The End

Finally, the rain. After four months of scorching, dry-season sun, we arrived home from a perfect weekend – camping on the beach in Robertsport – just as the grey cloud over Monrovia broke open. We stood on the balcony, watching the torrential downpour, the wind bending the trees, the flashes of lightening. I imagined the thunderous racket it must be making against the corrugated tin huts, and the people laughing inside, seeking shelter.

And suddenly, it was all so beautiful to me. The landscape of rich green brush and raging ocean. The red sky.

In my last month in Liberia, I came to understand why Eric, and perhaps God, wanted me to come here. As I finally surrendered to the sweltering heat, stopped trying to avoid all the germs, learned to be vigilant but not afraid, accepted the situation for how it was, not how I thought it should be, my focus shifted from the discomforts and the tragedies to the rewards.

It is so easy to be helpful here. To bring about happiness. While in the ocean one day, I noticed a teenage boy watching me from the shore. He hung around for at least 30 minutes, kicking around a half-inflated soccer ball, and shouting out encouragingly whenever I caught a good wave with the boogie board. Before Eric and I left, we asked if he wanted to try the board. He shook his head and lowered his eyes, explaining that, like most Liberians, he couldn’t swim. “I’ll go in with you,” I offered. His face lit up and he grabbed the board, running in to the water and lying down where it was only knee deep. He laughed joyfully as waves zipped him to the shore, again and again. I remember the ecstasy in his face.

When the night is dark enough, even a small candle makes a brilliant light. (This line, from a book I read in seventh grade, has stayed with me always.)

Our last day in Liberia, Dr. J. organized a goodbye ceremony for me in the hospital chapel. I arrived just as morning service was ending, and grabbed a seat on the edge of a pew. My colleagues’ voices lifted in rich gospel melody around me, reverberating off the cement walls of the small room. I closed my eyes and was surprised to feel the tears well up in them, as I considered the richness of spirit that I would soon be leaving behind. Somewhere along the way I had come to adore these people, this hospital, this country. I felt grateful to have had the opportunity to get my hands dirty with them (both figuratively, and literally, given the frequent lack of soap and running water in the hospital). They would continue to truck away in this mess, long after I left.  Dr. J presented me with a gift, and kind words of gratitude for my service there. Throughout the day, doctors, nurses, pharmacists, lab technicians, came over to say goodbye. Some even brought me gifts.

Before I left, I checked on Fortune, a four-year-old boy who had stopped breathing the day before, after being given too much Valium to stop a seizure he was having secondary to malaria. I was relieved to find him sitting up in bed with his father, looking like a new boy. Vanessa, an ICU nurse from the U.S. who volunteers once a week at JWH, had been observing me the day it happened. She had noticed the nurses making a commotion around his bed, and when we went to investigate, we found him lethargic and sputtering occasional, wispy breaths. I had sent her running for a pediatric bag and mask so we could do artificial breathing. She had tried the ER, the delivery room, the OR, everywhere she could think of, without success, until she finally found one in the dental clinic. We breathed for him until the effect of the drug wore off, and watched him closely for the next few precarious hours. Sitting on the bench with Vanessa afterwards, listening as she vented her frustration over nearly losing Fortune because of a lack of supplies and trained staff, I remembered how I felt when I lost my first diabetic patient because there was no insulin in the hospital. Anger is a great motivator. Just the morning before, I had attended my final meeting with the Diabetes Society of Liberia. They are now incorporated, have textbooks, and a plan. We said heartfelt goodbyes and they committed, amidst laughter, to not stop until they achieved their goal, coined by Eric, of “Taking the Die out of Diabetes”! I smiled inwardly as the infuriated Vanessa went on about needing to do resuscitation training for the nurses, and create a crash cart. You go, Girl.

*****

Two days earlier, we’d sent out text messages to our friends suggesting that they swing by the Boulevard Café on our last night in town. We were touched at how many showed up. We laughed as they filled up the courtyard – did we even have this many friends in Toronto? Wonderful people from all different countries – smart, kind, brave and fun – it had truly been a privilege to get to know them. Dolo’s girlfriend, Dorita, came all the way from Ganta (a 6 hour drive!), and they presented Eric and me with beautiful African outfits.

Halfway through the evening, our party was interrupted by the sounds of mayhem outside the courtyard. Another episode of mob justice: someone had been caught stealing a laptop from a car and was being attacked by the crowd. There in that moment, as the sounds of our friends enjoying themselves on a balmy night mingled with the ruckus of the angry mob outside, as we did our best to maintain normalcy and vigilance at the same time, was the paradox, the beauty and the beast that is Liberia.

She is magnificent, with her endless coastline and fiery sunsets, but you cannot walk on her beaches after dark. She is full of children, but has lost her innocence. She is in a time of stability, working on her growth and development, but the UN talk of leaving in a year, and everyone knows that there are enough arms hidden under the forest floor to equip an army.

There is no doubt – she is complicated. But as a wise man once told me: the best women always are.

Field trip

Early in my trip, I met a young woman who worked for a non-profit organization dedicated to supporting local orphanages. My last week here, I took her up on her offer to take me around to visit a few.

