A Woman's Life

Several weeks ago I was standing beside a patient bed in the pediatric ward at Biharamulo Hospital and I happened to glance down at the floor. I had become used to the malodorous fragrances ever present in the hospital by this time. It no longer surprised me to see a patient squat on the floor to defecate during patient rounds. The sight of cockroaches scurrying to find cover under a patient's bag of clothes now seemed commonplace. What caught my attention this day were the bare feet of the mother who was silently sitting on the side of her child's bed as the group of white coats discussed the intricacies of the case in a tongue completely unintelligible to her. I did not know anything about this woman and still I don't claim to understand the complexities of her life, but even without her saying a word her feet revealed much about her and her and her way of life.


She lacked shoes...even the $3 red or blue plastic sandals that are ubiquitous here... most likely because with 4 or 8 or even 10 children to provide for, shoes were a luxury that she could not afford. Without protection from earth and elements her soles had become calloused from long treks over gravel roads and uneven footpaths, often baring the load of not only her own body weight but also the weight of the baby strapped to her back and the bundle of firewood or bag of cassava or bucket of water that she balanced gracefully atop her head. Alternate exposure to dry, dusty paths baked by the intense morning sun and then to a myriad of tiny rivers or pools of muddy water that arise within minutes of the first drops of rain from an afternoon downpour in the rainy season had left her toes and heels dry and cracked. Bruises and scrapes in various stages of healing gave witness to the difficulty of traversing even the most well-known paths in the deep black of shadows of a night with no moon and no street lights...indeed no true street...for hundreds of kilometers. The thick musculature of feet and toes were evidence of the long hours she spent trudging barefoot through muddy fields of rice or maize or potatoes in order to provide food for her family... and hopefully enough extra to make a small profit selling the surplus in the market. She probably was ignorant of the fact that the incessant, though not severe, itching of her feet was due to the tiny hookworms in the soil or the schistosomes in the pool of water where she baths and washes her clothes that penetrated her skin en route to their new living quarters in her gastrointestinal or urinary tracts. Hers were the feet of one who has worked tirelessly, and with little fruit to show for it besides her remaining living children, ever since she completed her government-sponsored primary schooling and realized that she would not be able to attend secondary school (high school) because her family only earned the equivalent of twenty dollars a month and could not afford to pay for further schooling (if in fact she even completed primary school). Her feet had carried the weight of a new infant every year since she had been given in marriage because as a woman in her culture she had no liberty to refuse her husband's advances, and because birth control methods were too expensive or not available and even if she had access to them her husband would likely frown upon them because for him more children meant more respect and higher status.


Her feet were the feet of a woman who understood more fully with each new Land Cruiser that sped by her as she traversed the main road leaving her enveloped in a cloud of red dust, and with each copy of Glamour magazine that somehow made it to her village, that her degree of poverty was unimaginable to many people in more developed countries. And yet they were the feet of a woman who was proud...she walked with head held high... and so refined that in addition to all of her other work she somehow found the time and energy to make sure that her dress and sarong were so meticulously cleaned that when she brought her child to the hospital one would think she had just purchased a fine new wardrobe and would never guess that her day had started in an overcrowded, single roomed, mud-brick house in which she slept on a mat on a dirt floor.




These were the feet of a survivor, of one who has had no choice but to be a survivor because she happened to be born in a poor corner of a poor country on a poor continent where climate and microbiology and economics and a long history of international power struggles have left her and millions like her to bare the brunt of the world's burden of poverty and disease and suffering. I have struggled to try to figure out what is my role...if any...in her story and in the story of a hundred men and women like her that I have passed every day while I have been here in Tanzania. My time here has been rewarding and I feel that it has been valuable if for no other reason than to be reminded that there are a multitude of people who are innately just like me whose entire lives are characterized by struggle and suffering. By no means has everything about my experience here been depressing though. I have had the pleasure of seeing people who are suffering smile and laugh and somehow enjoy simple pleasures that I would have overlooked completely. If I close my eyes the sweet laughter emanating from a group of children in tattered clothes playing with a ball made of wrapped twine in a filthy slum is indistinguishable from the sounds of a similar group in the latest fashions playing in a posh playground in Manhattan. In fact when I open my eyes the sound rings even sweeter. In spite of the pain and the tears that abound there is vibrant life here. Even the clothes people where seem to celebrate life and color. When there is occasion to smile people do so unabashedly and with no self-conscious thought of their crooked tooth or their sun-leathered face...and their smiles are the most beautiful you will ever see!




