, the burial practices of the paramount chiefs. Apparently not many people are invited to these funerals. But rumor has it that the recently deceased has his head removed and replaced with the preserved head from the prior chief, who probably died decades ago. Then the recently deceased’s head is preserved for their successor. I teach much more boring stuff: diabetes, hypertension, fluid management.

8:30 AM: Morning worship

All the staff come together for worship. We sing a hymn together. Often times the organist is late, so they just jump in and try to figure out what song and what key we are singing in. Then there’s a small thought presented by the staff (everyone rotates through). Three days a week it’s a worship thought, two days a week it’s a health talk or policy talk. Afterwards is announcements, which last anywhere from 2 to 40 minutes.

9:00 AM: I try to do as much work before anything actually starts.

Every day after worship there are ~5 impromptu sidewalk meetings. I look around, see if I have questions for anyone, then I escape to my office or the wards. This is the time that the staff go for breakfast. So I’ve got about 30 minutes before anything happens and I can see any urgent cases, organize my office, do administrative work, etc.

~9:45 AM to whenever afternoon: Work, work, work.

Often times, it doesn’t feel like I’m a doctor. I feel like more of a firefighter. There are constant interruptions and little ‘fires’ to put out. I’m learning this is cultural. I can be in an exam room with a patient and a nurse will come in to show me a normal lab result from the ward. Accounts will come ask questions about bills. Nurses who are changing shift will interrupt my office consultation with a patient to say good afternoon. Patients I’ve already seen will come back to ask a few more questions. Sometimes the patient who I’m seeing will provide feedback, translation, or medical advice on whoever has interrupted their visit!

Sometime during the day, we sneak up to the canteen to eat lunch. Linda cooks very well and it is delicious. It’s usually less than $2 for both Rachel and I to get food and a drink. Although with the prevalence of typhoid, we are starting to eat there slowly. We will increase in the future. Since Rachel works part time, she heads home around 2:30. She’ll go to the market, cook food, clean the house, organize the laundry, all the things that allow me to live.

As things slow down in the evening, I wander through the hospital. I look at all the patients, without opening their charts: Do I know their story? Do they look sick? I chat with all the nurses: Is there any trouble here? I’m paid to worry, so I’m always looking for trouble. I find that if I don’t do this, I get stopped 4-5 times when I’m actually trying to go home.

About 5:00-9:00 PM

I walk home to the house and greet the outgoing day guard. Rachel and I eat supper and are usually interrupted by the night guard. After we’re tired of being sweaty, we shower and retreat to the bedroom which hosts the only air conditioner in the house. We do most of our communications at this time: email, whatsapp, facetime, so that our recipients are awake.

9:00 PM to 6:30 AM

Our night guard patrols around the house. It’s not uncommon to wake up with the crunch of gravel just outside the window and a flashlight shining through the frosted glass. It was unsettling at first, but has become more and more reassuring over time.

In the US it always seemed like the limiting reagent was time and schedule. Spontaneity was crushed by planning. Since being here, it seems that my limiting reagent is energy. Since time is fluid, I can prioritize anything I want. But it means that when I’m worn out for the day, somebody might ask for more. Both have their advantages, but so far, I’m really enjoying not having a strict schedule.

Bra Blog

On my way to work every day I pass by the saddest, tattered, dusty bra on the pot-hole ridden dirt road I traverse. It has been here as long as we have – so at least 6 weeks. It has been walked on and completely flattened by motos, trucks and cars. How did it get there? Why is it there?

     It seems odd to write a blog post about a bra, but it is now something that is on my mind daily- for a few seconds anyways. It has made me think of other bra encounters I have had, most frequently in the market. The traders throw out a rectangular sheet of cloth and literally dump a pile of bras on it, welcoming customers to dig through their selection while motos whiz by and dozens of passerby’s observe. It’s a far cry from an air conditioned, private, pink colored dressing room with a button to summon an expert to help find you the perfect fitting brassiere.

     Speaking of perfect fitting… I see many female patients every day. When examining patients everyone is quite willing to disrobe without prompting so I can clearly hear their heart and lungs. Many of them are pregnant or have given birth and are breast feeding. I’ve been astonished by how many breastfeeding mothers do not have well-fitting bras. I’m talking 3 to 4 times too small. Which is extremely uncomfortable and not to mention unflattering, but probably more comfortable than going without (which is perfectly acceptable here by the way).

These experiences have helped me realize how disproportionately poverty affects women. Poverty is why the streets are littered with trash, which includes a bra. Poverty leads to less access to birth control which contributes to more pregnancies and lactating mothers who cannot afford new bras and clothes to accommodate all the changes that happen during these times. And if they can afford it, the shopping experience is far from glamorous. Even the Viktoria Secret we snapped a picture of on our way to the capitol looked a little sketch. So when I walk by that bra that’s had a rough life I chuckle every time, but I also am thankful I won the lottery in life and got to buy my bra in Secret.

     

Economics

Today I found myself standing at the foot of a bed. The smell of rotting flesh, moist plants and dirt, old dressings, and the feel of a foot that is moving freely of its leg has forced my mind to seek refuge somewhere else. When overwhelmed by sensory stimuli, where does any reasonable brain turn? Economics, of course.