Our first stop was to a foster home, to check on the progress of a little girl they had removed from an orphanage where she was suffering from neglect: at 4 years old, she had been apathetic, withdrawn, not yet walking or talking. My friend was delighted when we saw her. After a month with one-on-one attention from her foster mother, this girl had blossomed. She was animated, clearly attached to her mum, and had even begun to speak. While we were there, another foster mother asked if we would check on one of her kids who was not doing well. That is how we discovered Dekontee.

Dekontee was found in a garbage dump last year. Her estimated age is around 18 months. Her foster mother, who cares for children with special needs, brought us into her house. We were shocked when she came out of the bedroom carrying a skeletal baby, dehydrated and malnourished, covered in oozing pressure sores. I have never seen such a sick looking child.

My friend and I looked at each other and at the child with concern. How many such nightmares exist behind closed doors? How could no one have known about this? Apparently there is a nurse assigned to check on the children in foster care, and my friend said she would follow up to find out why Dekontee had been overlooked. In the meantime, we agreed that we could not leave her there. We loaded the baby and her mother into the truck and brought them to the MSF hospital, where she was admitted to the ICU for aggressive rehydration and nutrition.

Drained after this unexpected detour, my friend asked if I still wanted to visit another orphanage, or just go home. She assured me that the one we would visit next was uplifting – an example of an orphanage that works. She wanted to show me this one in particular because I had treated the oldest girl there when she was sick. Thank goodness I agreed, because it was the sweetest, most memorable experience. Like Dorothy landing in Oz, I was immediately surrounded by adorable munchkins, grabbing my hand, snuggling up to me, and, no kidding, they even sang and danced:

We took a tour of the house, an unlit cement structure with three bedrooms. One for boys, one for girls – both sardine-packed with wooden bunk-beds – and the last for the couple who ran the orphanage. Unlike most institutions, where the directors’ family live and eat separately from the orphans, I learned that the girl I had treated, as well as two other children I met that day, were their biological kids, but they slept amongst the others, and everyone ate together from the same pot.

Surveying the surroundings, I was struck by the absence of toys, TV, video games that normally litter the homes of most children I know. A friend recounted his experience taking wealthy donors to see the well-run orphanages, watching fifty-year-old men become tearful because “these kids have nothing, and they are happier than my kids at home, who have everything.”

We are wit you

Have you ever seen a depressed ten year old? It is so unnatural. Unwilling to smile, dragging herself about, refusing to eat or drink. The first time I met Julia, she was sitting on her hospital bed alone, her emaciated arms in her lap.  A cloud of flies swarmed around her. She answered our questions in a quiet, monotonous voice, her eyes vacant. The nurses told me that she was refusing all her medications. “She ten, O,” I chided, “Can you jes force her?” But they had already tried. She had torn out her IV and feeding tubes, and since she had multi-drug-resistant HIV, they were concerned about the risks to themselves in doing procedures on her. She told a nurse that she wanted to die, to join her mother. Both of Julia’s parents had died from HIV. Her wealthy aunt shunned her because of her disease, and forbade the young girl’s sisters from seeing her.  I learned this from a man who came to visit her one day. His wife used to work at Julia’s orphanage – she and Julia were extremely attached. The orphanage recently fired many staff, including his wife, which may have contributed to Julia’s depression. I asked if he and his wife would consider adopting her. “Of course we would consider it. She is a human being, and needs love just like all of us.” He said he would need to speak to the orphanage director first, to find out what would be involved. I hoped each day for good news. But we were too late. Julia died over the weekend.

It was not HIV that killed this girl. Julia died from neglect.

Most doctors now think of HIV as a chronic condition that can be managed with lifelong medication. Dr. J once told me that if he had to choose, he’d rather be a Liberian with HIV than diabetes, because then at least your medicine and care are paid for.  Thanks to organizations like the Clinton Foundation and others, HIV is actually a well-funded, appropriately treated disease in Liberia. But there is still much stigma.

A month ago, I attended a workshop here on HIV. Some HIV-positive people stood up and shared their stories. One man told us how, before he was diagnosed, he kept getting infections and never fully recovering. He became progressively sicker, and lost about 30 pounds, until he was so weak that he could barely walk. Doctors told him to get an HIV test, but he was terrified, and refused. Finally, his mother found out what was going on and dragged him to a center to get tested. When they called his name, he panicked. His mother took his hand. She said, “Don be afraid. We are wit you.” When his result came back positive, he was devastated. He suggested leaving home, so he wouldn’t be a burden to his family. But she promised him, “I will stay wit you, til you ah strong enough to tell everyone thi story.” He got care, started on antiretroviral therapy. And there he stood before us, years later, looking healthy, energetic and proud, in a t-shirt that read “Fight the stigma, break the silence”. He called his mother up to the stage, and we cheered her.

A 3 month-old boy, Augustine, was brought in by his HIV-positive mother, Mary. He looked like a one month-old in size, betrayed only by his mature face, which looked exhausted and terrified. He cried or whimpered incessantly, and his skin creped over his tiny skeleton in spite of our attempts to keep him hydrated. He did not improve on antiretrovirals and potent antibiotics. We couldn’t figure out what was wrong. His mother slept in his crib with him each night, and we’d often find her crying when we did rounds. “I jes feel bad fo him,” she’d say, “He in pain.” As a last ditch effort, someone suggested adding anti-tuberculosis medications. To our amazement, over the next week, he became less agitated, and put on some weight. We were thrilled. But one day on rounds I noticed a small black spot on his arm. “What’s that?” I asked the nurse. “It from the IV. It jes a bruise.” The next day, the black spot got bigger. When I investigated further, I learned that he had received several doses of an antibiotic into his skin rather than his blood vessel, before the nurses noticed that the IV was misplaced. The black spot was necrotic skin. We watched in horror as the spot grew over the next few days to cover most of his upper arm, finally blistering and splitting right down to the muscle. Augustine was back to crying all day again, feverish and pathetic. Mary’s hurt and despair was obvious as she watched us pass by each day on rounds. She pleaded with us to do something. We didn’t know what to do.

