“I am departing totally convinced,” the great Russian playwright Anton Chekhov wrote to a professional acquaintance in March of 1890, “that my trip will yield a valuable contribution neither to literature nor to science.” Chekhov prepared to leave for Sakhalin Island, a distant part of the Russian Empire north of Japan filled with convicts and criminal exiles. If this trip would offer nothing to literature or science, what could Chekhov, a physician and member of the literati, gain from this sojourn? He knew he would see suffering and pain there, the nadir of human existence. Why descend on that path?
His decision perplexes us further when we realize that Chekhov experienced misery and anguish his entire life. His father flogged him and his siblings regularly. In 1875 he came down with a severe infection of his abdomen. His brothers left home against their father’s wishes to work in Moscow, leaving Anton to absorb his father’s beatings. Meanwhile the family shop went bankrupt and Anton’s father fled, leaving his mother to face his debts. Anton’s brother, Nikolai, would die at a young age of tuberculosis. And as Anton became a physician and eventually attained success as a writer, he developed pulmonary tuberculosis, too. And yet, Chekhov departed for Sakhalin Island.
In the eponymous book on his trip, Sakhalin Island, Chekhov fastidiously describes what he sees: the people he meets, the geography of the landscape, the weather, and the suffering of the exiles. Yet he ignores our most burning question: Why give up precious time — especially given his deadly illness — for months in the bowels of humanity? What drives one to do this?
Though he does not directly address this in his book, his March, 1890 letter quoted above hints at an answer: “Even assuming that the journey will yield me precisely nothing — nonetheless, however, might there not occur, during the entire journey, two or three of the kind of days which I’ll recall my whole life with delight or bitterness?” Such an excursion might provide moments of invaluable self-reflection. And they might bring with them a sense of gratitude, a reminder of great deeds and what matters in life. He clarifies,
No longer than 25 or 30 years ago our very own Russians, while exploring Sakhalin, achieved astonishing feats, for which a human being might be idolized, but we don’t need all this, we don’t even know who these people were, but only sit gazing at four walls and complaining that God has created mankind so imperfectly.
A trip to Sakhalin would also shake Chekhov from the morass of daily life in which he found himself.
Chekhov also sought to expose the impeachable offenses committed at Sakhalin:
From the books which I have read and am reading now, it’s clear that we have allowed millions of people to rot in prisons, to rot for no purpose, without any consideration and in a barbarous manner; we have driven people tens of thousands of versts through the cold in shackles, infected them with syphilis, perverted them, multiplied the number of criminals, and put all the blame on to red-nosed prison overseers.
Here is Chekhov’s chance to reveal such barbarism, to see and understand what life is like beyond the confines of European Russia, to reflect on his own life, to appreciate what was done to build such an outpost and to shame those who turned it into the festering residence of the Demogorgon. And so, at the age of 30, sick with tuberculosis and the knowledge that he might soon die, Chekhov undertook his brutal journey.
After years of training, lassitude overtakes young resident doctors for a surfeit of reasons: exhaustion with long hours, one’s own feeling of ignorance, meager pay, and the steady push and pull from patients, colleagues, hospital administration, nursing, and life beyond the inpatient wards. Everyone wants something from you, an order in the computer for Tylenol, another note on top of the hundreds of others you’ve written during residency, another training module for HIPAA compliance laws or electronic health record training. These meager requests accumulate quickly and trap us in a morass of bureaucracy and mindless tasks.
American medicine piles on such red tape for some good reasons. In serious academic medical centers the department chairs rightfully build in layers of support for trainees. Before making a decision about a patient, a junior resident speaks with a senior resident and then the senior resident consults with a fellow and then the fellow talks to the attending physician. In other words, strata exist to ensure that we make the right decisions. Second, nurses add another layer of protection — a good, experienced nurse will double check a physician’s decision or order; the same thing goes with a pharmacist who releases the medication to the nurse. Moreover, some of our patients are well-educated and curious and ask us to explain our decisions. All this leads to better care. In one study from 2018, patients with all levels of complex medical illnesses had better outcomes at academic medical centers.
