The Value of Seeing Wisely: A Western Pediatrician’s First Day of Rounds in a Tanzanian Hospital
March 28, 2017
Happy Publication Day to Tony Bartelme and his book A Surgeon in the Village: An American Doctor Teaches Brain Surgery in Africa! In A Surgeon in the Village, Bartelme chronicles the inspiring story of the doctors who helped cultivate medical sustainability in Tanzania, a country with just three practicing neurosurgeons for a population of forty million people. He follows the journeys of accomplished neurosurgeon Dr. Dilan Ellegala, born in Sri Lanka and raised in South Dakota, who took it upon himself to establish a “train-forward” method of teaching surgery that transformed the country’s healthcare system. Tanzanian farmer Emmanuel Mayegga became Dr. Ellegala’s first student, who then taught another Tanzanian how to perform the surgery.
Bartelme also chronicles the budding relationship and eventual marriage of Ellegala and Carin Hoek, a pediatrician from the Netherlands with whom Ellegala founds Madaktari (‘doctors’ in Swahili) Africa, a nonprofit organization that incorporates his train-forward method for other Tanzanians. The following passage describes Hoek’s first day of rounds as a pediatrician at Haydom Lutheran Hospital in the Lena children’s ward. While watching children receive treatment for severe burns, she comes to terms with her expectations from being trained and educated in the Netherlands and how she would need to adjust them in her new post.
To Carin’s eyes, some of the children looked as if they wouldn’t last the night; rail thin, they had the faraway gazes of prison inmates. A few children did indeed look well, but Sakweli made no move to discharge them. Odd. The ward was full; shouldn’t they discharge these healthy children to make more room?
A voice in her mind said, “Wait, Ca. Just wait.”
OK, I’ll wait. She would keep her hands behind her back, ask [her mentor] Sakweli basic questions: What steps do you take to diagnose a patient with malaria? How do you decide whether a patient has TB? Happy questions, ones that told Sakweli “I’m here to learn, not lecture you about how I did things in the Netherlands.”
In the next room the children had bloated bellies and terrible edemas. “If you are wondering whether this is a kidney edema or malnutrition, look at their expressions,” Sakweli said. “If their eyes show despair, it is malnutrition, kwashiorkor.”
Carin stared at a baby girl with big brown eyes, a swollen belly, and patches of hair; her brows were shaped in two pleading squiggles. Sakweli moved to another room with more starving children. Sometimes Sakweli spoke so softly that she could barely hear him. Her legs began to ache; her muscles grew stiff when she observed others; and her mind mimicked her hair in the wind, scattering even as she tried to move it back in place. Yes, the cottage needs work; I need to mend the holes in the mosquito net. What about Emma? She’s leaving soon. What do you give someone who leaves Haydom? When the tasks grew too numerous to remember, she took out a pen and scribbled notes on her arm. Soon her arm was full of temporary tattoos.
“Aaaieeee!” A child’s scream brought her back. They rushed to an open door. Carin smelled decay and soap. Two nurses were next to a galvanized tub that contained a girl who looked to be about eight years old. She had the same swooping eyebrows as Angela’s. The girl’s eyes were full of tears. She had bandages around her torso, shoulder, and left arm. Her legs were missing from her knees down; the stumps were wrapped in gauze.
“Pole sana, basi, pole sana (sorry, all right then, sorry),” the nurses said as they unwrapped another bandage. The girl’s scream rose like a wave, then broke into a foam of sobs and shallow breaths. Her exposed flesh was black and pink. A few feet away, her brother watched with wide eyes. His back was charred from his buttocks to his neck. He was next.
“Oh, what happened?” Carin asked.
“Burns,” Nurse Angela said. A pot of boiling oil fell on them. The girl lost her legs, but they were both on a list to get skin grafts. A plastic surgeon from California sometimes visited and did grafts. And the AMO named Mayegga also knew how to do them.
“Angela, this suffering breaks my heart. Do these children get any pain medication?”
“Oh, yes, we give them acetaminophen.”
Carin smiled back, but this one was forced. Acetaminophen? Tylenol? That’s for fevers and headaches. In the Netherlands, they put patients under when dressing severe burns. She moved her hands from behind her back to the front. Painkillers, where are the painkillers?
Wait, Ca, wait. Put it on the list.
Still shaken, Carin followed Sakweli and Angela to neonatology, which doubled as the orphanage. By the wall, a high table contained a row of babies. A few of their faces had bluish-gray tints. They’re hypoxic!
Another table of babies was across the room, the orphans. Some had rolled onto each other’s blankets. They looked healthy. Trying to be positive, Carin said to an older nurse named Mama Kidogo, “The orphans look very happy.”
“Their tears run inside,” Mama Kidogo replied.
Carin looked at the premature babies struggling for oxygen, and then back at the orphans who had equally uncertain futures. Like divorcing parents, the arguments in her mind grew louder. Make changes, she thought. Immediately. Then the voice again, that damn voice. “Wait, Ca, wait. For at least six months.” But how could she wait? Even for a minute? Don’t these children deserve the best care possible? Now?
“Please excuse me,” she said. When her mind overflowed like this in the Netherlands, she fled to the beach, especially if the weather was gray and windy. Then the beach would be empty and she could face the wind and sing and scream into it, and because the ripping wind drowned everything but her own voice, it was just her and her thoughts. She could sort through the ones that mattered. Was there a place like this in Haydom?
She left through the double doors, passing Lena’s photograph. She marched back to her cottage, thinking about the children and then the Flying Medical Service plane she’d arrived in the day before. Yes, the airstrip.
She exchanged her clogs for running shoes and followed the dirt driveway to the hospital gates. Was it right to stand by and let a child suffer? I could have done something. Her mentor’s voice again: “No, dear, they managed for decades without you. Aren’t you really trying to comfort yourself?”
When she reached the airstrip, she pulled out a pink moleskin notebook and crouched on one knee. She used her knee as a desk and jotted notes about procedures and protocols she wanted to change. In a few moments, she filled several pages with scribbles and arrows and underlined words. Then she walked briskly back to her cottage, tore the pages from the notebook, and stuffed them in a wooden nightstand. She sealed the drawer with duct tape, then stood straight, took a deep breath, and burst into laughter.
Her mentor had been right all along.
About the Author
Tony Bartelme has received numerous national awards for his investigative reports, including honors by the Scripps Foundation, Sigma Delta Chi, and Gerald Loeb Foundation. He has been a finalist for the Pulitzer Prize three times, including the series that is the basis for A Surgeon in the Village, which he spent four years researching and writing. He was the recipient of a 2011 Harvard University Nieman Fellowship and is a graduate of Northwestern University’s Medill School of Journalism. He is senior projects reporter for the Post and Courier, in Charleston, South Carolina, where he lives. Follow him on Twitter at @tbartelme and visit his website.