The tissue in his arm was now covered with pus, and we were concerned that, given his weak immune system from the HIV, the infection could spread to the rest of his body. We considered amputation. The surgeon felt that we should wait. The baby was a poor surgical candidate, being so sick and frail. He would likely die anyways, he suggested, and cutting off his arm would be too disheartening for his mother.

His mother continued to hope. She cried for him. She fought for him. Every day, she’d report to me angrily: no one had come to see him that day on rounds, or they had neglected to change his dressing that day. Sometimes I would take him to the OR to change his dressing myself. He was so frail. Holding his limp arm over a basin as we flushed the pus out with sterile water, I felt sad and futile. HIV, TB, and now this? I admit to a wistful thought one day about euthanasia being a kinder option than the slow death this poor baby was suffering through.

When I returned from my week away in London, Mary ran up and greeted me with a big smile. By some miracle, the infection in Augustine’s arm had finally begun to dry up and look better. He had gained some weight and seemed more comfortable. Over the next week, he continued to do well. His face filled out, he looked rested. One day I came in to find him adorably dressed in camo pants, a T-shirt, and a tiny baseball hat. His mother bounced in to the room, her face beaming, to tell me that they were being discharged from the hospital.

Mary continues to return with Augustine every day for his dressing change. She holds her head high, and carries him around to say hello to the doctors and nurses, reminding us that, truly, there is no medicine like love.

Riding the waves

Although I was quite happy to return to Liberia, my body put up a fight: an airsick-bag-clutching migraine that started halfway through the flight and lingered for days. Eric had arranged for our Liberian housekeeper to stay over the night I got back, to let me in to the guesthouse since he was out of the country for a few days. When we finally pulled up to the gate at 2am, the guard welcomed me home and informed me that the housekeeper had left for the day. I stared regretfully at the enormous padlock on the door and the iron bars over all the windows, designed to keep the house safe from robbers, rebels, and now, weary Canadians. My friend Andrea took my apologetic early morning call and not only shared her bed with me, but (I saw upon waking) even gave me her pillow while she slept on a jacket. The next night, I returned to the guesthouse. Was a bit nervous to be there alone, but having tested its impenetrability the previous night, figured, what could go wrong? Woke up at 3am, drenched in sweat. Fumbled for a towel in a darkness so black that it could only mean one thing: the generator had run out of fuel. I opened the window, unsure whether the hot air was worth the occasional breeze, jumping with every outside sound till sleep finally overcame me.

Another inspiringly generous friend, the one who had loaned me her winter clothes for my London trip, was going out of town and offered for me to stay at her place until Eric returned. She has the nicest apartment in the city. I was so grateful, and moved in the next morning. I languished under the chill of her 24 hour AC, cranked up her ipod speakers and danced through her apartment, enjoying the electricity, the safety, the hot showers. But inside me, a somber thought: this attitude is not sustainable.

Liberia, it was clear, did not agree with me. At best, I was tolerating the situation. I could have left it at that, but I wanted more. I wanted to understand, and to love Liberia. I needed a new approach. I sat on my friend’s balcony, overlooking the ocean, and wrote…

I have been blaming Liberia for my aggravations, for the dangers and devastating conditions, but Liberia’s chaos is not its own fault. It is the fault of the history it came from. Liberia is, in the words of President Sirleaf (paraphrasing Winston Churchill), “a conundrum wrapped in complexity and stuffed inside a paradox”.

There is nothing simple about this country. If it were just bad, no one would care. If it was just poverty, it would be easier. Liberia is messy, confusing, magnificent, disgusting. As Rimu said, it is raw. She likes raw. Me, not so much. I like soft. I like hidden. Liberia invites me to be open, honest, angry, sad, naked, to tan, to drink, to smoke, to party, to gossip, to scream, to sing, to dance. To sweat.

I suddenly remembered the therapist in the dentist’s office, holding up the Anger Sheild and its two questions:

What am I demanding? What am I protecting?

I am demanding order. Structure. Comfort. Reason. Peace. Cleanliness.

I am protecting my sanity. My wellbeing. My looks. My environment. I am protecting my long-term vision of being healthy, comfortable, having children.

I was surprised, and embarrassed to see that it was all about me.

And the strangest thing is, for all this armor, it’s not working. Liberia is stronger than me. All of the above are why I moved to Toronto. Toronto offers reason, comfort, structure, cleanliness.

But what about fun? What about hysterical laughter? What about living fully and richly and using up every last drop of yourself? Don’t you have any desire for that?

Yes.

What about the joy of sun hitting your face and warming you up after a swim in the ocean? What about dancing until your body takes on a rhythm of its own and you lose sight of everything around you because you are lost in the music? What about earning your wrinkles and your face telling the story of a million laughs? What about having a life that really matters? That tells a great story? That lingers on in people’s hearts long after you go?

