Sickness

I made a personal promise to myself at the beginning of the year that I would not let these blogs digress into a commentary on my gastrointestinal tract. If you have appreciated this goal then read no further. For those of you who are still with me, welcome to my level. During my first few months in Malawi being prepared meant carrying toilet paper in my back pocket. I never had serious intestinal problems, but I never knew where or when Malawi’s microscopic populace would hold a party in my gut. As time went on one of two things happened. Either my body dominated the locals or, as is more likely, the locals setup shop inside my intestines and decided to exist in a continual state of asymptomatic parasitism.

The problems which marked my first few months in Malawi had nearly faded as I entered the home stretch of my time in Africa. Aside from the heat, which drenched my shirt everyday by 8am, things were going well. I had discovered that my neighbor Ayub had the best fan in a 20km radius and had consequently taken to absconding to his house in the afternoon. On one such afternoon I was basking in the afterglow of a huge afghani meal when I began to feel a dull ache in the gut. I initially passed off the pain as the result of overstuffing my shrunken stomach, but later that night the pain returned. After dinner I laid down on the bed and began massaging my abdomen and complaining to Jes who was taking her customary pre-bed shower. “When did it start?” She yelled over the shower water.

“This afternoon at Ayub’s… I think its just gas though,” There was a pause in the conversation as Jes rinsed her hair.

“Where does it hurt?” I moved to the left side of the bed so that I was visible through the open bathroom door.

“Right here,” I said, jabbing a finger in my lower right abdomen.

“Huh, weird,” said Jes as she turned off the water and began toweling off. I went back to massaging my abdomen for several minutes until Jes walked by on her way to the kitchen and said in an offhand way, “isn’t that where your appendix is?” My heart did one of those sudden big lub-dubs that is followed by near normal heart beats and a feeling of anxiety flowing from your heart to your extremities. I had actually already noticed that the pain coincided with my appendix but somehow having another person make the same observation added to the credibility. The pain was pretty minor though and I convinced myself that it would probably subside by morning. It didn’t.

The dull ache in my abdomen continued throughout the next week in both a very reassuring and disturbing way. The pain didn’t get any worse, a fact that I used to rationalize to myself that I was okay. The pain also didn’t get any better, a most unsettling detail that provoked worst-case-scenario dramas to play out in my head as I tried to sleep.

My medical options were slim; I could try to get the problem looked at locally or I could go to one of the private hospitals in Blantyre. When Jes had gone to Koche, the local clinic up the road, the young man examining her had proudly announced that he was going to be taking his MSCEs soon. The MSCEs are high school performance exams so Koche was obviously not a good option. The Mangochi District hospital was a little bigger and a little farther away but also did not have much to recommend it. Mangochi District Hospital serves 50,000 people and has three doctors. An American medical student who worked there once recalled to me that he had seen ants crawling inside an IV tube attached to a person. I had heard good things about the hospitals in Blantyre, but they were a 5 hour bus ride away, a journey not to be taken lightly. I didn’t feel justified going to Blantyre since the pain was, admittedly, pretty minor. I had heard horror stories from a friend in college who had had appendicitis and my lackluster symptoms didn’t seem to compare. I decided to hold out a while longer and hope for the best.

I woke up Sunday morning and the pain was worse. I tried to tell myself that it was worse because I had spent the last week pushing and prodding my abdomen, but the time for rationalization was quickly passing. It was at this moment that I realized how nominal my ‘health insurance’ really was. Jes and I had both purchased catastrophic travel insurance before we left the states. The policy, aside from having a high deductible, was pretty good. It would airlift you out in case of emergency and would pay up to two million dollars. Yet before you can be flown out of country you need to find a plane, that means Blantyre or Lilongwe. Both cities are hours away on bad roads and I sincerely doubt a leer jet is standing by. As comforting as those travel insurance plans feel, I suspect Jes and I were, and are, at the mercy of local medicine in nearly all emergency scenarios. As I faced the prospect of acute appendicitis, my options were really no greater than a well to do Malawian.

I decided that I had to act now as it would take a considerable amount of time to access medical care. I talked to Jes and we made the decision to go to Blantyre if it was appendicitis. Mr. Sibale, the director of MCV, was at the campus on Sunday and we discussed my options. He knew a doctor at a local private clinic that I could probably see Monday morning with little delay. ‘Little delay’ was key since a visit to the district hospital could mean waiting the better part of a day. Every time I walk past the district hospital I see a meandering line of people emerging from the entrance, baking in the blistering sun. The line moves so slowly that people can be seen sitting or sprawled on their backs as they wait. I resigned myself to the fact that I would have to wait till Monday for any answers. Much of the country closes down on the weekends and this, to some extent, includes transportation and medical services.

