After the call from Jonah, I found myself gripping the back of his motorcycle as we traveled to the new health center in Nyahuka. Just a week before, Jonah christened the operating theater with the first C-section, an emergency for the wife of a “big man” who called in a favor. Now there was another mother with an obstructed labor and the baby was in distress.
I had just enough time to splash cold water on my face, check that I had my camera in my bag and throw it across my body. It was November and the rains had come, increasing the humidity factor. After just five minutes on the dusty rut-filled main road, sweat began to seep through my cotton dress. I was grateful that the Nyahuka Health Center was less than two kilometers away. I wondered how laboring mothers in need of C-sections managed before the center opened, when most had to travel a rocky 12 kilometers to the only hospital in Bundibugyo, on the back of a motorcyle taxi. The ambulance, a dilapidated white pick-up truck, was rarely on the road due to a lack of petrol, so after hours of unsuccessful labor these expectant mothers had to endure a jarring ride over a bumpy road. I could not imagine a more discouraging way of ushering a new life into the world.
As we sputtered along, I studied the various dwellings that sat back from the edge of the road, some made from cement, others from mud. , Shrubs and eucalyptus trees were dotted between them. Among the few people I saw walking along the road in the sweltering heat was a woman balancing firewood on her head, two teenage boys who gawked at us with curiosity, and a teenage girl who was bending over a tap as she filled up a well worn yellow jerry can with water gushing from a spigot..
Jonah guided the motorcycle past the main entrance of Nyahuka, through an inner gate and brought us to a gentle stop beside a modest two-car garage-like structure squeezed in next to the lab. The pediatric and adult wards are to our right, housed in an unremarkable single-story cinder-block building. In the shade of the veranda which lined the front, an elderly man was curled onto a mat sleeping. Near him a young woman with stubby braids leaned against the wall, her eyes half shut as she lazily watched a toddler crawling beside her.
Until recently this health center has not even had a doctor to perform these life saving operations, but that changed with Jonah. He’s not just well liked; here in Bundibugyo, Dr. Jonah is all but revered. As the pride of his people, he’s a living example of what hope and resources mixed with talent and hard work can accomplish. Still, getting posted to Nyahuka was a struggle.
With his medical background, one might have expected that this native son would’ve been eagerly embraced. After all, he was only the third doctor Bundibugyo had ever produced. One of the previous ones, Dr. Sikyewunda, is now the top public health administrator for Bundibugyo so he no longer sees patients. The other doctor from this area was trained overseas, but represents Bundibugyo in Parliament. So of the three, Jonah had the unique distinction of being the only one offering direct patient care. In addition to Jonah, there were only four other physicians providing medical coverage for this district’s 200,000 residents. Two were Ugandans who worked at the hospital, but they were not from this district. The other two are an American husband and wife missionary couple who I’ve come here to work with for two years on an HIV prevention program. Scott and Jennifer are based at Nyahuka, but neither of them do surgery. Yet, the health care needs are overwhelming. Malaria is a major killer and Bundibugyo is reported to have one of the highest rates of sickle cell disease in the world.
Despite these realities, confirming Jonah’s appointment to Nyahuka as its head physician took a miracle. The politics surrounding this decision were not unrelated to the fact that Jonah was from the “wrong” ethnic group: a Mukonjo in a district where power is centralized among Mubwisis. After months of delays, frustrating layers of bureaucracy, and numerous documents misplaced and re-submitted, the unlikely happened. The Chief Administrative Officer, (CAO pronounced “cow”), a cooperative well-intentioned man, who oversees all government postings in Bundibugyo, was transferring to another district. Scott met with the CAO on his last day in office and was able to persuade him to act on Jonah’s behalf. The CAO’sfinal act was to dictate and sign a letter confirming Jonah as the new head of Nyahuka Health Center.
****
The reception area was empty except for a pair of black flip flops. It was quiet. The walls of the health center were a sterile white, the ceilings unusually high. Sunlight filtered in through the burglarproof windows, which were well above eye level. The only sound I heard was the padding of our footsteps. The government had yet to provide electricity to this district. Despite the lack of ceiling fans or air conditioning, the air was cool, hushed. The mood was solemn.
In the next room there was a silver industrial sink. Jonah leaned over the sink, grabbed a bar of soap and began to scrub his hands and arms up to his elbows, repeating this gesture over and over.