I feel uncomfortable in this place not only because I don't know the language or the cultural nuances but because it makes me confront difficult questions like is it wrong to take this woman's photograph- even with her permission- with a camera that cost more money than her family will make in three years? I make myself feel better by giving her a copy of the picture. She flashes a radiant smile in response to the gift and I am struck by the fact that her beauty would rival that of most models in Europe or America. What does it say about me that I somehow feel proud of myself for having done my part in making her life a bit better by going out of my way to give her this generous gift? The copy cost me twenty cents.

The Front Lines

Biharamulo district is located in the fertile corridor of Tanzania that lies to the west of Lake Victoria and is home to roughly 400,000 people. It is one of the least developed regions in Tanzania. Agriculture (mostly bananas, coffee, cattle, and goats), fishing, and mining are the main industries in the district but a large portion of the population survives by subsistence farming- though some may be able to make a small profit in a local market if the rains make for a good harvest. For many years Biharamulo district hospital was the only hospital for the entire population. There is one medical doctor employed by the hospital, who also serves as the medical director. Due to the overwhelming patient burden, several years ago the responsibility for health care delivery in the district was split between Biharamulo District Hospital and a hospital in a neighboring district so that now the hospital...and the one medical doctor in the district...is responsible for the health of only approximately 200,000 persons. This ratio is, of course, much higher than the average doctor:patient ratio in Tanzania, which is 1 to 25,000. In the United States there is one doctor for every 400 people.

Five assistant medical officers (AMOs) and a handful of medical clerks are responsible for most of the medical diagnoses and treatment plans in the hospital, which has 130 beds though many times more than one patient may be admitted to the same bed. AMOs receive three years of training after secondary school (high school) to become medical clerks. After working for several years in health dispensaries around the country (treating basic medical illnesses like malaria and pneumonia and referring more difficult patients) they can choose to return for two more years of training at one of the teaching hospitals to become an AMO. At Biharamulo and elsewhere they are responsible for just about everything that has to do with patient care. They make diagnoses, decide on treatment plans, perform procedures such as lumbar punctures or pleurocenteses. They run the HIV specialty clinics and do most of the operations in the hospital including cesarean sections, hysterectomies, appendectomies, and even bowel resections. Although he is often pulled in three directions at once due to his administrative duties, the medical doctor makes "major ward rounds" in each of the wards one day a week, during which he sees each of the patients on a given ward, and will help with difficult patients or some major operations whenever the need arises. Medical officers are in short supply, but the nursing shortage is so severe that a ward of almost 70 patients may be staffed for much of the day by only one "assistant nurse" who has had only one or two years of training after secondary school.

Malaria is by far the leading diagnosis in the hospital, followed by severe anemia which is often secondary to malaria. Malaria is so common and complications so severe that it is a national guideline that any child younger than five years old with a fever should be empirically started on antimalarial medication. Because falciparum malaria is the most prevalent species of the parasite in the region "cerebral malaria" is a common complication of malaria in children here and manifests as neurological complications including strokes and swelling of the brain as a result of red blood cells becoming lodged in the small cerebral vessels. Most children who develop this complication do not survive. Pneumonia is another common diagnosis in patients of all age ranges. Diarrhea is a very common complaint and may be simply viral and self-limiting, bacterial and requiring antibiotics, the result of intestinal worms of various sorts that are ubiquitous here, or all-to-commonly the presenting symptom of HIV infection which has a prevalence of about 10% in the region. There are a significant number of patients with TB in the hospital, but surprisingly there were only 98 documented cases of TB in the entire district last year. Meningitis is very common and usually presents very late. In a matter of two weeks I saw three cases of meningococcal meningitis (a very contagious form of the disease) in children, one case of meningitis that presented in such a severe stage that when I did the lumbar puncture to look at the spinal fluid I had to use a syringe to draw the fluid out (usually it flows like water) because it was frank pus, and another child who had presented with such severe meningitis that I had to tell the AMO who was about to do a lumbar puncture that if he did the procedure the child would die right on the table- the child was unconscious and had one blown pupil and one pinpoint pupil which is a sign of severe brain swelling and doing an LP would cause the brain to herniate into the spinal canal due to the pressure gradient. Traffic accidents are extremely common presenting with all types of injuries including complete quadriplegia. Post-partum hemorrhage, hypertensive emergencies, strokes, diabetes were also seen. All too often we had to just give our best guess at a diagnosis because we did not have the lab capabilities to do the tests that would be needed to confirm or deny our hunches.



