Taxonomy of Grief

It's ten at night and I am making a run back to the hospital to check on a patient. Two new roadblocks have been set up since the night before. They don't even seem like roadblocks, really; it's just the lights shining in our eyes that make us stop. It could be anyone behind those flashlights—we can't tell even when we pull up. Only by straining can we see the soldiers. Our driver rolls his window down and waves our paperwork. There is a long exchange in Hausa, and finally a black face, washed out by the glare of the light, says, "Médecins sans Frontières. Oh, oh, well, okay." He waves us on.

I am in Nigeria with Doctors without Borders, an international humanitarian organization widely respected as a provider of medical care to various third- and fourth-world countries, often under hazardous circumstances. We are here doing crisis medicine, handling a meningitis outbreak in the heart of the sub-Sahara. The outbreak is killing thousands and thousands of people, and we have come because the Nigerian government is unable (read too inefficient, corrupt and useless) to muster anything near the resources needed to fight back. There are about thirty of us ex-patriates in Kano, five doctors, ten nurses and the rest "administrative." Unfortunately, there were not enough of us to begin with, even before the cholera cases started.

I am an emergency medicine physician; I have been for over ten years, a long enough period of time, I have discovered, to forget why I went into the field to begin with. Over those ten years I have played trauma doctor, social worker, breaker of bad news, heart failure doctor, Band-Aid placer, substance abuse counselor, frontline medic, post-traumatic-stress victim and a thousand other roles. The result was not surprising: I needed a change. I needed a new perspective. Hence Africa.

To be honest, before I came here I had imagined an experience I thought to be very Albert Schweitzer-like. This image had me working in a jungle camp of friendly natives where I serenely administered vaccinations under a tented canopy of brilliant green leaves. The truth: it is a squalid disaster here. We are understaffed and underequipped. The hospital we use had been closed for fifty years. Our staff is made up largely of Nigerian nursing students, most of whom have never even seen an IV before, much less started one. There is no sanitation, no windows, dirt floors, a single hand pump for water, and flies everywhere. Overall we have at least two hundred patients at any one time, but that is just a fraction of the total number of victims. The mortality rate averages about 20 percent.

But it would have been 100 percent without us.

The meningitis outbreak is not a pandemic, not quite on the scale of the cholera outbreak for Rwandan refugees in Zaire, but even so, every morning I have to clear away the dead or the near dead from the front porch of the emergency clinic to make room for the dying. I am currently in charge of the meningitis "emergency room," formerly a one-room post office. I examine everyone on a bare wooden table, where I also diagnose, treat (chloramphenicol and/or ampicillin) and arrange for a "bed." (Usually a bed is a piece of swept earth. The few beds we have sport only bare wire springs, no mattresses.) When I first arrive in the morning, it is so busy that if someone dies inside the clinic we put him or her on the floor and just step over the body until the relatives come to take it away. The atmosphere is that of complete chaos, but we have saved lives here, in this small room and throughout the hospital. We will save more, if the government allows us to stay on.

There's a measles outbreak as well.

We see most of the desperately ill in the morning. They come in early, after curfew lifts, and they sit and wait for me. The first hour is always a disaster. I wade down the hallway doing triage. "This one's sick, get him in now." "This one's dead, forget it." "This one's almost dead, just leave him be." To the families, it must seem as though we are passing judgment from on high: this one lives, this one doesn't. I don't think they have any idea what it is I see in each patient when I pass my sentence. I don't know if they know it has nothing to do with me at all, that I have no special power. Still, they accept what I say. No one argues, or rarely do they; no one pleads with me to change my mind, to take one more look. No one reaches out to hold me back, to convince me. Everyone in this line accepts the judgment I pass on to them, even if it is a death sentence.