I had never witnessed surgery of any kind, but was eager to do so. In university I considered pursuing medicine and chose public health instead. But over the years, my curiosity about the intricacies of the human body remained. I was grateful for this opportunity. To observe Jonah performing a C- section was rarer than rain during the dry season here in Bundibugyo.
“Pam, watch me and when I’m finished, you do the same. Even though you’re not part of the operation, you still need to glove and gown like us.”
I asked if I could take pictures inside. He glanced at my small camera case and nodded.
“Come, come let’s go. We don’t have much time.” I slip the strap over my shoulder leaving my bag hanging on a hook.
The theater is a modest size and resembles an uncluttered New York City studio apartment. Only a crash cart and low table line the white wall on the left. In the far corner are some empty shelves. A portable screen is pushed up beside them. The door at the far end of the room is a soft hue of pink. Oliva, the midwife, is already here along with an anesthetic nurse and a nursing assistant. All the women are dressed as we are, indistinguishable from each other.
A woman is lying in a fetal position on an exam table in the center of the room.Her eyes are closed and she is naked except for a kitengye. This brown tiger-printed African cloth, covered her pregnant belly. A drip hooked up to her right hand hangs from a tall pole beside her head
The patient’s eyes flickered open and then closed again as Jonah exchanged a few words with his team. He looked over the consent form Oliva had written out in a thin blue exercise book which served as the patient’s chart. Then he handed it to me. The title reads: Consent for Operation (C/S + BTL). Below that: I, Yosefus, consent for such an operation with anesthesia as suggested by the surgeon/Dr for the best of my wife’s health and the baby. The date is underneath. Yosefus’ right thumb, identified as such, and smudged on the top left corner beside his name is evidence of his approval. And then these words: I have explained the above information to the mother’s husband, who seemed to understand and signed in my presence. Oliva has put her signature and date below this statement.
“So the patient herself doesn’t have to give consent?” I asked.
“No, in a situation like this, it can either be the patient or her husband. They also want a BTL so I’ll be able to show you that as well.”
“She’s agreeing to have her tubes tied?”
“It’s not very common here, but this is number six and maybe her husband can’t feed any more children after this one.”
In almost 20 years of working in public health in the US and UK, I’ve never seen a hand-written consent form before. As I take a photo of it, I find myself wondering if the patient herself has consented to be sterilized. Or will she wake up in a few hours to find out she can no longer have children?
Jonah told me this couple had come across the border from the Democratic Republic of Congo, 10 kilometers away, like 20% of patients seen at this health center each year. I think that Nyahuka must be closer than venturing to a similar facility in their own country. Entering into Uganda at this point required wading through the Semliki River, or during the rainy season when the water swells, being carried above it by strong men for a small fee. If you’re Ugandan or Congolese, the immigration authorities don’t ask for documents, making this type of travel uncomplicated.
“Are we ready?” Jonah asked, gesturing to the anesthetic nurse. She nodded.
“We must move quickly,” he tells me. “The patient had already been in labor for over 24 hours.” The fatigue was evident on her face. Her eyes continued to alternate between shut and half open. Small bubbles of perspiration like soap suds soaked her forehead. Nudging the woman onto her back, the nurse gently extended her right hand and adjusted the drip. As the liquid seeped in through a large vein, the patient’s eyes closed for good. The nurse removed the kitengye and hung up a green sheet, creating a barrier between the patient’s head and the rest of her body. She also covered her with more green cloths, arranged to form a triangle-shaped opening of exposed skin just below her belly button.
Jonah sterilized this spot with an alcohol swab, took a sharp blade and began to make an incision, sliding through the skin as if using a box cutter on paper. This motion took me by surprise. I am tempted to look away, but I forced myself to keep watching. Jonahmade a clean vertical cut, which exposed several inches of thick muscle hidden just beneath the skin. He secured it in place with silver tongs that resembled shiny butterflies.
Jonah moved at a swift pace with the hope of reaching this infant in time. I stood back and observed, trying to be inconspicuous, taking the occasional photo. Fascinated by this view of the human body, I’m in awe of how deeply protected the baby is in the womb.
