Nothing Human is Alien to Me

Dear Friends,

The swollen thigh presented a problem.  The hour was late and a debate commenced.  I could send the HIV-positive mother of three to the central hospital.  Recalling the patient who was allowed, criminally, to sit on the government ward for a week with a foul, dead leg, I decided against a transfer.  The abscess should be dealt with today.

There is a reason I am an internist:  Fear of scalpels.  Yet there I was holding one, having put Esther gently to sleep.  The pus had already exuded partially.  The cut must go deeper.  I probed.  Out came blood, steadily, relentlessly.

Now what?  I washed and cleaned, reaching terrifyingly far down the gaping hole into which the nasty bacteria had burrowed.  Gauze packed the space, and then a bandage was tightly wrapped round the limb.  Antibiotics, pain medicines, and her antiretroviral drugs comprised the rest of the therapy.

The next day the bleeding had ceased, but the purulence oozed.  And for the next 20 days¾save three when attended to by my colleague¾the nurse and I irrigated and cleaned and packed the wound.  The process became progressively more painful as the infection eased and tissue re-grew, nerve endings again sensitized.  Every day, thirty minutes, sterile kits, short-acting anesthetics, syringes, saline, my time¾it adds up.  Her mother came in to observe.  I explained, urged Esther to keep to her medicines every day.  Her sorrow and depression were evident.  Was this a waste?  What would happen when she returned to her impoverished rural home?  No one would dress this wound properly, healing though it was.

A constant refrain in international health these days is "sustainability," as in "That's not sustainable"¾as in, having a scarce doctor in Africa pack a wound for three weeks is "not sustainable."  Maybe it's not sustainable because we have set the bar so low for what constitutes acceptable medical care that such suffering people are left to their own devices, under the general rubric of "unsustainable"¾as in, you the patient are unsustainable.

She left looking beautiful, wrapped in a colorful bright yellow Malawian chitenje and head covering, limping under her own power.  Two weeks later our nurse, visiting a nearby clinic to help improve HIV care, reported that the wound had nearly healed.

The Roman Terence wrote, "Nothing human is alien to me."  So I pack the putrid, tedious wounds, and at the same time contemplate if doing so is a waste, is unsustainable.

Our community health worker Luka and I pick our way through garbage-sodden streets on the outskirts of Lilongwe.  We reach our destination.  The house is burned out from a recent fire.  HIV-positive mother and small child sit next to the charred, blackened vat where traditional beer is made.  It stinks, the odor of stale decay.  A 16-year-old niece is brought.  She tests positive.  How did that happen?  She appears unmoved, face blank and placid.  Mid-afternnon, we return past bars full of men, sullen and drinking.

Nothing human is alien to me.

It's late and the clinic is closed.  My colleague and I are astonished.  The needle continues to pour pus from the man's infected knee, hundreds of milliliters.  I aspirate viscous material; he milks the cap of the joint.  Still the brown flow gushes.  My hands are covered, the syringe now slipping from the pasty glove.

Nothing human is alien to me.

Harold defines long-suffering.  First TB, now cryptococcal meningitis which threatens his sight.  Many times I have put a needle in his back.  I want to do so again, to remove the pressure slowly eroding his optic nerve.  He readily agrees, no opposition, no complaints.  I ease in the tapered point.  The case around the spinal cord is hard. The room is hot.  I become flustered.  More lidocaine.  It shoots back and lands on my naked arm.  The risk is very low, but I am unnerved.  Gloves removed, arms washed.  Should I try again?  He can't see well.  I re-glove, insert the needle, unsuccessfully.  It was all for nothing, the risk to him, the risk to me.

Another young man is very ill.  He also has cryptococcal meningitis.  And is it now TB?  The heart, the lungs, the abdomen¾all filled with fluid.  I slept 2 hours the night before, hacking and coughing from a cold.  The nurse calls at 8 PM.  Joseya can't breathe.  I knew I should have drawn out the fluid earlier that day, but it was busy.  Why should I go in at this hour?  One better have a good reason to be about at night in Lilongwe.  Anyway, he's going to die.

I get in the car.  We barely get the patient on to the procedure table.  A brother holds him steady.  The needle angles in, directed upward to miss the air-filled lung.  A cloudy, particulate green solution streams forth, over 2 liters of it.  I move to empty the collecting bag, the sticky, infected water bathes my gloved hand.  These gloves are terrible, the realization hits me in slow motion.  I take them off, stare at the still dry powder underneath, rubbing my fingers together scratchily.  Vision telescopes when you hit this level of fatigue.  What am I doing here?  His breathing eases considerably.  The night is comfortable.  He dies the next day.

The nurse asks me to come for a sick patient.  They can't draw blood.  The report of the positive HIV test result from the fingerstick sits unconcealed.  Why did it take so long for this guy to be tested?  Why is it still like this in 2011?  He has clearly been sick forever, a wraith and a wreck lying prostrate, not knowing the year or even the day.  I move to do what I always do first:  feel the pulse.  Why is it wet?  I pull back my fingers:  they are red.  No one has bothered to clean this man's arm after they poked him repeatedly with a needle.  I wash my fingers with bleach and alcohol and soap.  There is a paper cut.  Where did that come from?  Did blood hit that?  I think of my family and start a course of prophylaxis, the second in the past year, before returning to the bedside.

Nothing human is alien to me.

We sit in the dark.  Light hurts the skin and eyes of our albino patient, a class of citizen mercilessly marked as different, exotic.  She takes her TB medicines and is improving, but she is afraid to start antiretrovirals.  Her father drinks and does not know of her HIV status, although we also found TB in his sputum and suspect he too is infected with the virus.  She fears he will shout at her, yell all over the neighborhood.  One of our nurses lives nearby and confirms this kind of behavior.  The atmosphere is oppressive and glum in this room where she spends most of her life.  Honestly, I want to leave.  We stay for 30 minutes, working out a plan for her to receive the care she needs.

For the One whom I follow did not shirk from the woman afflicted with a dozen years of bleeding.  He touched the lepers, ate with the repugnant outcasts.  Nothing human was ever alien to him.

I don't really know what is sustainable.  I do know what we are supposed to do.

Grace,