In the afternoon I round on my intensive care verandah and three intensive care tents. These are where most of the critical cases are, not that we can do a whole lot of intensive care. Médecins sans Frontières has shipped down over four tons of supplies, but it is pitiful to see how little four tons of supplies is for those of us who practice Western-style medicine. We have liter bags of normal saline, IVs, IV tubing, and a few drugs: ampicillin, phenobarbital, Valium and paracetamol—a form of injectable Tylenol. The backbone of our therapy is something called oily chloramphenicol, an oil-based slurry of a venerable antibiotic; it is long lasting and dirt cheap. Listing what we have makes it seem like a lot, but simple things go missing. For example, we have no tape to tape the IV catheters down. Fortunately, someone at the start of the mission figured out that you could take the labels off the saline bags and tear them into strips. With these strips you can tack the IVs in place. We also have no gloves—but this may be, partly, a cultural thing. The first day I worked, the first time I went to start an IV, I looked around automatically for the glove box—de rigueur in America. There was nothing like this, so I asked Pierre, our chief logistician and head of supplies, for gloves.

He gave me a funny look. "Gloves?" he asked. "You're just starting an IV. What do you need gloves for?" He shook his head and raised his eyes heavenward. "Americans," he said, tapping his forehead and walking away.

I started after him. "'No gloves' is not an American thing, it's a French thing. You guys are crazy."

He didn't look back; he just raised his hand over his head and waved at me. "Okay, okay," he shouted back to me.

He found me a box of gloves.

The other French thing is the smoking. I had dinner before I left with another American who had spent six months in Burundi with a French crew. I don't know what his medical experiences were like because all he could talk about was how much the French smoked. "Meetings, dinner, lunch, at work, after work, in the wards, in the shower for Christ's sake."

The first thing the mission director asked me when I arrived was: "You don't have that American thing about smoking, do you?"

I raised my hands. "No, no," I said, "not at all."

This apparently was all the mission director wanted to know from me. Afterward I never saw or talked to him again.

Back in the car, we continue on past the roadblock, down a street lit by the shallow beam of our one working headlight. The shops and stores that line the main roadway are all shuttered. This is a street that is packed with hundreds and thousands of people during the day. It's dead quiet now.

Pierre, of the gloves argument, is sitting in the backseat trying to read some shipping labels by starlight. As the chief logistician, he has the unenviable job of trying to maintain some small degree of order in a whole sea of African chaos. He is returning tonight to bring in a fresh supply of oily chloramphenicol. I am going back to see a patient who, with luck, might still be alive. I admitted her just before I went home. A little girl. I had been starting an IV on an older woman, deathly ill from meningitis (she died about twenty minutes later), when I looked up and saw a young couple scurry across the open field in front of the ICU tents. I waved them over and they stopped breathlessly before me. The man handed me the bundle he held in his arms. It was a baby, maybe eight months old, and the baby was seizing. Great spasms, with arms extended, joints locked and legs twitching. She could have been seizing from anything, malaria, meningitis, cysticercosis, even a simple febrile seizure. What to do?

In the U.S. the workup would begin now: hundred of dollars of laboratory tests, x-rays, IVs. The poorest child in America would have a bed covered with a spotless sheet and a half dozen people crowded around it, trying to save someone's precious baby. But this baby, now, was examined on a mat on the ground with flies everywhere. The only diagnostic tool I had was my stethoscope. I couldn't look in the child's blood for signs of malaria. I couldn't tap the spinal fluid to make certain of a diagnosis of meningitis. (After the first week, when the epidemic was confirmed, we never tapped anyone. There wasn't time or equipment. If the patients were sick, you treated them for meningitis. If they didn't have meningitis, they would die.)

I squatted down by the child and pulled down on one arm while Simon, my nursing assistant, knelt down over the other. We had to use old IV tubing as tourniquets; there wasn't anything else. Simon and I squatted there, tap, tap, tapping the arm, up and down, looking for a vein to administer the IV. Babies this age are the hardest, even when they are not seizing. Their veins are thread-like and deep under the skin. This time I got one in before Simon. Usually he's a much better shot.

