By Sarah J.
I began shadowing a set of doctors and nurses two weeks ago at a small, private clinic called the Old Arusha Clinic.
What strikes me about these doctors is their agreement to work with imprecise and unknown information in order to heal or at least alleviate the pain of their patients. This is the case with all doctors, as science is imperfect and the human body frequently refuses the guidelines carved out by human minds. However, here in Arusha where technology is limited to pre-WWII surgical tables and ether is the choice of general anesthetic (a gas banned in the States in the 1950’s due to its most inconvenient flammable property and the consequent explosion of unwitting patients), doctors work within more limited knowledge than most. If the patient’s symptoms don’t immediately fit into 1 of the 5 main categories of illnesses the clinic, no, the city can treat (malaria, tuberculosis, typhoid, intestinal worms or HIV), the patient is released with a handful of mild pain killers and a hope, by both doctor and patient, that the mysterious ailment will quietly disappear.
Every morning from about 8:30am to 1:30pm I sit in with doctors as they interrogate one patient after another, 80% of which are diagnosed with malaria. I’ve been invited to observe minor surgeries every Tuesday and Thursday, while Saturdays are reserved for more invasive, major operations.
My first surgery, I observed three medium-sized lumps removed from the breast of a healthy, 22-year old Tanzanian woman. It was bizarre being on the other side of the divide. This time, I was the one in blue scrubs, green hat and cloth mask, hands clasped in front of me. I never quite grasped how all-powerful doctors are in the surgical room (or operating theater, as medical lingo goes). This woman was stretched out naked and completely unresponsive to stimuli and the cold instruments cutting, pulling and probing at her intimate flesh. Doped up on demurral, ketamine and valium, her eyes flitted between wide open and ¾ slits, her mouth slack, her fingers lax. She was so utterly at the mercy of whoever happened to enter the room (which was realistically anybody since the theater opens out onto the hospital’s backyard – no maze of white doors to block the entry of unknowns). It was unnerving. Her life, so sedated, was no longer safeguarded by her conscious mind. It was the most physically vulnerable state I’ve seen ever someone in.
Perhaps it was memories of other vulnerable moments, baring one’s heart, speaking a brutal truth to a loved one, recognizing one’s emotional reliance on another that made me feel a startling association with the premise of this situation and yet a sense of total alienation from its circumstances. Here was a beautiful, naked human being voluntarily delivering herself into the hands of another. And yet, at the same time, she was nothing but an unresponsive object that presented a small, intellectual challenge to the room’s educated. Her breast jiggled unceremoniously when the table moved. Her chest heaved mechanically to the narcotics rushing through her veins. The woman, let’s call her Jana, was reduced to a single breast as the rest of her body was covered in green sterile sheets and a sheet was hung separating her head from her doctors’ view.
Dr. Mshana made a 1-inch incision around the top of her nipple. I stood back in expectation of horror-movie blood, or at least a few squirting vessels, but that first cut merely revealed a pure white, rubbery substance – fat tissue. It was only as Dr. Urasa, the qualified staff surgeon, prodded his index finger deeper and deeper into the wound that blood reached the surface, pooling at the edges quicker than the doctors could blot it away with gauze. 6 sterile instruments clamored for a hold on the wound; two small rake-like objects pulled the flesh apart and kept the wound open for probing fingers, and the remaining 4 clamped on what seemed to my naive eye, indiscriminate pieces of pulpy meat. Every once in awhile, an electric autocautilizer was used to seal off broken vessels spurting blood – the flesh was literally burned to stop the bleeding, like a rope’s end burned to prevent it from unraveling. Once a tumor was located by fingertip, it was pulled to the surface of the wound with a small claw-like tool and then snipped off with surgical scissors.
All 3 lumps were ultimately removed, only 1 of which I actually witnessed. I was forced to leave the room three separate times during the 2-hour operation. I couldn’t overcome my repulsion of seeing a grown man tug on the flesh of an open wound so hard his arms shook. The sound of metal clinking metal as the instruments were repositioned inside the breast. The sound a plastic glove made rubbing against the sides of an open wound. Fingers buried in flesh futilely searching for a hard fatty substance. I was certain the skin was going to tear, a gash splitting effortlessly down her rib cage. Apparently though, human flesh separates easily at the edge of a sharp blade, but fingers can push and turn underneath it without leaving a stretch mark (although the patient feels like a truck hit them the next day).
Each time I collected myself and reentered the room, I was determined to make it through the rest of the surgery calm and observant ( “. . . it’s just a standard procedure, this is beneficial for the patient, these guys are experts . . “). But, every time I remembered she was human, just like me, my vision grew distorted, the room swam and that tangy flavor of bile bubbled up in my throat. I didn’t want to keel over on my first day in surgery so I quietly shuffled out of the room . . . . 3 times!
(lump removal surgery in Tanzania - $70!)
Since then, I’ve observed the removal of lipomas, large growths, the correction of hernias and hemorrhoid removals. Each time, the sight of blood and guts have affected me less, and the act of stitching more. Even now, two weeks into it, my world spins when incisions are sutured up. Friday, I staggered out of the room nearly falling to my knees as an 8-inch incision was sewed together. Crazy, how the mind and body behaves and reacts.