Monday morning came and the pain was worse. As I went to the breakfast table I felt my abdomen jarred by pain from the movement of walking. Jes joked that it was probably because I was so heavy footed, but her teasing manor couldn’t mask the nervous edge in her voice. I didn’t feel like eating so I drank a protein shake while Jes picked at some bread and mangoes. Sibale arrived at 8am. I stepped gingerly into the front car seat and bade farewell to Jes. We had both decided she should stay and pack incase we had to go to Blantyre. The 30 minute drive to the clinic was mostly paved but bumpy dirt patches caused me to rise off the seat in a vain attempt to shield my abdomen from the rough road.

The clinic was part of an Islamic charity that has a large compound with a school and a large garden. The school and the garden looked well maintained and I became hopeful that the clinic was equally cared for. It was, but unfortunately quality does not go unnoticed in Malawi. Several men were sprawled out on the front steps and every available seat and patch of floor was occupied by sick looking people. I was ushered over to the check-in desk where the attendant promptly asked to see my health book. A health book is a small notebook used for medical records. It has things like your weight, age, sex, and notes from past clinic visits. Never having visited a Malawian clinic in a patent capacity, I had no health book. Every clinic is pretty strict about patients having their health books and seeing as I have chewed out patients for not bringing them I really couldn’t blame the attendant’s instance. Fifty cents later and I was the proud owner of a Malawian health book, yahoo, only $2499.50 more until I satisfy my insurance deductible. I was then ushered over to a line of chairs against the back wall. After several minutes of waiting someone came out of the door to the right of the chairs and the person seated next to the door rose to enter the examination room. Immediately, every other person in line shifted to the next seat with amazing speed, considering most were probably sick. I was reading at the time and kind of missed the cue so was leapfrogged by the woman behind me. ‘Oh well, I’ll get it next time,’ I thought.

After five or six more seat changes I was the one entering the examination room. I was pretty thrilled; the queue had only taken about a half hour. Inside, there were two women, a small bed, a scale, and an old-school blood pressure machine. I immediately realized this was not the doctor’s office, just the pre-doctor screening. I guess there are hoops to jump through in every country. I was weighed (147lbs, okay I have lost some weight on the beans and rice diet) and had my blood pressure taken (120/80 – pretty good numbers, guess I am not dying yet). I was then ushered to the next, longer, line of chairs. To my relief, the door at the end of this line read, “doctor’s office.” Forty minutes later and I was face to face with a doctor with just enough gray hairs to exude a reassuring and competent manner. I had done some research on appendicitis and so tried my best to convey actual symptoms without imagined or embellished details which always occur after one reads what they are ‘supposed’ to be feeling. The doctor asked me some questions and did all the physical appendicitis tests. “Well,” he said, “I think you have acute appendicitis.” He started writing in my health book. Reading his scrawl upside down I saw the entry: refer to Mangochi District Hospital for management. “So you think I should go to Mangochi District Hospital?” I asked. He looked up, a bit startled that I had been reading his notes.

“Mangochi is where we refer appendicitis cases,” he said in a voice that sounded like he used this line frequently.

“So they can treat appendicitis at the district hospital?”

“Well it where we refer patients for appendicitis.”

“I heard that,” I said, “but would you recommend going there?” He stopped writing momentarily and fixed me with a gaze that for the first time suggested he was pulling out of automaton mode.

“Well, if you need surgery you may want to go to Blantyre,” he said.

“Do you think I will need surgery?”

“In my experience most appendicitis cases are surgical.” He paused again, and then said in a rather frank voice,

“You should go to Blantyre.”

“That’s what I needed to know,” I said, and thanked him for his assistance. He gave me some useful information on hospitals in Blantyre and within minutes I was on the phone to Jes. “We’re going to Blantyre,” I shouted into the phone as the SUV bounced along the bumpy road. Jes had spent the morning wrangling transport and had serendipitously been connected with Octavio. Octavio is the former ambassador of Portugal and I had spoken with him on several occasions as he often stays at his lakeshore chalet near MCV. He happened to be returning to Blantyre with his wife, and upon hearing about my medical predicament, had moved up his departure time.

I decided to remain in Mangochi since it was on the way to Blantyre. I waited on the dusty steps of Peoples, the local quickie mart chain. The sun was overhead and the temperature was steadily climbing into the mid-nineties. I pushed on my abdomen to see if the pain had gotten better. Ouch! Still there. After about a half hour of imagining a gruesome death on the steps of Peoples, Octavio’s gleaming Toyota Land Cruiser arrived. Octavio was dressed in a smart polo and the air conditioning was blasting. As I stepped into the car I felt as if I was also stepping out of Malawi…well, at least out of Mangochi. In just two and a half hours –a full three hours faster than the bus – we arrived in Blantyre.

Jes and I had decided upon the 7^th Day Adventist hospital which came with good reviews from everyone we talked to. Their slogan is: we care, god heals. I secretly hoped the hospital also healed, but was prepared to accept intervention on my behalf from any source. After proving that we had adequate financial resources (in my case, being white was enough), I was ushered back to a waiting room that was so cold I was shivering within minutes (in retrospect the room was probably in the 70’s, but these days anything below 80 is too cold).