The father took my scribbled note and ran off to the pharmacy. We squatted there watching the baby seize, watching minutes tick by. Finally the father returned, triumphant, with the ampules. Simon broke them open and I drew up what we needed. I injected the baby slowly with phenobarbital, 5 mg, 10 mg and on. This should have stopped the seizure. Nothing. She kept twitching, seizing. I tried to get an idea from the family how long this had been going on. If it hadn't been long, the baby had a chance. A seizure lasting over an hour or more, though, meant there was not much use in even trying. I tried to ask, but either I couldn't make myself understood to Simon or Simon couldn't make himself understood to the parents, because I never did get any information.

We drew up more phenobarb and gave it slowly through the IV. Still, the baby seized. I had nothing more, no oxygen, no monitor. No other medication. If this didn't work, the baby was dead. After a few minutes I drew up another 20 mg and injected it slowly. Nothing else I could do. As I sat there brooding about this, the baby's spasms slowed a bit and became almost hiccup-like. Then, suddenly, the spasms were gone; the baby sighed deeply and was still.

We gave her ampicillin, oily chloramphenicol, and paracetamol for her fever. The nurses found a place for her between another young child with mild meningitis and a woman who had been desperately sick but now was doing much better, even walking a little today. "I'll be back later," I told the nursing students. "Don't anyone touch that IV."

So now I'm back. It's quiet at the hospital and dead black. The night-shift nurses are dozing at the two tables wedged between the tents and the verandah. A single candle lights up one table. I jostle Chuckie, Mark and Amos to wake them up. It's funny to think that I get on French nerves as much as they can get on mine. My first act in coming to the hospital was to award each nursing student an "American" name, a modification of whatever their name was in Hausa. My righthand man, Siminu, became Simon. Umar became Omar, Chafu became Chucky, et cetera. The French hate this. "That is so colonialist!" Pierre would tell me—but the nursing students love it. They laugh and clap each other on the back. "Now I shall go to America," one tells me dreamily, and I know that feeling—everyone has it when they are young—and sometimes I think I've never lost it: that feeling that somewhere in the world—not here but somewhere—there is a place one can find oneself . . . where someone could be who he or she really is. In Nigeria it is America. Oh, America.

I poke at the students. "The baby that was seizing," I whisper. "I've come back to check on her."

They all yawn and stretch, looking around. They seem as puzzled and astonished to find themselves here as I feel sometimes. Someone scrambles for another candle for us to round with. Silently, or as silently as we can, we creep through the verandah and on to the tent. I am holding the candle high, not sure where we deposited that family. There are no beds at all in the tents. Each patient has a mat—brought in by the family—that serves as a sickbed. At the foot of each mat a family member sits—or, as now, dozes. The family member serves as the patient's caretaker—making dinner, feeding, washing. The hospital merely supplies and administers the drugs. If a patient requires any drug beyond that which our meager pharmacy supplies, the patient's family must get it from an outside pharmacy and bring it for us to administer.

I walk cautiously through the tent, past the sleeping figures. Bags of saline are randomly tied to the tent cross beams; we have no IV poles. Tubing snakes down here and there to a patient, who stirs restlessly or lies still as death as my little entourage and I pass by.

The baby is there, sleeping comfortably. The sign I made is still in place. For some reason the night nurses regarded it as one of their duties to remove all the IVs sometime during the course of the night. No matter how much I begged, pleaded, bargained, requested, the IVs were always gone in the morning. Finally, I scrounged up a single roll of tape, which I used to tape a sign over the IVs. The sign reads:

I, Dr. Grim,
will kill you if
you touch this IV.

I also added a homemade skull and crossbones, a sign universal enough, apparently, so that even Nigerian nursing students understand what it means.

My seizing patient still has her IV in place. She is sleeping peacefully in her mother's arms. The mother is sitting there pretty much as I left her, bolt upright and wide awake. She looks transfixed by the saline bag and the loop of IV tubing that dangles from it, dripping precious Western medicine into her child's vein. I flick open the baby's eyes, and she shakes herself restlessly, sighs and sleeps on. Normal respiratory pattern, heart rate, pulse. I hold the candle up to her face. It is not the face of the dying child I left, but the face of a sleeping angel.