The medical staff, nurses and doctors, are the some of the most compassionate and professional I’ve met here in TZ. The nurses spend precious time with their patients, chatting about life and making sure they feel comfortable. There are three doctors, 2 Tanzanian and one American. The oldest doctor, who owns the clinic and has been working there for the past 29 years, is brilliant, witty and comedic in a manner I don’t think he’s aware of. When I observed my first suture removal, Dr. Urasa called me over to look closely at the jagged nature of the seal, performed at another hospital. After commenting that this surely wasn’t the work of his clinic, he quoted Kipling’s famous line “The East is East. The West is West. And the twain never shall meet” as evidence of the permanence of a jagged heal. He’s a 73-year-old man, thick white hair, tall and gangly, though slightly stooped that constantly totters around in old and cracked wooden clogs, his “surgical shoes”. It was a gift from a Swedish patient over a decade ago. At the completion of my first minor surgery (a growth removal from the under thigh of a relatively large woman), he stepped back with a satisfied smile and said “ahh, see there! That’s a good stitch!”, right as his surgical scrubs slipped down around his knees because he hadn’t tied them well enough. He hastily pulled them up, tottering precariously in his old clogs, too caught up in his words to catch the humor in the moment. It was pure comedy.
Of course, so much else to relay, if you’re still reading, here are some thoughts I’ve been pondering:
There’s a total reliance on medication and painkillers for common things such as flues, pre-menstrual cramps and mysterious chronic headaches.
The doctor-patient relationship among Wazungus (a Swahili catch all phrase for white people) is a world away from the relationship shared by Tanzanians. Tanzanian patients accept an inferior role to that of their doctor, assuming doctor knows best; there are no extraneous questions asked or symptoms mentioned unless directly asked. Oftentimes, as I’m sitting in the doctor’s office with a patient, the doctor will run through the patient’s history and then his test results in a 20-minute monologue directed at me. In English, often a language patients only faintly grasp, he’ll explain to me the meaning of a high white cell blood count combined with an insulin deficiency. Then, after soliciting any questions from me, he’ll finally turn to the patient, who sits patiently in his chair the entire time, provides a sentence-long description of their diagnosis, writes a prescription (a patient never leaves his office without one!) and marches him out. The patient rarely inquires into the nature of the stated illness or the method of prescribed treatment. In fact, once a woman discovered she had tested positive on a pregnancy test only by catching the word in her doctor’s explanation to me before he properly broke the news to her.
Wazungus, on the other hand, demand lengthy explanations, descriptions, even predictions about the course of their illness. Mostly all good things – never accept a truth without understanding it. However, I do think we’ve been coddled a bit too much by our medical professionals – Tanzanians undress readily in from of me and their doctor, unquestioning of my presence as long as the doctor is present to validate it (added to the fact that nudity is nothing private in Tanzania). Whereas one wazungu parent brought her child in for a small sore on her foot and demanded a blanket to cover her daughter’s bare legs. We are used to a level of privacy and comfort Tanzanians don’t demand, making it much easier for the doctor to do their job. It would be perfect if the doctor-patient relationship could combine a little of both of these culturally different relationships – pertinent inquiry on the patient’s part without demands for inconveniencing comfort.
Every day, I watch the decline of a woman suffering from AIDS combined with severe diabetes and a strong bronchial infection. Her husband died 2 years ago from AIDS. Until two months ago, she’s showed no signs of the advanced stage of HIV. She was a high profile, world traveler providing consultancy in marketing and sales to top-end businesses. Now, two months after contracting bronchitis, she’s left immobile and unable to speak. Each day I’ve seen her, her condition grows visibly worse – although at first it was hoped she could return home to die, the best hope now is that she will die a quick, relatively painless death here in her hospital bed. Such a dynamic, intelligent woman reduced to an emaciated, wasted state in 60 days – the power of disease and the vulnerability of our bodies to it is devastating. HIV/AIDS is a familiar foe here – every one of my friends knows personally 5 or more people who are suffering or have died from it. A frightening reality for all, an accepted fate by those forced to prostitution (men and women in search of income) and even those who get married (infidelity is a matter of course here, by both sides of the marriage bed).
The strength of the family unit here in Tanzania is evidenced by the hordes of family members that attend their sick in each hospital room around the clock, no matter how minor the illness. An older woman, in for severe dehydration and intestinal worms, a common and easily-treatable illness, is constantly surrounded by at least three women talking with her, lying down with her, just being with her. Every family brings in their own food and drink for the patient – there is no food service at the clinic. There are also no visiting hours or restricted visitor regulations.
Can medical doctors provide comprehensive care to patients, assisting them in their psychological health and lifestyle choice as well as their physical manifestations of pain? If not, could I be content curing sick people while not providing thorough preventative care? If not, where does that leave my interest in the medical field? . . . a path not as clear as I would have it . . .
By Sarah J.