On the other hand, because of this layering, trainees often feel dispensable. Whether true or not, a stratified system makes the decision and reasoning of one person seem less relevant. I am not arguing that residents don’t matter. In fact, they matter quite a lot, as do their decisions. But it can seem, in the thick of it, that they don’t.
Furthermore, in a system like ours, the immediate availability of lab tests and imaging creates a sense of security and reliance on powers beyond one’s own intellect. If we’re uncertain about the exam and history we simply order an advanced radiologic study. Such blessed resources, alas, distort our reasoning. Consequently, we practice medicine in a defensive way, in order “not to miss something.” This, too, makes medical work feel less relevant, less significant.
With all this in mind I resolved to leave my training hospital for sub-Saharan Africa to teach and practice medicine. I traveled with one of my professors to a resource-poor setting. Here was my chance to do something good and fulfilling, to teach and to care for patients without access to a limitless medical system. I, too, would benefit from this trip, and not just educationally. I anticipated an antidote to the aimlessness one feels during training, the purposeless rut in which we often get stuck. I would see and understand what life is like beyond the confines of American medicine, reflect on my own profession, and appreciate the Western medical miracles while trying to bring some sliver of them to others.
I thought of Chekhov’s journey to Sakhalin Island, a foreign land inhabited by those far less fortunate than his Euro-Russian comrades. I, too, hoped to escape “gazing at four walls and complaining that God has created mankind so imperfectly.” And so, at the age of 31, I boarded a plane for sub-Saharan Africa.
One evening we saw a patient admitted with a diagnosis of “altered mental status.” The nurses brought her up to the ward and placed her on a cot in a corner of the room as flies hovered around her, alternately landing on her arms, legs, and face, and floating toward the window before about-facing and landing back on the patient. At the age of thirty, she suddenly lost the power of speech and movement on her right side. Intermittently, she held her head with her left hand and cried out in pain, the obvious signs of a terrible headache. The nurses tied down the left side of her body so she wouldn’t pull at her IV.
We asked the residents to transfer the patient to a coveted and expensive intensive care bed in case she got worse. Most patients, no matter how sick, do not qualify for a high-acuity bed. But a young patient with a potentially salvageable life and a child at home needed intensive care and she needed it promptly. When we came back the next morning, though, the patient was still in the same corner of the room. She no longer had an IV and thus could not get any IV medications. And she was much more somnolent than she had been the day before. She barely opened her eyes during the exam. How did this happen? How was she left to lie in a corner of the room without any medical care overnight? When we asked the staff, we received shoulder shrugs.
As foreigners, we had little control over patient placement in the hospital. We asked one of the physicians if we could bring her down to the ICU ourselves.
“You are white doctors,” she replied earnestly. “You can do anything.”
We pushed the patient down to the ICU on a rickety stretcher with malfunctioning wheels. Unfortunately, however, basic ICU care there did not function as well as it does in the United States. While we examined other patients, the young woman developed a “blown pupil.” The pupil failed to constrict when exposed to light; it fixed in a dilated state indicating deadly brain herniation. Due to high pressure in the skull, the temporal lobe of the brain (the uncus) pushes downward and compresses the oculomotor nerve, causing pupillary damage. After one of the residents notified us, we rushed back and explained to the ICU team that this was a medical emergency — the patient needed an IV medication called mannitol to decrease the swelling to save her life. After one dose of the medication, her pupil returned to normal size and she woke up.
We left the hospital soon after this tumultuous experience, hoping that she would survive the night. But she passed. The next morning no one knew what had happened. As we exited the ICU after receiving the news, I turned to one of the autochthonous physicians and exclaimed: “That is so upsetting!”
“Welcome to Africa,” she replied.