I turn to look up at the nursing students. "Well, we've saved another life here," I tell them. Someone translates this into Hausa and there is a nervous murmur of confirmation. They are all so proud of their work.

I hold the candle up and look around. Shadows dance everywhere in its light. I can see the baby's IV tubing more clearly now and see that it is covered with flies. There are flies almost everywhere you look. During the day the constant fanning of the relatives keeps the tent somewhat clear of them, but now, at night, they range free. The woman on the next mat over, unconscious and with no relatives, has a dozen of them feasting at the edges of her closed eyes.

Across the tent I see the policeman's child. His father is chief of the local police bureau. He makes, according to Simon, $20 a month when the government remembers to pay him. This is much too little to be able to take his son to one of the private clinics. I get up and go over there to say hello to his mother. I gaze down at the child for a moment, remembering. He came in sick, very sick. We gave him chloramphenicol and he only got sicker. One evening during rounds I found him, blue-black, scarcely breathing, sweating, as close to death as I had ever seen anything that was still alive. Again I had no way to tell if this was meningitis or malaria or anything else. He had "failed" chloramphenicol, for whatever reason. I could only give him what medicine we had left, ampicillin and chloroquine. But first we had to get an IV in, which turned out to be impossible in this dehydrated, almost prune-like little boy. Simon tried and I tried, over and over. The child lay there dying, and his only hope was for us to get a butterfly needle threaded into one of his hair-sized veins. But we couldn't get anything. Finally one of the senior nurses came by, looked down his nose through his rimless spectacles, cluck-clucked, and knelt down beside me to examine the arm. He got it in, first try.

We gave the child IV ampicillin, and within a few hours his fever broke. Still, when morning came, the child looked deathly ill. His mother spooned teaspoons of water into his mouth, but he didn't move, didn't swallow. The water spilled out along the edges of his lips. Why didn't you just let him die? I thought to myself. Now he's just going to suffer longer.

Suffer. To suffer. Suffering.

That afternoon I stopped by again to see him, and he was making little sipping movements with his lips and actually swallowing the water. His mother sat there, cross-legged, her scarf covering her hair. Her son's head rested in her lap. She was always there, always awake, always watching her boy. A day or two ago he actually opened his eyes and could lift his hand weakly to touch his mother's arm. Earlier today I had come in and found him sitting upright, very precariously, with his stick limbs girdered to give him some balance.

His father, the policeman, had pulled me aside yesterday evening as I was rounding. He held his hands out, cupped, as if he were offering me water.

"Thank you," he said to me. He was as formal as his freshly pressed uniform. "Thank you, thank you." That was all, but what else could he say or do?

Tonight the mother is wide awake, with the child sleeping beside her. She sits in dignified silence watching her son. She nods to me as I kneel beside her. I pull my stethoscope out of my bush jacket and press the bell against the child's bare rib cage.

"Breathing good," I tell her in Hausa. I know a total of four phrases in Hausa. The others are "Getting better, little by little," "It was Allah's will" and "He's dead."

Next to the child, though, is an empty space where there was a patient of mine when I left a few hours earlier. It was a young woman tended by her husband. We were treating her for both meningitis and malaria, but I'm not really sure she had either. The ampicillin and the chloramphenicol we poured into her seemed to do nothing. She wasn't very sick to begin with, but she got sicker as the days wore on. For the last two days it was clear she was dying. Her husband never left her. He nursed her with what he had, a little soup, a cool wet rag to her forehead. He would patiently wave away flies for hours at a time. He never asked us for anything; he never seemed to do more than to accept what fate doled out to him. When I tried to explain that I was going to try to treat his wife with IV chloroquine for malaria, he nodded and said nothing. What will be, will be.

I point to the empty space and look at Simon. He shrugs.

That woman was all that man had.