Eric came home from Tanzania and we returned to the guesthouse. I went back to work the next day, delighting nurses and patients with chocolates, pads and pens and tea from the UK. Saw lots of patients, almost 60 on one day. I sweated profusely, accepted offers of local food, was unfazed when the hospital again ran out of water. The elements didn’t bother me as much. I wasn’t as scared of getting sick. Saw how lucky I was to have the guesthouse we do, the pool we can go to, the car we have access to. Understood that all of it, no matter how crude it is by North American standards, is a gift. The only time I lost my cool was when I almost missed my meeting with the country director of the Clinton Foundation because my driver bailed at the last minute. But by strange coincidence, as I was scrambling unsuccessfully to find a taxi, I heard the woman with the next ER patient say her name. It was the same family name as the country director! It was his wife, bringing in his mother in law. I called him and asked if he wouldn’t mind my being late, so that I could see her. He was grateful, and I now had time to find a taxi. The meeting went well. He was excited to hear about what the nurses are doing for diabetes, and offered suggestions and support.

On the weekend, Eric and I attended the screening of an episode of On Surfari (a social consciousness raising travel-surf show) that was recently filmed in Liberia. About 30 of us gathered in Chuck’s backyard, to watch the show projected onto the wall of his house, followed by the recent Superbowl. As we watched the game under the almost full moon, enjoying the gentle breeze and the sound of the nearby ocean, drinking Club beers and laughing at the lizard cutting across the screen, it was hard to imagine that we were in a dangerous place. I could understand in that moment why someone like Chuck had chosen to bring his wife and kids to live in Liberia. He told me once that he would have gone crazy being a dentist back in the US. Here in Liberia, he is so much more. He has done massive facial surgeries, even tracheostomies (putting a tube directly into the neck to help someone with a blocked airway breath.) He lives on the beach with his wife and kids, often fosters children. He surfs every chance he gets. Pretty sweet.

And then there is the other side of life in Liberia. I was sitting in Eric’s office this morning when I heard the shouting, and screaming. When I looked outside, I could see men running on the road with shovels and sticks, joining an angry, excited mob that pushed their way in to domestic compound across the road. Someone explained to me that they were beating a man who had been caught stealing people’s cell phones. We watched them from our locked up compound, and called the police, who never came. The guards were surprisingly nonchalant. Mob justice is how they deal with small crime here. The street is clear and quiet now, with no trace of the violence except in my disconcerted mind.

My new attitude does not preclude acknowledging the danger. It simply accepts, rather than resents, that danger exists, and considers that sometimes being somewhere dangerous has amazing, life-altering things to offer. One surfer explained to me that the best time to catch a wave is when you find yourself in its darkest, scariest point. A moment too soon, or too late, and you miss it. But catch it, and you have harnessed the power contained in that wave, which is an experience I’ve heard described as Nirvana.

And so, when I faced the fierce ocean that had just sent me for a scary tumble off the boogie board I recently acquired (precursor to surfboard, I hope), I felt a certain pride and excitement. I knew this was supposed to happen, that I was being educated on the ways of the waves, that by falling I would eventually learn how to stand.

Liberia, teach me to relax. Teach me to stay healthy amidst the dirt and danger. Teach me to hone my instincts, to know whom I can trust and whom I cannot trust. Teach me to embrace the elements. To live with less. To be beautiful when I am dirty and untamed. Teach me to have faith. To feel still within the chaos. To understand that security is an illusion. Help me discover the raw side of myself that Africa beckons to, and that I have been resisting.

Robertsport, Liberia (courtesy http://www.timesonline.co.uk)

London musings

2/16/2010

London has been a wonderful break so far. Spent the weekend with friends Sam and Rimu, who joined us from Holland. They love my makeup-free, blowdry-free, style-free look, and I must admit I am enjoying the freedom of having only one outfit to choose from. (Since I didn’t bring any winter clothes to Africa, I am living off the generosity of an expat friend who loaned me a few layers for my getaway). I am deriving unprecedented pleasure from brushing my teeth with tap water, eating apples (unpeeled!), walking on streets after dark. There have been a few shocks, naturally. The nose-numbing cold, white people everywhere, the abundance of choice in all things material and gastronomical.

Sitting in Starbucks, I watched as a mother coddled and sang to her shrieking child, to the dismay of all the other customers. Though the bloodcurdling screams were annoying, I felt refreshed by the defiant scene. I find myself aware of how parents here fuss over their kids, painstakingly loading them in and out of cars and carriages, picking up toys that spill over. I strain to catch glimpses of them – their sweet red cheeks and button noses – for they are few, and elaborately bundled.

I remember my shock when I first arrived in Liberia. “Where are their parents?” I asked Eric. There were children everywhere. Walking themselves to school in pressed uniforms, running and playing outside the shacks, selling oranges and bananas on every corner.

credit: Rabuna Fi ministry

Liberian kids are mostly well behaved and mature. Discipline is different in Africa. A Tanzanian friend who married a Swedish woman laughed at the differences they would undoubtedly face in child rearing. “In Tanzania”, he explained, “if a neighbour smacks your child, you will thank them, because it means they cared enough to teach your child not to do something wrong.” Mothers lift their babies up by an arm and swing them over their backs to tie on with a folded lapa. I keep waiting for the pediatric dislocated elbows to roll in to the ER, as they do on a regular basis back home. But they never come. Are they made of tougher stuff, or does Liberian living make them tougher? I was recently admiring the strength of a boy no more than ten as he drew heavy buckets of water from the well outside Eric’s office, gradually filling up a five gallon barrel. My mouth fell open when he squatted, lifted the enormous barrel on to his head, and proceeded to walk home.