Yes, there was tragedy, but there was also hope. As we tore through floors and floors of patients in the sultry African heat, soaked in our own perspiration, we altered prior diagnoses, treatments, and medication doses, asked for labs tests, performed procedures. For some patients, we made little difference to the outcome, merely offering a diagnosis where a previously erroneous diagnosis plagued the paper chart (no electronic health records existed). But for others we made enormous improvements in their health care simply by changing a seizure medication. By doing so, we often contradicted some of the more senior physicians in the hospital. Of course, we did not in any way malign the hospital’s physicians. We came to help and to teach and we sought the accurate treatment and diagnosis; mendacity for diplomacy’s sake was not an option.
We could do this only because we luckily trained in a system with abundant resources, worldwide experts, and subscriptions to all levels of scientific journals. This evoked a sense of guilt. But even more discomfiting, we were told we could do anything because of our skin color.
In 1922, George Orwell joined the imperial police in Burma after poor grades and a tenuous chance at a university scholarship limited his academic options. It was nearly 100 years into British rule in Burma (it had begun in 1824). During their reign, the British destroyed and burned villages, abolished the Burmese monarchy and exiled families form their homes if they were disloyal. Indeed, one can imagine the kind of tension this created between the imperialist British and those under the yolk of their rule.
In his essay, “Shooting an Elephant,” Orwell describes the kind of moral dilemma and its accompanying moral disgust he felt as an imperial policeman. He absorbed the hatred the Burmese felt for him and the English staying there. They insulted him, tripped him during football games — small acts of rebellion to make his life and the life of his comrades more difficult. Orwell despised the job, he “hated it more bitterly than I can perhaps make clear.”
He continues,
In a job like that you see the dirty work of Empire at close quarters. The wretched prisoners huddling in the stinking cages of the lock-ups, the grey, cowed faces of the long-term convicts, the scarred buttocks of the men who had been flogged with bamboos — all these oppressed me with an intolerable sense of guilt.
Imperialism, Orwell suggests, turns one into an inhuman, brutal monster and destroys one’s conscience. Consequently, one loses all sense of agency. As Orwell readies himself to shoot a wild and destructive elephant in front of a crowd of Burmese, he explains,
Here was I, the white man with his gun, standing in front of the unarmed native crowd — seemingly the leading actor of the piece; but in reality I was only an absurd puppet pushed to and fro by the will of those yellow faces behind. I perceived in this moment that when the white man turns tyrant it is his own freedom that he destroys…. For it is the condition of his rule that he shall spend his life in trying to impress the “natives,” and so in every crisis he has got to do what the “natives” expect of him. He wears a mask, and his face grows to fit it.
The imperialists do what is expected of them from the population they rule. They keep up appearances. This, according to Orwell, defines a relationship where one group rules over another. And in the attempt to carry the White Man’s Burden, the British became entangled and confused in their own power, perceived moral high ground, and colonial duty.
A medical mission is by no means the same as nineteenth-century imperialism, but there is undoubtedly a residue of it. Being told that we can do anything because we’re white physicians is part of that. The other part is fear of us and what we might do because we’re white. I remember performing a lumbar puncture on a patient to obtain cerebrospinal fluid for diagnostic and treatment purposes. I stuck the needle in the patient’s back and she began screaming at me, using the slang in her language for “white doctor.”
We strike a tenuous balance between helping and imposing our ways on the patients and physicians of this African hospital. If we are seen as doing the latter then all we have done is for naught. As my professor said to me, “we are not here to change their system.” It is not our place to point out the failings of an overburdened third-world hospital. On the other hand, we cannot, for the sake of truth and patient survival, allow them to make incorrect diagnoses and treatment decisions. And even if one threads the needle perfectly, even if we are deferential and humble and polite, our abilities and technology still clearly surpass those of most of the continent’s. It produces the same sense of guilt Orwell felt, though to a lesser degree. But it also creates an absurdly high expectation of us, to know all, to fix all, to make everything better — our own version of shooting an elephant. There were multiple instances where young residents would pull me aside and ask me about patients we weren’t going to see. “Can you tell me if this is right?” they pleaded. We did our best, but I couldn’t shake the feeling that we were wearing a mask and having our faces grow to fit it.