After more clamping and stretching, Jonah eventually reached the wall of the uterus. Once he perforated it, a foul-smelling liquid the color of muddy water squirted out, soaking his apron and splashing onto his face mask. Jonah jumped back. He recovered quickly, and reached in with both hands and lifted out an almost white mucous-covered newborn. The baby is still and appears to be wrapped in clear plastic like a frozen chicken one would buy in a Kampala Superstore. While Jonah is holding the infant, Oliva clamps the umbilical cord and cuts it.
“It’s a girl,” he said quietly, handing the newborn to her. There was no movement or sound from the baby. Oliva placed her on a table by the far wall, covered her with her mother’s kitengye and checked for a heartbeat and pulse. I was convinced the baby was already dead. Using a suction ball, Oliva removed as much mucous as she could from the baby’s nose and mouth. Once she cleared her airways, she covered them with a hand pump and began to administer oxygen. Then she gave her tiny chest compressions, alternating back and forth between oxygen and applying pressure. While she attended to the newborn, I pleaded silently for her life. Meanwhile Jonah continued to focus on his patient. The baby was out, but his work wasn’t over. He extracted the placenta and discarded it in a slop bucket.
“OK, let me look for the fallopian tubes.” As he poked around inside the patient’s uterus, I conjured up the two dimensional pictures I had seen of them in many a biology textbook. “I know they’re here.” A few seconds pass. “Ah here is the first one,” he said extending a long pale innocuous rubber band for me to see. It is completely unlike the image I had in my head.
“That’s it? How did you know how to find it?”
“Ah,” he said. “They teach us these things in medical school.”
He chuckled as he he snipped the tube and sutured both ends. He repeated the process after identifying the other one and then began to sew up his patient. Just as he was about to finish repairing the patient’s lower abdomen, the baby let out a tentative, barely audible cry.
We all cheer.
* * * *
On Tuesday afternoon, I stopped by the maternity ward at Nyahuka to check on how the patient and new arrival were doing. When I entered, I saw a dozen women, a few of them heavy with child stretched out on twin beds. Others had bundles of small babies beside them. One infant was whimpering; another was nursing. The newborn I was looking for was asleep in the arms of her father, an older man, lean with well carved biceps. Worry spills out of the hollow of his eyes. She was barely visible, hidden in the folds of a new kitengye. Her mother wasn’t well enough to begin breastfeeding. On pediatric rounds yesterday, Jennifer provided boxed milk for the baby, whom they have named Nightie. Her father was spooning tiny amounts of this liquid into Nightie multiple times a day. He’d been faithful, Jennifer told me. To his credit and by God’s grace, the baby appeared to be hanging on.
Nightie’s mother however looked worse than she did when I saw her on the operating table. She couldn’t hold open her eyes; her skin was dull and sandy. The sweat collecting on her face had seeped down to her pillow. She had been unable to eat since the operation. Fluid attached to a pole beside her bed provided either nutrition or antibiotics–I couldn’t tell. Her weak state and inability to nurse her own baby were cause for concern. I felt uneasy seeing her so detached from what was happening around her, saddened that she wasn’t able to enjoy her daughter’s first few days. I didn’t know how long it took for one’s body to recover from major surgery like a C-section, but this mother was struggling.
Nightie’s father and I exchanged greetings. I offered a smile. His mouth remained tight. Neither one of us spoke Lubwisi, so I didn’t stay long. In my basic high school French, I told him I would stop by tomorrow.
At Nyahuka’s Wednesday HIV clinic, I encountered an unexpected stressor. One of my roles was to help facilitate a smooth registration process for the patients. However, David, the Clinical Officer scheduled to be there, didn’t turn up. I learned he was out of the district attending a training. By this time the waiting room was clogged with over 30 patients and anxiety was mounting about whether they would be seen. Jonah was doing rounds on the adult wards and agreed to come once he was finished there.
When Jonah arrived close to noon, his shoulders were stooped and he was moving slowly. He looked wasted from a full morning. Nevertheless, he tried to be his usual cheerful self as the patients lined up on the benches outside his “office” scrambled to claim their places. His office was sparse, furnished with only a table and two chairs. There was no sink or exam table, and there were no gloves. By the time he got through seeing every patient and the charts were returned to the back office, it was well past the lunch hour and I was wiped out too. I ask Jonah how Nightie’s mother was doing.
“There’s no improvement,” he said. I couldn’t tell if the seriousness of his tone was due to his fatigue or her condition, or both, but I dragged myself over to the ward. I found the patient’s husband keeping watch at his wife’s bedside. Nightie was asleep on a mat beside the bed frame, but her mother was non-responsive.