Fertility is a popular topic at the clinic. A woman came in last week complaining that it had been 6 years since her last child, could I help? She told me she had four children already. “Fo chil? An you wan mo?” I asked incredulously. She nodded, giggling. Perhaps people want to buffer against the high child mortality rates in the country. Perhaps it reflects the limited availability/use of family planning resources. Perhaps it is because, in a country with so much recent trauma, children bring hope and laughter and joy. Whatever the reason for the remarkable fecundity, I notice, in London, the absence of sweet little faces, endlessly curious, smiling, waving. I miss them.

In my last week before my UK holiday, two pediatric patients grabbed my heart: Jacob, and Fatima.

It was hard to mask my horror the first time I saw five-year-old Jacob’s face. Where his right cheek should have been, his mouth grew in to a gaping hole, a garish display of rotting teeth and bone. His father, who brought him in from a village 350 miles from Monrovia, said it had begun as a blister four days earlier. His mother was notably absent – she had apparently died three years earlier, of unknown cause.

I had never heard of, let alone seen, Noma (Cancrum oris). It is a gangrenous infection of the face, usually affecting children under 12, which occurs in the context of extreme poverty, chronic malnutrition and poor immunity. Noma has not been seen in any industrialized country since before the 20^th century, thanks to improvements of sanitation, nutrition, and immunization. The exception was during World War 2, when it was endemic to Auschwitz and Belson concentration camps, and was studied by the infamous Dr. Mengele. I cannot understate the debilitating nature of this illness. Without treatment, victims usually die within a week. If they get treatment and survive, they are left horribly disfigured.

We put Jacob on strong antibiotics, debrided the dead tissue from the wound. With a dressing over the hole, held in place by a bandage wrapped around his head, he looked like a little mummy. He quickly became the ward darling, following nurses around as they doled out morning medications, running up to me when I arrived, then back to his father to whisper “the white lady is here!” If you couldn’t find him, you just had to look behind the empty wheelchair rolling back and forth along the hallway. We were all disappointed when his HIV test came back positive. We dreaded telling his doting father, but he took the news well. Turned out he had known about his wife’s illness, and his HIV tests had consistently come back negative.

We initiated Jacob on antiretroviral medications (a challenge even for adults, given their long list of side-effects), and made arrangements for his father to take him back to their village. Next January, the Mercy Ship, a traveling hospital that brings specialized surgery and other services to the world’s poorest countries, will be returning to Liberia. Our hope is that if he does well, Jacob can have his face reconstructed by a visiting plastic surgeon.

The other patient is a girl I wrote about previously, the one who was sent to us from MSF. Fatima’s small hand on my arm lingers with me. She had placed it there the first time we met. When she lay like a vision of life passing in the ER, to warn me against pressing too hard on her sore belly. She survived surgery the following day, in which they found feces throughout her abdominal cavity – evidence of a perforated bowel, presumably secondary to typhoid. At the end of the day, one of her family members jogged up to me as they saw me passing outside, and told me she had been asking for me. I was sure they were mistaken, and doubted that she would remember me from her septic state when we met. When I arrived, she was awake in her bed. She turned her head weakly toward me when I sat beside her, and, unable to speak, lay her fragile fingers again on my forearm. I visited her each day, still hesitant to hope, upset by the green bile that continued to fill the bag draining from the tube up her nose. I had no idea if she would make it or not, but feigning optimism, encouraged her family to have patience. Eventually the tube came out and she was able to eat. Her strength came back slowly. The day before I left, I did a double-take upon passing a beautiful young lady sitting in a silky sky-blue sundress outside the peds ward: “Fatima?!” She smiled shyly at my delight. Fatima is now almost fully recovered, but remains in hospital dealing with a horrible wound infection at the site of her surgical incision. This is par for the course in a hospital setting where the water ran out last week. What is important is that she will live.

As my week in London winds down, I wonder if I am ready to return to such stories. I have only a month left in Liberia. I got an email yesterday from the country director of the Clinton Foundation, agreeing to meet with me to discuss diabetes care. At our last meeting, the nurses who I have been meeting with weekly gave themselves a name – the Liberia Diabetes Foundation – and outlined goals and responsibilities for themselves. They have a radio spot and a community talk lined up. Ready or not, I want to see this through.

***

2/18/2010

Toward the end of my last day in London, I emerged from the Tube to find that my guidebook had been wrong, and the National Gallery did not, in fact, stay open late on Wednesdays. I lingered in Trafalgar Square before heading back to Sam’s. In spite of the cold and darkness of that evening, the square was alive with activity. Teenage boys doing tricks on rollerblades, less skilled youth taking turns sliding head-first down the wide wooden banisters, couples holding each other as they strolled, families taking photos in front of the majestic fountains. Beautiful statues framed the scene. I thought, here is the potential of a wealthy city at its best. I tried to imagine such a scene one day in Liberia. I could not – the gap is too wide. But this did not evoke any ill-feeling in me. Granted, London did not need all these streetlamps, the multi-coloured lights beaming through the fountains, the cobblestone. But it was wonderful, enjoyable, and I couldn’t imagine a Liberian begrudging such beauty. I considered how lucky I was to see this scene that most Liberians will never see, and tried to capture it in my mind, to share with them when I get back.

