This week after holding a patient’s airway open in our High Dependency Unit, as blood poured intermittently in pools from his open mouth, whilst interns frantically chased for a more definitive piece of equipment, I walked despondently over to a young man, profoundly emaciated, with heavily jaundiced, sad eyes. He was lying stiffly in a bed, a large growth obscuring the whole of his left cheek, his oxygen nasal cannulae trailing across his mouth. Noticing this, I tried to move it back into place as he looked directly in to my eyes. ‘Make you feel better’, I said, struggling to get the tubing to lie comfortably on his face.
‘I don’t feel very well’, was all he said in reply. ‘I know,’ I responded, knowing he probably understood little of what I could say, ‘I know’, and tried to give his hand a comforting squeeze. He was alone, just like the patient I was tending to before, surrounded by bustle and noise, in a dark, densely packed ward. He died later that night from metastatic cancer. He was 25.
The next morning, as I walked through the bay on my ward round, I was quietly devastated, to find a newly wiped down bed of one of my other patients. An 18-year-old-boy. His grey mattress still had scattered on it, a blue dog-eared health passport, and some paper notes. Recently admitted with overwhelming meningitis, on a background of newly diagnosed HIV, and likely an expanding brain mass, with no fast imaging available, only certain antibiotics, and very few other options than what he was already being given, he had died overnight, the very same evening I had begged for a bed in HDU, to no avail, as everyone there was ‘much sicker’ than he was.
I can still remember his red patterned shirt, the smoke-stained jacket he wore, the grey, windy, cold afternoon he was getting so much better, and we collectively thought about discharging him soon, and then how he suddenly started to get so much worse, his pupils beginning to dilate and his wavering voice disappearing in a haze of soaring confusion. I can still remember his two teenage friends lovingly spoon-feeding him, changing him, and his concerned bed-neighbour telling us, emphatically, daily, ‘he is not well’. I also still remember being told the next slot for the research-donated MRI was a long 10 days away.
Death. Here, we are surrounded by it. We walk away from bodies every day. We walk on to the wards and find people dead, whether heralded by a guardian collapsing on to the floor and crying, heart shattered by their loss, or by being ushered over by a concerned medical student to a newly cold body, shrouded in a limp home-brought sheet. Here more than anywhere else, death is commonplace. This is a world without a crash bell. Without a resuscitation team. Where cockroaches crawl in the defibrillator. Where it can take a week to get an ECG.
Death occurs from a lack of facilities, a lack of resources, a lack of medication, a lack of staff, a lack of money and a lack of admission to hospital when there is still a chance something could be done. Yet, moving a patient to take up one of the 6 cyclinders of oxygen we have per ward, seems as much a herald of the end as booking an MRI (of the ten allotted slots a month for general medicine) (as both are uniformly reserved for the incredibly unwell and dying).
It would be easy to stay on the ward and run from patient to patient. Is it heartless to walk away, each day and go home to the relative comfort of a gated house, with a cheery summery garden, hot water and electricity? Sometimes it feels like it.
As often as the daily commute in to work is punctuated by the beautiful echoes of the church-going crowd outside, praying in song, it is also struck by the screams of torn-apart families, swallowed in grief.
It is unsurprising then, why faith and spiritualism is so important in Malawi. A proportion of the patients who arrive at our hospital have been to visit their traditional healer/herbalist first (estimated at just under half). My first brush with this was a young woman in general medical clinic, who had a razor blade scraped across her chest as a child, in good faith, to help release ‘the demons’. Another was a young man with AIDS who spent weeks in my bay, finally having sought help when he was overwhelming unwell, having contracted typhoid, TB and meningitis, after taking local herbs for months, with minimal effect.
They come to the hospital as a last resort’, I was told by one of our guides on a recent trip up to view the UNESCO ‘Chongoni’ Rock Art, primitive paintings traced to the Iron age atop a plateau in the forested foothills of the mountainous Dedza area, in the central territories, ‘because they are terrified – they think everyone dies there…’
As we gazed out from a cave, at the beautifully scenic panorama set against a cloudless blue sky, of scattered, green fields, where the predominant occupation is agriculture, and a large amount of children leave school at eleven years old, there were square clusters of billowing, tall trees at every village. ‘Graveyards’, he told us.
The graveyard is divided neatly in to those for ‘Christians’, and the ‘Gule Wamkulu’. Gule Wamkulu (literally ‘great dance’) is a legendary cultural heritage descending from the Malawian Chewa people, still very much shrouded in mystery and interlinked with the myths of old-age Malawi, as well as being for some, an adopted religion.
The Gule are thought to communicate with the spirit world, and the ancestors, through symbolic dances, adopting oversized masks and animal skin, to a rapid, rhythmical drumming, with their costumes pride of place, in the cemetery. ‘’Half of the people here are Gule Wamkulu’ he said, ‘and the other half are Christian’. Here, the chief of the village was Gule.
.‘Often,’ the guide added ‘people feel like the traditional healer or the spiritualists treat them better than the doctors’.
Is it so incomprehensible that in a world hit by years of poor harvests, with vast swathes of the population suffering from famine, where life expectancy only recently climbed from in its 40s and where the young die, so often, that people believe in bewitchment, in spirits, in magic, or simply in non-traditional medicine? That they seek more than what the hospital can provide them? That sometimes they simply don’t understand their illness? That they don’t understand why so many of them get so sick, so quickly?
Death should never become commonplace, we should continue to be surprised by our patients deaths, we should not just become universally accepting, but in our setting, where removing oxygen from one patient to let another live becomes a daily decision, it is easy to see how this becomes so difficult. Yet, I am acutely aware that our patients need more. Here, more than anywhere, I have found the hospital both a place of healing and of intense fear.
Moreover, from this, learning to not take the grief from the ward home with you, when there is a mortality rate of well over every 1/10 of your patients, yet also continuing to hold on to that grief, so that you keep fighting, even when it might seem fruitless, for the ones who might live, is an immensely difficult yet valuable lesson, that we grapple with, whilst in the comfort of an unchangeably stunningly beautiful Malawi.
Thank you for reading – Pri.