The young woman lying in the grass in front of Block Two was evidently a problem, but it was hard for me to tell how much of one, or whether I, as a doctor, was supposed to respond. She appeared to be asleep, like some of the other patients who had vacated their mangy hospital beds in order to stretch out on the grass and absorb the warm Nairobi sun. But in her case, something had clearly gone wrong. I might have guessed this from the expressions of concern on the faces of the nurses who were discussing her. The other patients, all women, sat in the grass, watching the nurses and watching me.
In my time as a volunteer doctor at that impoverished public hospital in Kenya, there was a way in which all the desperate situations blurred together. It became difficult to know which ones to care about and respond to, and which ones simply to let pass by. In the end, it was hard not to let many desperate situations pass by, much the way one notes but then decides not to pay attention to the fiftyish, disheveled man with the prominent body odor who boards the bus and talks to himself for the duration of the trip. If one began to worry about where he will spend the night, or how he became the way he is, it might be too much. So one sits and lets the personal tragedy unfold without giving it too much thought.
Block Two was a long, single-story building divided into wards, each with eight beds and from six to sixteen patients. The doubling up of patients in beds was something I tried to discourage, particularly if there were empty beds in other wards. The logic of putting two patients in a bed when other beds were open eluded me. But then, so did the logic of the way many things were done in Kenya.
My time on Block Two challenged my sense of myself as a caring person. There was so much to care about and so little one could do about it all. The care I could offer seemed pitifully limited compared to the magnitude of the problems at hand, and also compared to the care I had put into matters I knew I could influence, such as the sensible purchase of a television set in the United States a few months before my departure.
I was able to invest meaningful energy in the care of at least a few of my patients, although it was rare that I came to regard individual patients as “mine,” for they were directly under the care of the local medical officers below me. In theory, the medical officers attended to day-to-day needs, leaving me free to supervise. Frequently, however, there was no one for me to supervise.
On one such day, an emaciated seventeen-year-old girl was admitted. She was coughing, panting hard, and clutching her abdomen. I felt certain she would die, but I also felt that, even in the worst of circumstances, a seventeen-year-old girl deserves a fighting chance. I attempted, in my broken Swahili, to construct a skeletal medical history as I examined her. Then I ordered a five-drug treatment for what I diagnosed as widespread tuberculosis due to a suppressed immune system, most likely caused by AIDS. It had been a few years since I had placed an intravenous line. On my first try, it fell out, but I placed it again, and it stayed.
For a week, the girl looked a little brighter each day. When no family members came to visit her, I asked the nurses where she had come from. They said she was an “abandoned housegirl.” Lacking economic resources, her parents had placed her into service at the home of someone of means. A housegirl unprotected by her family was uniquely vulnerable. In addition to household chores, her job description might have included forced sexual favors. There were a disproportionate number of teenage girls dying of AIDS in our hospital, and we suspected many of them had become infected due to such rapes. “Something is not right in Kenya,” two of my female Kenyan colleagues had once told me, shaking their heads.
The morning of the day I saw the woman lying in the grass, I arrived to do my rounds and found the seventeen-year-old girl sobbing and talking to herself in Swahili. I’d sometimes wondered what would come of saving the life of a young girl with AIDS who had no family and no job. It occurred to me now that she might be pondering the same question. I asked the woman in the adjacent bed, who spoke some English, what the girl was saying. The woman replied, “She is saying, ‘Where is my mother? Where is my brother?’ ”
I stood next to the crying seventeen-year-old. I had no tissues to hand her, so I patted her shoulder and said nothing while she cried. It seemed to me that the only thing worse than crying was crying alone. After a few minutes, I left her alone and continued on my rounds.
Conditions that day were superb by the standards of Block Two. A new, young medical officer had arrived. Not only had he come to work despite feeling ill himself, but he insisted on seeing every one of the thirty-five patients on the male side of the block. His predecessor had never taken such an interest, and I was duly impressed.