Burnout

That evening, I found myself slumped on the floor of the balcony, contemplating going home. I was tired of being sick. I was tired of Africa.

My colleague and friend, Dr. Gabor Mate, wrote a book called When the Body Says No, in which he argues that when we say yes to things that we do not want to accept, our body refuses for us by manifesting illness. It seemed obvious what my body might have been refusing – children dying, inadequate health care, Africa, with its inherent dangers and discomforts. But what could I do about it? Why couldn’t I cope? I felt like I had failed, and I wasn’t even sure what the test was.

I spoke to Eric over dinner. He was concerned, and supportive, and admitted that he had been worried about me. Did I want to go home? He asked. I searched my heart, and realized, no, I just wanted to feel better. We considered the options, and came up with a plan.

Step 1: Drugs. I had always been critical of our practice of throwing a bunch of drugs at patients here, to cover all possible causes without having a certain diagnosis. But I was desperate, and, dismissing my concern regarding the small print for one of the drugs (carcinogenic effect of long-term use, in rats), I decided to take a dose of my own medicine.

Admiring retrieved shipwreck

Step 2: Take a break. I booked a 6 day trip to London, to visit my dear friend Sam. I’ll be heading there mid-February.  In the meantime, we took a break from Monrovia for the weekend, and drove with a friend to Buchanan, the second largest village in Liberia. Buchanan is renowned for its stunning beaches, and is also the site of Buchanan Renewable Energy (BRE), Liberia’s most interesting and inspiring link to Canada. This company was founded by a Torontonian, and was funded by fellow Canuck John McCaul MacBain, the self-made billionaire who founded the Auto Trader classified-advertising empire, and sold it in 2006 to set up the McCall MacBain Foundation, which promotes health, education and the environment in the developing world. BRE is clearing non-producing rubber trees (and replanting them, keeping the project carbon-neutral), to make wood chips which will generate electricity for Liberia and for export markets. They are also helping to rebuild Buchanan’s roads and bridges, and to clear the port, which is full of sunken ships.

We treated ourselves to the ‘Presidential Suite’ at the one hotel in town. (We were so excited when we saw that the wall of eight showerheads. Until we got in, and realized there was no hot water, and so little pressure that we needed to press our bodies against all eight trickling spouts to get wet.)

Over dinner with some BRE employees, we swapped stories and compared challenges of working in Liberia. One made us laugh about being quarantined by WHO when he was accused of having swine flu (the labs here couldn’t test for it and the postal system screwed up attempts to send the swabs to an international lab, so he ended up locked up for weeks with a common cold). Another left us breathless with his tale of surviving rebel attacks in Sierra Leone, including six weeks in the bush surviving on raw tubers.

I shared the story of the patient with the terrible face infection who died when the power failed. When I finished, even the tough tattoo-covered men agreed that I had earned a holiday. I smiled inwardly, thinking, okay, so maybe I’m not an African woosie after all. We topped the night off with some mirror-dancing at the local nightclub. (There was an bizarre moment when the hip hop stopped and a 50s-medley reminiscent of bar-mitzvah days came on. Eric and I swing-danced like good white-folk, as the rest of the dancefloor cleared.)

By the time we returned, 48 hours into my second antibiotic, I was feeling much better. I’ve continued to improve ever since. My energy is back, my stomach has stopped acting up. Africa is good again. I am still mystified as to the ultimate cause of my ills, but you can bet that the next patient who came to see me with a vague array of GI symptoms got more compassion than they bargained for, along with an aggressive plethora of pills.

Denial

Since our trip to Zanzibar in December, my stomach had not been right. I used to bemoan my patients who came in with a vague and endless string of symptoms, but now I had my own list: heartburn, headache, abdominal pain, nausea, fatigue. Even worse than the exhaustion was the apathy. I had no interest in anything (including writing, hence the long gap since my last entry).

After the second evening spent heaving supper into the toilet, I decided to get some tests done at the lab. The bloodwork was no problem, but providing a stool sample on command in a country whose diet emphasizes cassava and rice was no easy feat.  Ruled out pregnancy, malaria, typhoid, and – if I had a parasite – it remained elusive.

As I moped back to work, I was struck by a man pacing furiously outside the ER, shouting skyward to Jesus. When I offered assistance, he explained that his five-year old daughter was inside, unconscious. “Jes tell me if she dead, doc, jes tell me.”

I went to check on her. She lay on the cot like a rag doll, eyes open, not breathing. A passing nurse told me that Dr. F had already pronounced her DOA (dead on arrival). But I was sure I felt a pulse. Finding no resuscitation equipment or assistance in the ER, I lifted her limp body in my arms and ran to the operating room. I started blowing air into her with a bag and mask. But as the OR staff scrambled in slow-motion, unable to find oxygen, as they did not start the IV I called for, and as they watched me sympathetically, expending so much energy to save a girl who, they pointed out by raising her pale white palm to me, “has no blood”, I gave up. I searched for the pulse that I had felt earlier, and could not be sure that it had not been my own. I took in the pallor of her palms, her conjunctiva – signs of severe anemia, probably from malaria. With a heavy heart, I carried her back to the ER, and placed her gingerly on the cot. Her mouth slightly parted, adorable in her red floral sundress, she looked like she could wake at any moment. I stood over her sadly, feeling numb and confused.