Twice today I found myself faced with difficult economic questions. It seems that here, when someone is between a rock and a hard place, it is much more obvious. Money really could make a lot of things easier.

First was a woman in the female ward. At 45 years old, she is a 'defaulter.' Previously on HIV meds, but has quit taking them. She has been sick for weeks before coming to the hospital. She came in looking like a skeleton, speaking nonsense, hallucinating, and refusing all oral medications. We treated her for a myriad of infections and she began to get better, until Friday. Her abdomen became tender, her fever worsened, she became more sleepy. Yesterday, she was stable. On my arrival to the hospital this morning, she is gasping, and non-responsive. Nobody knows which family members know about the HIV diagnosis.
I begin to hold meetings. So many draining meetings. It feels like divorce court, custody battle, criminal court, all mixed into one. First with the daughter, who knows the diagnosis. She recommends I talk to the patient's mother, so I gather them into my office for the second meeting. The mother guesses what's coming. Even though we are sitting across a desk from each other, while sitting, she turns her body away from me. She only glances over her shoulder to look at me when she thinks there's good news. Her frame visibly shrinks as I say HIV. She sheds a few tears. Secrets are common here. Crucial things are kept from the ones closest to you. Everything I say all day to this family comes as a shock.
After a few hours, the mother recommends I talk to the brother. The brother faces me squarely, stoically, calmly. I get the sense that he is the decision maker. We have a prayer. We make a decision. Nope. After a few hours the father shows up. We do it all again.
At every meeting, my message is the same. 'She has HIV. Her body cannot fight infections well. We have given her the strongest medicines. Any HIV medicines would kill her. We are out of options. She can stay here to die, or you can go home.' All the meetings have the same conclusion; she needs to go home. Transporting a live corpse is much easier, cheaper, and more legal than transporting a dead one. Strangely, this was not the most difficult part of this case.

The accountant, Junesa, comes to me asking about the case. I explain that there is nothing that can cure her and I'm just keeping her comfortable. "They haven't paid anything on their bill. It's 1.6 million Leones." ($160 USD) I tell him that I cannot answer his implicit question, 'Should we let them leave without paying anything? They won't come back to pay the bill on a dead woman.' What I do tell him was meant to be empowering, but probably felt like a ton of bricks.
"We are outside the realm of medicine here. This is about families, death, social customs, priorities. Things that I'm too new here to know anything about. On one hand, this woman probably should go home to die. On the other, it's the 6th and we can't pay everyone's salaries. I will support any decision you make."

How is he supposed to make this decision? His colleagues have been without pay for almost a week. With many hospital workers making about $3 a day, this 1.6 million would pay almost one and a half salaries for the month. On the other hand, this family is losing a 45 y/o woman. She is supposed to be making income for everyone. Now there are funeral costs. Are we going to financially cripple this family and deny this woman a death at home, over money?
Junesa is a good man. She made it home before she died, hours later. But there is still no way to pay salaries.



That was about 1pm. Now fast forward to 5:30 pm. It's Sunday. I'm trying to go home. I get word there's an emergency case in the male ward. I correctly assume that my plans for a 6pm lunch are going to be postponed.



A young, by US standards, approximately 47.5 year old man was in a RTA (road traffic accident) about 10 days ago. His leg was obviously broken with exposed bones about 8 cm above the ankle. They took him to the biggest hospital in the country where he received X rays and IV medications. He wasn't miraculously cured, so they left the hospital about 7 days ago to use "traditional medicine." This evening, he's in my hospital bed with a BP of 80/40, altered mental status for the last 2 hours, and no electricity or staff to run labs. I text Dr. Kabba, the surgeon, on his day off. He makes some calls and one of the theatre staff comes to the hospital to give me access to the dressing supplies.

The Traditional Medicine consists of twine, wrapped around thinly split bamboo that is holding into place some thin cloth. Under the gauze is 2 cm thick, black, moist, putrid plant and dirt material. It crumbles away into clumpy flakes that soon cover the lower part of the bed. Underneath is another thin cloth, and underneath that is rotting flesh. All of this is soaked in a pretty foul body fluid.
Like I said before, economics is sounding pretty good right now.

After cleaning the wound and applying some clean dressings, I pull the family aside. 'Tonight, I am going to try to stabilize him. If he survives the night, the only thing we can do to save his life is an operation to remove the leg. I don't know the exact cost. But if you are talking to your family, ask for money.'
"How much?"
'I don't know for sure. Dr. Kabba will make that decision in the morning. My guess is three to four million. If we don't do this operation, he will die.'

This leads me to my questions for the day:
- How does capitalism work, when the options are: "pay 3 million or die?"
- How do you place a monetary value on dying at home with family?
- Is providing a good death an ethical option, when you can't pay those who are currently living and feeding children?

Somebody may have the answers to these questions. But it's not me.
However, I do hope that by writing this before falling asleep, it will help me dream of dusty, boring economics books. That way, I can avoid dreams of other things I've smelled today.