All was not lost and
there was really no reason to be upset; after all this was her first pregnancy
and she was still young. This was the sentiment expressed by the relatives
of an 18 year old girl with eclampsia (seizures) who delivered twins, one of whom
had been still born; the other had died two days later. After seven and half
months of carrying the twins, it appeared a period of grieving for her losses
was not a luxury afforded to her or something that has much place in a society
where women expect only a proportion of their pregnancies to have a successful
outcome and where surviving pregnancy itself is by no means guaranteed.
On Fridays I see patients sent over from the antenatal
clinic run by the two midwives. As with all things in life, medicine is full of
abbreviations. In obstetrics G refers to Gravidity
(the number of times a woman has been pregnant) and P refers to Parity (the number of times a woman has
delivered after 20-24weeks) with pregnancies ending before this time including
miscarriage denoted with a “+1 or 2”. For example, a woman pregnant for the 3rd
time with 1 child and 1 previous miscarriage would be noted as G3 P1+1 (a
relatively common situation in the UK). One recent patient in clinic came with
abbreviation G9 P7 3A. The extra ‘A’ was new to me but I quickly learnt that
the midwives used this to convey how many of the patient’s children were still alive.
In the UK one assumes that a woman’s children are alive unless anything is
written to the contrary. However, here it appears the assumption is that some
of your children will have died and the question is how many. So the short abbreviation
“G9 P7 3A” in fact represents an untold tragedy whereby the woman is now pregnant for the ninth time,
has given birth to 7 children, only 3 of which are alive. This is not far from
average. The human side to such abbreviations is seen readily on the children’s
ward. At 6.30pm yesterday, I was called to see a 2 year old who had just been
brought in. Although his mother stated
the only problem to be ‘generalised body pain’, one look at the child, who was
frantically gasping for breath, indicated his condition was critical. Sadly without
the facilities of oxygen or intubation (to breathe for him) he was not long for
this world. At 6.58pm there was a new child on the same bed waiting to be seen,
the body of the first child had been moved to the end of the ward and wrapped in
a sheet, and the father of that first child was having a frank discussion with
the nurse in charge about how quickly they could have his corpse for burial.
Perhaps the most upsetting aspect is that this is ‘normal’; engrained and
expected. There is little interruption to the ward activities; student nurses
delicately but quickly cover the bodies of patients that have passed away,
nurses continue with their duties and parents continue on with their lives. Sometimes
not even tears are shed. At one point last week I was concerned that not even
the practical exams for the student nurses that were taking place in the centre
of the open ward would be stopped as a man took his last breath. (Thankfully
they did decide to have a temporary pause in the proceedings although this was
seen as being particularly kind.) As an
outsider I find it difficult to keep the balance between, on one hand, wanting
to remain appalled and shocked at the current situation of an almost daily
routine of loss of life, but on the other hand, needing not to be so horrified that
you cannot function when the next child is carried through the door who needs
assessing and treating. I apologise if these ponderings are an outlet to keep
that balance in check.
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| The new shower... |
Last month we were in Freetown to visit the medical council.
Although our hotel didn’t quite hit the five star mark, it did have a trickle
of cold running water from a rusty shower head. To us this was luxury. The
simple matter of removing the need for one hand to be occupied with pouring
water from a jug to wash improved the ablution experience considerably. Since
then I have spent several hours in our ‘bathroom’ in Segbwema trying to
construct a ‘shower’ from a 5L plastic container, rope and dental floss; all
quality products purchased in ‘Poundland’
before our departure. Those who are acquainted with my DIY skills will be unsurprised
to hear that thus far, results have been mixed. A palliative care consultant
when teaching on how difficult it is to judge what one person views as “quality
of life” once stated to me that quality of life is about how near a person’s
expectations are met by the events of their daily life. Whilst a hot shower
sounds appealing, when you have no anticipation of any running water, a trickle
of cold water from a shower head certainly exceeds expectations and improves your
quality of life. Whilst not wanting to
demean the devastation and misery of women in Segbwema who have children still
born or who die very young, realising how these events fit with their
expectations of pregnancy, child birth and motherhood can perhaps help to understand
their perspective on what we, as outsiders, may view as life shattering events
and explain the resilience with which they cope. Ultimately, expectations need
to be changed but this is neither quick nor simple.
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All is not bleak and life here is filled with moments of
both enjoyment and humour. I still find it difficult not to conceal a wry smile
when male patients seen in clinic do not respond to the translated line of
‘What’s the problem?’ or ‘How can I help?’ but simply stand up and pull down
their trousers to reveal enormous hydroceles (swellings around the testicles)
the size of large grapefruits. (How childish of me I know...) There is also
time to enjoy the simple pleasures of sitting on the steps outside our house
drawing with an ever growing gathering of children who have now discovered our
supplies of paper and colouring pencils, or walking home down the hill with
Amie, the 6 year old granddaughter of one of the nurses who Janna is helping to
read, or honing our scrabble skills and successfully placing ‘JUICY’ onto a
triple word score (51). One of the
happiest times of the day is early evening when I walk down to the TB ward and
see an ever improving Evelyn smiling and enthusiastically returning my wave
through the open wooden shutters to the ward.
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| Shutters of the TB ward |
I listened with interest this week on the world service as promising results of trials of a malaria vaccine were publicised. Although such progress is undoubtedly good news, Benjamin Franklin conducted extensive research on electricity in the 18th century and a few hundred years on the hospital only has the resources and infrastructure to provide electricity less than 10% of the time. I hope it doesn’t take as long to get the malaria vaccine coverage up to this level here.
How fitting, the power has just gone off for the night…..