I found her father outside, and confirmed to him that his daughter was dead. As he resumed his pleas to Jesus, the girl’s mother let out an agonized scream and began prostrating and rolling around in the dirt, beating her chest with her fists. We tried to lift her up, but she kicked us off.

I attempted to leave the hospital after that, but as I was being driven away, a nurse chased after the car, begging me to come to the ER. She pointed to a woman who could barely walk, whose abnormal blood results showed that she needed an urgent blood transfusion. Apparently there were no other doctors in the hospital.

I ended up working for another 2 hours in the ER. Admitted an eleven year old girl who was sent to us from the MSF hospital for an urgent surgical problem (they do not operate there). She looked deathly ill. Green bile filled the bag collecting liquid from the tube in her nose. Her urine was copper coloured. Her abdomen was distended, hard, and extremely tender. I called the surgeon to advise him. He told me he had heard she was coming, but that he would not be able to operate until tomorrow. The operating room was out of anesthetic.

Culture clash

A few weeks ago, I got a flustered call from Chuck, the dentist, asking me to meet him at LGH hospital, where he was bringing a patient who was “spewing pus out his face”. He was concerned the patient would lose his airway because of all the swelling in his mouth and neck. By the time he arrived with his assistant, I was waiting with three American doctors who were volunteering at LGH, as well as a Liberian ENT doctor, and the chief of the hospital (he had been called to request permission to take the patient to the OR.) We took one look at the patient – face engorged, straining to breathe, drooling, unable to speak – and had immediately agreement between the North American contingent: he needed urgent intubation (insertion of a tube through his trachea) to keep him from losing his airway.

Unfortunately, our Liberian colleagues disagreed. The ENT doctor wanted to take the patient to his clinic upstairs, to get a better look inside his mouth with his fiberoptic camera. Dumbfounded by his failure to recognize the urgency of the situation, we turned to the chief for reason. His tone was apologetic but firm. “I feel it is important that we respect the opinion of the specialists in this hospital.” We barely had a chance to argue before he iced the cake: “Also, this patient has not registered yet. Can someone please bring him back to the front desk?”

We convinced him to let a family member register on the patient’s behalf, but were begrudgingly forced to follow the patient as he was wheeled to the ENT clinic. We trailed behind him, muttering under our breath, our pockets stuffed with airway rescue devices and drugs.

We watched incredulously as the ENT doctor had the patient recline in his chair (this puts weight on the airway and makes it harder to breath), and inserted a camera wire through his nose. We nearly lost our own airways, holding our breath as the patient choked and sputtered. When his oxygen saturation dropped below 80%, we could take it no longer, and insisted that he abort the procedure. At that point, the Chief agreed, and advised us that the OR would be ready.  We grabbed out airway equipment, the oxygen tank, the patient, and hurried down corridors and up the elevator. Finally we reached the OR.

“Where do you all think you are going?” Nurse Janet, hands on her hips, blocked the  entrance.

Pointing to the patient, sputtering for air through his ballooning face, we anxiously explained the situation.

“Well, I haven’t heard about this, and you can’t come in.”

While the nurse and the doctors fought, (“Obviously you don’t care about this patient,” “I do too care about the patient! Don’t you talk to me like that,”) the patient started peeing all over the floor. Ben, Chuck’s dental assistant from the UK who had only been in Liberia for a week, looked at me sadly, “Is this Hell?” he asked sincerely.

Finally, we convinced the nurse to allow some of us in the room and the procedure got underway. The patient was intubated, securing his airway. Chuck did an extensive operation to release the pus from the deep abscesses in his face. They didn’t have any drains in the OR, so instead, we inserted foley catheters (normally for the weewee) into his face. Despite all these obstacles, including losing power for ten minutes during the surgery, the operation was a success. We left him in the hands of the American docs, who admitted him to the surgical ICU, which had the one operational ventilator in the hospital.

The next day, Chuck called me to let me know that the patient had died. Apparently he survived the night, but sometime around noon there was a twenty- minute power failure. Presumably, no one bagged oxygen in to him during the time that his ventilator was not functioning.

Finding solutions

I have heard this story with some slight variations, but this is the version as it was originally told to me.

Belle Yellah is a remote village in the Liberian rainforest, once famous for its political prisons where previous governments locked up dissidents. The President, Ellen Johnson Sirleaf, was once imprisoned there. Last year, she promised that a road would be built to this village by Christmas Eve, to end the town’s isolation and bring development to the area, and that she and her government officials would visit on Christmas day.