The next day, four days after having Nightie, her mother was dead.
* * * *
After dinner, I looked at the photos I took in the operating theater of Nightie and her mother. When I returned to the health center, I found Jonah standing outside on the veranda. “I’m really glad the baby made it.” I said. “Were you surprised that the mother didn’t pull through?”
“No, I wasn’t,” he said. “You remember during the surgery when that brown liquid splashed all over me? That wasn’t normal. The bad smell was the sign of a major infection in the uterus, but of course I didn’t know about it until I was inside her.”
His remark takes me back to the operating room and I realize in hindsight just how sick Nightie’s mother must have been by the time she was admitted. No wonder her thumb print wasn’t smudged on that consent form. Even then, she was probably already slipping in and out of consciousness, not really able to engage in a conversation about the procedure that was about to happen, let alone cognizant enough to provide informed consent. And I can only imagine the anguish her husband must’ve been in by that point, watching his wife battling not just for their baby’s life, but for her own, yet unable to help either of them.
“This family is very fortunate the baby survived. If she’d been in there much longer, she wouldn’t have been alive by the time we got to her.”
“I wonder why they waited so long to bring her here?”
“It’s hard to say. There could be many reasons. Perhaps a lack of funds for transport. Or maybe because of the five children before, she didn’t think she’d have any difficulty pushing this one out. When midwife realized this delivery would be different, they had probably already lost so much time. Now that the mother is gone, it’s going to be very difficult for the baby since she’s not getting breast milk. I wonder if the father will be able to manage. He’ll have to try and find a woman in the family to care for her.”
“I really didn’t expect her to die,” I said.
“Look, this is the reality of practicing medicine, especially here. Many terrible things take place that wouldn’t happen if we had the resources and support to do our best for the patients. This family came from Congo. If they had come sooner, before the mother’s labor was so advanced, she might have had a different outcome. But we saved the baby.”
I take a deep breath and then can’t resist asking one more question: “Jonah, how do you live with these kinds of deaths?”
“Medicine is like this; We do our best with what we have but often it’s not good enough. And death can sometimes come very quickly.” Then Jonah looked away from me and out towards the outline of the Rwenzori Mountains, hazy and purple in the distance. He paused for a moment and lowered his voice. “Truthfully, Bundibugyo is a very difficult place to practice medicine. Extremely difficult at times. If I didn’t have a deep sense that this was my calling, that this is where God wants me to be, I wouldn’t be here. Even though this is my home, I wouldn’t be able to stay and do this day after day.”
After a moment, he turned and headed back into the ward. I stood there on the veranda. Living in Bundibugyo has been difficult: the crushing poverty, the lack of infrastructure, and preventable tragedies such as this one. I was almost half way through the two year commitment I’ve made to this community, which I intend to keep. But still, if I didn’t sense this was a calling for me too, I would be tempted–especially at times like this when it just feels too costly–to get out.
I think about Nightie and hope she’ll be okay. I wonder what her prospects for survival will be. Most children here are breastfed for about 24 months. Who will fill this role for Nightie over the next two years, if she even lives that long? Perhaps Nightie’s father has a female relative who is weaning her own child and could take over nursing Nightie. Then, I recall something I saw on my first day here at the health center.
A transplanted Nigerian, I had just arrived from New York City where I had been living for 14 years, and Jennifer was taking me with her on rounds. One of the patients we encountered that morning was a baby girl in a similar situation to Nightie’s. That baby was born in a village, but her mother had died while giving birth so the infant had become badly malnourished. When the grandmother brought the baby in, Jennifer and the nurses urged her to try to breastfeed. She was around 50, unsure of her exact age because birth certificates are not issued in this district, and had finished having her own children some years before. However, they encouraged her to keep putting her granddaughter to her breasts whenever possible. That stimulation can sometimes re-activate the hormones which produce milk. Success depends on a combination of how emotionally committed the breast feeder is to the child–the strength of that unspoken bond– as well as persistence and the suckling motion. Jennifer told me that in that case the grandmother had been reluctant, but the staff persuaded her to keep trying. It worked. After a few days, her milk started to flow again and that baby began to gain weight. Grateful for the communal nature of nursing in this cultural context, I pray Nightie will be as fortunate as that child was.