My doctor was a young and very nice Chinese man with an American accent. He became excited upon hearing that I was here volunteering for the year. “That’s how I started out in Malawi too,” he said, and then with a sheepish look added,” and I never left.” After a bit of poking a prodding he said, “I am going to admit you and call the surgeon for a consult, it does present like appendicitis.” The doctor seemed worried about my condition and before I left the examination room the surgeon had been called and was on his way. I was promptly put in a wheelchair and wheeled to the ward, a trip that actually involved going outside and down an alley. Nice to know I am still in Malawi. As I was taken down a barren but very clean hallway I couldn’t help but feel as ifI was in the 50’s. Nurses (all female) walked up and down the corridors wearing white dress uniforms with little white hats. My room was painted white and was barren except for a curtain and an old-style iron frame bed. Behind the curtain was my roommate, an older and well-off Malawian man.

The surgeon also poked and prodded me and after asking several questions said, “I don’t think this is appendicitis; wrong place wrong symptoms. It could be an infected caecum. We will give you IV antibiotics tonight and if it doesn’t get better we will operate tomorrow.” The surgeon left and I picked up War and Peace and prepared for a long night in the hospital.

A small placard on the wall said, “Visiting hours strictly enforced. Patients will be billed for unauthorized visitors present outside of visiting hours.” The approved visitation times were very short and I thought the stipulation seemed rather strict. Visiting hours were also maintained at the hospital I worked at during college, but the rules were pretty lenient and almost anyone could visit at anytime if they checked in. The rules at the Adventist hospital also seemed at odds with the attitude of my doctor, who had encouraged Jes to stay with me, even through the night. The rationale behind the visitation rules became clear when, at 5:30, the hospital was besieged by an army of visitors. The halls were suddenly filled with a mass of talking bustling people darting in and out of rooms. My roommate had about 30 visitors crowed around his bed. Visitors entered the room single file dressed in their Sunday best. They all spoke with my roommate briefly, then relegated themselves to the far side of the bed and stood in respectful silence while others took their turn. Visitors entered in phases, and although there were never fewer than 20 people in the room, it was obvious the different visitors belonged to different parts of my roommate’s life. Some groups interacted with the intimacy and familiarity of family, while other groups were clearly professional associates. Many visitors, upon noticing my glaring lack of visitors, came over to talk to me. It was quite nice to have the company and I ended up meeting the author of the biology textbook Jes uses in her class. As much as I have bashed Malawian textbooks in past posts, his is one of the better ones. Upon hearing I was from Oregon he became excited, exclaiming that he had done his undergrad at Whitman, small world.

After the half hour visitation period had passed I gained a full appreciation for the strict rules enforced by the hospital. All the people are nice, but very exhausting. United States hospitals can escape with lenient visitation policies because no one comes to visit. Okay, that’s a bit of an exaggeration, but in the entire year I worked at Penrose St. Francis Hospital in Colorado Springs I did not see as many visitors as I saw in just a half hour in the Blantyre hospital. I have come to the opinion that everyone and their uncle, their neighbor, and their distant cousin visits hospitals in Malawi. Seeing the positive affect these visits had on my roommate really made a strong case, in my mind, that we need to step it up in the old USA. The visitors even improved my mood since my roommate, in true Malawi style, shared his extra visitors with me.

My first night in the hospital (or any hospital for that matter) strangely reminded me of trying to sleep on a long airplane flight. People kept waking me every 3 hours to tale my blood pressure and refilled my IV. Jes, feeling guilty about sleeping in my bed in the presence of sisters (all the nurses are nuns), had been sleeping on the cement floor but after several hours of fortitude was overcome with weariness. The nurse, upon entering the room to find Jes in my bed, made a comment along the lines of: “what took you so long.” Morning came slowly but was punctuated by another half hour of visitation when my roommate once again entertained dozens of guests.

I spent the following day in the hospital in a manic cycle as my abdominal pain fluctuated from better to worse to better. By the end of the day the pain was a bit better and the surgeon decided that my problem was actually an intestinal block which should pass with proper medication. I was pretty stir-crazy by this point so was very in favor of being discharged. The surgeon agreed that I was probably safe to leave but recommended I stay close by until the symptoms completely disappeared.

I am feeling completely better now and am back in Mangochi. The experience made me appreciate how accessible quality medical care is in the United States. I was in one of the best hospitals in Malawi and there were no CAT-scans, no MRIs, and I suspect, few specialists. There was a poster on the wall advertising the visitation of a neurosurgeon to Blantyre. Apparently a neurosurgeon from South Africa spends part of his year visiting, for several days each, seven sub-Saharan African countries. The poster listed the dates he would be in each country and stressed he was only doing consults. While this neurosurgeon is shared by seven countries, my home town of 50,000 people has two neurosurgeons to itself. The level of care available in Malawi, even at the best institutions, is limited. Imagine having access to care only as sophisticated as a community clinic in the United States. Who do you know who would be suffering? Who do you know who would be dead?