I enjoyed a modest triumph myself that morning. A young man had apparently been admitted a few days before with possible tuberculosis, but no doctor had examined him. His chest X-ray, which lay on the bed, revealed the classic signs of a collapsed lung. Despite his desperate status, he had apparently lain there for two days, struggling to breathe.
I derived a certain sense of satisfaction from making the diagnosis, though the indications would have been obvious to even a minimally trained medical professional. You see, I had missed a chance to make this same diagnosis exactly five years before, during my internship. I had gone home to bed one night having forgotten about a pending chest X-ray for a patient with AIDS. When that patient’s condition deteriorated the next morning, the attending doctors found a collapsed lung. One look at the previous night’s X-ray could have prevented the crisis. The surgeon who treated the patient scolded me, and I nearly cried.
Now, in Kenya, I could look at this X-ray of a collapsed lung secure in the knowledge that, this time, someone else had failed to make the diagnosis. It’s strange how, amid all that unmitigated human suffering, some part of me could still seek a petty salve for my past failure.
The treatment for a collapsed lung is immediate insertion of a plastic tube into the side of the chest, but this was not going to happen, because the hospital had no plastic tubes. The patient’s family would have to purchase a tube from a nearby private hospital and bring it to us, which would take at least a day or two.
Strangely, I was the only one who seemed to think the problem couldn’t wait until the family came up with the money for a chest tube. When the medical officer made ready to proceed to the next patient, I asked him for a hollow needle, remembering from my textbooks that even a needle could offer temporary relief. I actually felt more anxious about being out of step with the social norms of Block Two than I did about the medical emergency in front of me.
In went the needle. The patient winced, but nothing happened. I couldn’t understand it. I pulled the needle out and asked for another, which I put in slightly lower. A hiss of air emerged. The patient relaxed, thanked me, and told me he felt better. I urged the medical officer to push for a chest tube that day; I’m not sure whether he did.
When we had finished making the rounds, I walked over to the women’s side to check on a few patients. It was then I saw the woman lying in the grass and the concerned look on the face of our head nurse. I asked what had happened. Five minutes before, a nurse had watched the patient walk outside, then fall. And there she lay, still in the same spot, no longer fanning away the flies. Flies circled all my patients, but the sicker ones had more flies. This woman was surrounded by altogether too many flies. I concluded that she must be dead.
In an American hospital, the collapse of a young woman would be treated as an emergency, a potentially reversible cardiac arrest. A rush of nurses and doctors would administer cardiopulmonary resuscitation and jolts of electricity. But in a Kenyan public hospital filled with patients suffering from TB and AIDS, the same situation would be treated as “death” from the start. Since at least half the patients died, it was hardly even news.
There was still one thing I could do. My experience in Block Two had given me one peculiar but important insight: every dead person deserves to be officially pronounced dead by a physician. The patient herself would not know, of course, but the twenty live women sitting on the grass around her would certainly notice. They knew that death was commonplace here, but it would only have compounded their misery to see it completely ignored.
Stepping off the patio and down into the grass, I listened to the woman’s chest and flashed my light in her pupils: no heartbeat, no pupillary response. She was curled in a peculiar position. I straightened her out, closed her eyelids, and went back inside.
I washed up in a small washroom where the nurses took their tea. Lacking towels, I wiped my wet hands on my shirt and poured myself a cup of what the Kenyans call chai, a mixture of hot milk and tea. It was good and sweet. A young woman lay dead in the grass, and I could still think to myself that I liked this cup of chai. A nurse and I sat and talked, and we both admitted that something about the ward left us slightly nauseated that day. We acknowledged that maybe it had something to do with the dead young woman.
When I finished my chai and walked back outside, the young woman’s body had been removed. Then I saw the abandoned housegirl who had been sobbing in Swahili that morning. She was sitting on the grass, in the sun, not far from where the corpse had been. I didn’t know whether she’d seen all that had transpired there that morning. Thinking I should acknowledge her, I waved. She waved back. She smiled.
This essay originally appeared in the online version of Exquisite Corpse, www.corpse.org.