I was impressed by the scope of the responsibilities held by the medical staff, and I learned much from not only the medical director but many of the AMOs as well, especially about diseases such as malaria and TB and HIV that I have limited exposure to. However it was apparent that the work load was simply overwhelming. In each of the wards (pediatrics, female, male, and surgical) all of the patients are only seen once a week. On other days only the sickest patients are seen. Unfortunately if a nurse is not trained enough to pick out worrying signs or symptoms, or if a parent is unable to differentiate a soundly sleeping child from a child with a decreased level of consciousness, a very ill person may be missed. A number of times when I walked through the wards just to see if there were any sick patients that had been missed I came across florid meningitis or severe malaria that had been missed. At first my frustration was toward the nurses, or the AMOs, or the parents for waiting so long to bring their children to the hospital...but slowly I began to realize that my frustration ought to be directed towards a system as a whole (not just the Tanzanian health system...a system which we are all a part of in some way) that leaves families so poor that even the money it would take to travel to the hospital would mean that they would go without food for a time, a system that only provides one partially trained nurse to care for 70 people, a system that can pay its overworked doctors only $10 dollars a day, a system that provides only one fully trained medical doctor for 200,000 people.

But somehow in all of the overwhelming workload and disease and mournful cries of mothers who just lost yet another child...there were smiles like this one that greeted me every morning when I entered the pediatric ward...and those smiles gave me hope that maybe things will improve for these people who have waited long enough...

Biharamulo

It is only about 150Km as the crow flies from Mwanza to Biharamulo but the exhausting trip takes about 7 hours if everything goes smoothly, which is never something to be counted on. The trip begins just after sunrise at the shore of Lake Victoria, for the first leg of the journey is a 30 minute ferry ride that saves a 3 hour jaunt around a narrow inlet of the lake that extends south for a significant distance. On a clear, calm morning the ride across the lake is absolutely serene...but the serenity is short lived because if you fail to find your seat in one of the buses packed onto the ferry before the vessel reaches its destination on the eastern shore you are sure to have no option but to take the return trip on the ferry. As the boat approaches the bus engines are already running and almost before the ferry even stops each bus driver has his foot heavy on the accelerator and the steel monsters speed off down the uneven, unpaved, pedestrian-filled road eventually splitting to head off towards their individual destinations. The bus is already full, but the two conductors hang half-way out the open door looking for passengers that may be waiting alongside the road for the Zuberi bus, hoping that it did not break down or miss the ferry because if it did their plans to reach their destination will be canceled and they will have to try again tomorrow. As more passengers are picked up the remaining seats are filled and then the open space in the isle is utilized. Some passengers are in for the long haul all the way to Biharamulo. Some just catch the bus for several kilometers. Most have a small suitcase or duffel in their possession. Some have sacks of cassava they are taking to some town's market. One may have some chickens or a mirror or wheel of a bicycle.

At times the ride is relatively smooth. In fact there is even a several kilometer stretch of paved road at one point. I don't know why that particular stretch is paved, but it is very welcome. Most of the ride is over a washboard road and you will think your retinas may detach if there is no relief soon. The driver does his best to pick out the least traumatic line on the road, and since his vehicle is the largest on the road it does not matter if that line is on the right or the left or in the middle of the highway, everything and everyone else must make way for the king of the road. If you are not used to travel in East Africa you had better receive cardiac clearance from your doctor before taking the trip because even a healthy heart will threaten to stop beating a handful of times as the bus comes frighteningly close to colliding with oncoming vehicles or bicyclists that fail to yield right-of-way (which usually means careening headlong into the tall reeds at the edge of the road because the bus driver usually wants to drive with one set of wheels actually on the smooth "shoulder" which is usually on the "wrong" side of the road). At least a time or two along the way you will pass a broken-down vehicle with three sets of legs protruding from under the engine block and at least five people looking on. Occasionally the most talented drivers may display their superior skills of trail blazing and then take a lunch break while many gather to admire his handiwork.