They were on their way there this past December 25th, when suddenly the road ended. President Sirleaf would not turn back, and decided that she and her government officials would hike through the bush. They were told by the road-workers that Belle Yellah was an hour away. It ended up being a three-hour hike. The government minister who told our friend this story described frantically ordering guards to jump into the water on either side of the wobbly monkey bridges that the president was crossing, and watching in disbelief as the 72-year-old Sirleaf gathered her lapa and swung her legs over huge logs. The villagers cheered when they finally made it, but the President told them not to celebrate yet. She ordered that a chair be brought for her, and announced that she would sit in it until the road arrived.

credit: Adama B Thompson, EM photo

One can only imagine the contractor frantically ordering his men to keep bulldozing and paving. Three bridges were constructed that night. The road reached Belle Yellah at 3am. The minister described people crying with joy – many of them had never even seen a car. The ministers who had stayed behind rolled up in their SUVs, and those who had gone to sleep after the hike were woken up for the official consecration of the road. After that, the President finally went to sleep, and was on her way back to the city by 7am.

(Incidentally, the minister telling our friend this story was in the hospital with a pneumonia that she had acquired that trip.)

I love this story. How can I complain about the challenges of getting things done at the hospital, when even the President has to pull up her lapa and crawl through the bush for 3 hours?

Now that I have learned the secret (expect nothing to go as planned, and nothing to be done when they say it will be done), I no longer feel so defeated by the endless hurdles one encounters working in Liberia. Instead, I kind of see them as fun challenges. Like, how can I diagnose this baby’s ear infection if I have no otoscope? How can we trust our security guard when his answer to, “So what would you do if something happened?” was “God willing, I hope nothin will happen”?

As Eric said, jumping out of our car to see what was causing the long lineup of vehicles in front of us to be at a standstill, “Be part of the solution!” It has become my mantra. Our friend laughed when he saw him running to the front, but then joined him and recruited others and they helped push the stuck car out of the sand.

So now, if the hospital pharmacy is out of a medicine, I send families who can afford it to outside pharmacies to bring it back to the hospital for us to administer. Instead of relying on the nurses to carry out orders, I now also review them with the patient’s family, so they can remind the nurse if something is not being done. I have finally accepted that, no matter how many times I ask, nurses will not call the doctor on call. (I asked the ER nurse why she had not called regarding my patient who had died overnight, upon seeing that he was getting worse. “Because,” she looked at me, the retarded white doctor, “he wah dyin!”) Instead, I now give my cell number to the family of my sickest patients, so that they can call me directly and hand the phone to the nurse, if there is a problem. It has been much more effective. (I realize that these are unsustainable solutions, but one thing at a time.)

Given this context of lowered expectations, you can imagine how moved I was when Annette, one of the senior nurses at JWH approached me to ask if I would be interested in helping her and another nurse start a group to improve diabetes care at the hospital. They shared their vision with me – to become a diabetes center for all of Liberia. They have no training, no funding, no equipment, not even a regular supply of insulin. But they are inspired, and willing to donate their time, and that is just the attitude it will take to build roads through the forest.

Huh?? (poster for cell phone company)

Nothing a little blue paint can't fix

One Down

Happily, my African colleagues were wrong. (Sorry, Mom, no grand-fleas.) I could only tell Dr. D, because the other doctor, a Liberian, quit on Monday. Apparently it was over some minor controversy, no doubt combined with frustration over his surgeries being cancelled because of a lack of supplies, a call room with no electricity or mosquito nets, and being forced to operate without AC for 2 weeks before it was repaired. (I remember watching the sweat from his forehead drip into his patient’s abdomen as I assisted him during a surgery, a nurse fanning us with a piece of cardboard.)

Perhaps it also had something to do with the recent hiring of Dr. B. Well-educated in Europe and Africa as a medical doctor, surgeon, and public health official, Dr. B joined the team with an authoritative air that made it undeniable that he will be in charge when Dr J leaves. (After ten years of running JWH hospital, Dr. J is returning to the U.S. in May so his son can finish high school). Serious and efficient, with glasses poised low on his upturned nose, Dr. B appears to have an answer to every question. Appears to. I wouldn’t go so far as to say that he makes things up, just that I often cannot confirm his conclusions in any medical resource. He will look at an ECG on a patient whose symptoms have mystified all other doctors, and say, “Aha! She has a slight widening of the QRS in lead V4, which clearly indicates that she has left ventricular hypertrophy, which explains everything.” I look at my colleagues, puzzled, “Really?” I ask, ignoring the fact that the QRS in V4 doesn’t actually look wide to me, but surprised that I have never heard of this criterion for diagnosing LVH. “Has anyone else heard of that being true?” But then I remember that most of them do not even have their own textbooks. In spite of regularly contesting his conclusions and cringing as nurses who ignore me literally rise from their chairs and swoon when he walks in the room, I admire his range of skill, and as a Leo, cannot help but be impressed by the attention he garners. The other day I found him bare-chested outside the OR, chatting with some giddy nurses. “What can I do?” he asked sheepishly upon seeing my bemused, questioning look, “They won’t give me my shirt back!”

While it is a shame about losing our other colleague, I cannot blame him for quitting. There are approximately 100 physicians in Liberia, for a population of 3 million. The temptation to leave must be enormous. Doctors here are paid around $1400 US a month, in spite of whatever debts they may have accrued studying abroad, and the working conditions are deplorable. What they lack in education and resources they make up for in experience. Most African doctors do both general medicine and surgery, not because they have received more training, but because there is no one else to do it. (It was hard to convince people here that I was really a doctor when I admitted that I couldn’t do a C-section or remove an appendix.) Whatever shortcomings they have, I salute any doctor who commits to working in Liberia.