But for the most part the road is remarkably devoid of other vehicles. There is no in-flight movie but neither the talents of Brad Pitt nor Angelina Jolie have the captivating power of the scenes playing across the dusty windows on either side of the vehicle. The rainy season has turned the countryside into fifty shades of green. Birds ornamented with long flowing tail feathers or bright red breasts bounce between the acacia trees. Further down the road groves of banana trees provide shade for small circles of mud huts with a few children playing on an old termite mound in back. All along the way men pushing large banana stalks on bicycles or women carrying buckets of water on their heads or young men herding their cattle with a bamboo rod fill the road and part like the Red Sea at the sound of the oncoming behemoth.



Twice during the trip the bus stops in fairly large towns. Immediately people selling bananas and sodas and roasted goat strips and pineapples encircle the bus and lift their goods up the the windows to advertise for the passengers. There is just enough time to run out and use the toilet...unless you are a Muzungu and you neither know where the toilet is nor how to understand their directions when you ask, "Where is the toilet?" in Swahili. So you hold it or you somehow find the toilet and return to find the conductor, who fortunately noticed that the only white person on the bus was missing, yelling out to you, "This...express bus!"

By mid-afternoon the bus finally pulls into the town of Biharamulo. You step out and stretch your legs and push past all of the people trying to carry your bags for you as you tell them, "No thank you, I can walk..." and make your way to the hospital where you will spend the next few weeks.

Being confronted with human suffering is not new to me. I still remember vividly the desperate wails of a mother in Yemen after we had transported her daughter's lifeless body back to her village. I can still see the woman dying of AIDS in Uganda lying on only a matt on the dirt floor of her hut with a sheet covering her wasted body that revealed the bony outline of each of her ribs. I will still wonder why the young couple in Papua New Guinea who lived their entire lives in poverty had to lose their only son to what started as a simple pneumonia that probably would have been easily treated in the U.S. I have shed tears and wrestled over questions of why... and at times I have seriously questioned whether I can reconcile my faith in the existence of a loving God in light of the seemingly indiscriminate suffering I have seen. I had thought that I had the question of suffering worked out in my mind and that nothing I would see on this sort stint in Mwanza would shake me. I was wrong.

Sayi, a 20 year old girl who came to Bugando the first week I was here, was severely wasted when she came in- I could easily wrap my thumb and index finger around her thighs and upper arms. Her eyes were sunken and bright yellow. Her abdomen was filled with so much fluid that it looked as though she were pregnant. Her liver was 2-3 times the normal size on exam and packed with hard nodules. She came with no records at first and she would not speak, but after some searching we found an old report of an ovarian cancer that had been removed about a year ago. It was obvious now that her cancer had spread to her liver and likely other organs of her body. Ultrasound confirmed diffuse lesions consistent with metastatic cancer. There was nothing we could do for her to treat her condition or even alleviate her discomfort except for drain the fluid from her belly now and then for her to breath more easily.

I had thought Sayi only spoke Swahili or her tribal language, but several days after she arrived she asked me, "What is your name?" It turns out she had been in school when she became sick and hoped to become a doctor. Her English was broken but she was remarkably proficient with a fairly broad vocabulary. She asked me several times if I could help her and I told her that we would try to keep her comfortable but that there was nothing that medicine could do to cure her. At this she turned her head away from me and said softly, "I am suffering."

About a week and a half after Sayi presented, an 11 year old boy named Matiku came in with a long history of shortness of breath and fatigue. He had signs of right heart failure with distended neck veins and a large liver. He was not making much urine. He had an extra heart sound on physical exam and so an ECHO was obtained (I was surprised to see that we had an ECHO machine and a talented echocardiographer to run it) which revealed a large tumor that was almost completely occluding his right atrium. I don't even know how he was still alive because only a trickle of blood was flowing around the mass and allowing his body to get blood and thus oxygen. There was talk of trying to take him to the OR. No heart bypass has ever been done here, though, and so his chances of dying in the OR were about 95%. There was a 100% chance he would die without the operation, however. In the end the surgeon did not want to try the procedure.

Just before I left for my journey someone gave me a book by Francis Macnutt entitled "Healing" that argues that God still can and does heal people through prayer. The author argues that somehow the Christian church has largely adopted a theology that God does not heal because there is somehow more redeeming value, spiritually, in suffering than in health. The result of this shift in theology from the early church's conviction that God regularly healed people through the prayers of the saints has resulted in Christians today no longer even asking for healing. Macnutt's arguments are convincing. Jesus himself pointed out in Matthew 7 that even more than a parent would for his or her child, God the Father desires to give good gifts to his beloved. In John 14 Jesus told the disciples that the miracles they saw Christ perform would not cease with his passing, but rather that "whoever believes in me will also do the works that I do, and greater works than these will he do..." In James 4 we are told that "we do not have because we do not ask".

I am confident that God CAN heal miraculously. I just don't know if He DOES any longer...at least commonly. But I must say that I WANT to believe that He does. Several days after Sayi came in I asked her if I could pray for her, and she said yes. I prayed that God would comfort her and put His hand upon her...but I did not ask that He would heal her. I think I was afraid of the implications on her faith...and on my faith...and on the faith of all of the people in the room looking on...if I asked for God to heal her and healing did not come. Several days later, however, I was completely overwhelmed on rounds by the fact that Sayi had no hope for any relief of her suffering...on this earth at least... apart from divine healing. After rounds I asked her if she would like me to pray for her again, to which she agreed, and this time I specifically asked for God to heal her.

Similarly, when I realized the bleakness of Matiku's future I felt compelled to ask his mother, this time through a translator, if she would like me to pray for him. She said yes. Through the nurse I told her that medicine and doctors were powerless to help her son, but that I believe God is always powerful. I told her that I would ask God to heal Matiku...but that God can choose how He will act. I said that all I know is that God loves Matiku even more than we do...and that Jesus said that those who trust in Him would live...even though they die.

For the few days following my prayers for each patient I went into the hospital hopeful...in fact even expectant...that I would see Matiku and Sayi up and energetic and breathing easily. The more days that passed with their condition unchanged the more I began to doubt. Today I went in to check in on both of them. Both of them died yesterday.

Some would argue that questioning one's faith is a sign of weak faith. Perhaps... but I think that questioning is vital to a healthy faith. I have had two major "crises of faith" in my life as a believer in Christ. The first came in college and the second in medical school and during those two several-month long stretches I questioned everything about what I believe and why. It was incredibly difficult at the time, each time, but I am grateful for having experienced those empty times. And now I have come to believe that it is good for me to occasionally go back and question and re-think what and why I believe.

I will admit that in the past few weeks I have had fleeting thoughts that perhaps everything I have based my faith upon is contrived. When I see indiscriminate suffering it is logical to entertain the possibilities that 1) there is no God, or 2) God exists but either does not care or does not have his hand actively involved in humanity. But I look around me and see His hand in creation itself. I can remember back to my time in anatomy lab and be reminded of how convicted I was that only a powerful and creative force bigger than life itself could have been responsible for what I was seeing. I have decided that I believe the scriptures are in fact God's word made known to man- and if that is the case I can be assured that there is no questioning God's love for humanity, as He spared nothing to redeem His people.

I do not know what I think about whether God still desires to...and in fact does... heal the way he did 2000 years ago. I know that he has our best interests at heart. I am certain that the tears those who suffer cry are seen and probably felt by their creator. I believe also that just as Jesus pleaded in the Garden that "this cup would pass," he cries to the Father at the side of those who suffer on earth now and asks for the same mercy. But I believe that the prayer is concluded the in the same manner that it was 2000 years ago- "but not my will be done, but your will be done." Certainly there is good in relief of suffering. But I have also seen that suffering can enable those once blinded to see that this world is hopelessly in need of a savior.

I have not seen God heal miraculously, but I know that He is alive and actively involved in my life and I am certain that he desires to have an active part in the lives of all who suffer (and all who don't suffer for that matter). I just don't know how that will play out, and of course I could not expect to know the intricacies of how God may choose to act. But I know that He has called me to serve and to love and in so doing be an extension of His hands. I know that He has charged me to ask for good gifts. I know that He has promised hope to those who have no hope and all I can do is trust that as a loving Father He has his children's best interests at heart... much more so than I do.

Worth 1,000 Words...or More