She lay on a stretcher in the back corner of the room — the infectious disease corner. In the hospital I worked in there are no individual rooms for most patients; the badly functioning stretchers line up next to each other in a large, square room packed with people. No negative pressure rooms exist to sequester infectious patients. The powers-that-be stick patients in the back of the room and hope the disease stays put, too.
The patient’s face was gaunt and thinned with concave cheeks. And she was cross-eyed. Despite the obvious pathological changes, she looked to be a young woman. Her face, devoid of wrinkles, devoid of the dark recesses of the brow that oftentimes characterize the old, glistened in the sunlight.
We heard her story: a twenty-four year old female newly diagnosed with AIDS and cryptococcal meningitis, leading to increased pressure in her brain and on the nerves that supplied her eye muscles. Her CD4 count was 23 cells per microliter of blood (a normal CD4 count is at least 500 cells per microliter of blood). But we knew that she had not been infected from birth — the CD4 count declines, on average, by 50 cells per microliter a year. Indeed, she almost certainly had not been born with it given the following statistics: between 25 percent and 30 percent of children who have HIV at birth die before they turn one. More than half die by the time they are two. Most of the babies born with HIV become symptomatic with infectious diseases or fevers, enlarged lymph nodes or other symptoms. The average age of death for these children is between 6 and 7 years.
If she had not been infected at birth from her mother — referred to as vertical transmission — how did she contract the virus? Her mother insisted she was a virgin. After all, she was unmarried and came from a religious Muslim family. Indeed, every day her mother and sister traveled from the backcountry, a place with far fewer resources, to take care of her and feed her. With such a dedicated family, how did she get AIDS?
The residents brought in a 16-year-old girl from their clinic for us to see. She had experienced a few weeks of double vision when she looked straight ahead and when she looked to the left. She developed a chronic headache, too, and unsteadiness on her feet. Petite and quiet, she answered our questions in one or two words as we asked about her symptoms. A CT scan of her brain done at a new hospital one week prior to our arrival was reportedly normal. When she got up to walk she seemed to do okay, but when we asked her to walk on a straight line, the way a police officer might do with a suspected drunk driver, she stumbled and nearly fell.
We pulled up her CT scan. Her brain showed signs of hydrocephalus, a buildup of fluid and pressure within the cavities (or ventricles) of the brain. We brought her into the hospital and diagnosed her with tuberculosis meningitis; tuberculosis infected her brain, causing swelling, increased pressure, and damage to the nerves innervating the muscles of her eyes. Then we tested her for HIV. One doesn’t have to have HIV to get tuberculosis, but it is more likely to occur in patients with HIV. She was HIV positive, at 16 years old. Here, too, her religious family was shocked and again the father insisted she was a virgin.
We spoke with some of the infectious disease physicians at the hospital. Despite the evidence against it, they assured us she contracted it from her mother. They even told the family this. There was no social worker to help establish a sense of support at home. There was no police involvement. The powers that be brushed her diagnosis and its etiology under the rug. The patient would be put on the proper medications and sent home. Part of this dismissal has to do with the scant resources in the region. But there is, perhaps, something else at play. This is neither an inevitable tragedy nor an isolated incident. The statistics of HIV in young women are startling: In some parts of Africa, nine in ten new cases among adolescents occurred in girls. The reasons for this in poorer African nations vary, but there are clear and deeply problematic etiologies, including sexual abuse and transactional sex. Sexual abuse is not uncommon in sub-Saharan Africa. Data is not widely available, but some researchers have estimated that approximately 0.6-1.8 percent of all children in countries with high HIV-incidence in the region experience penetrative sexual abuse by an HIV-infected perpetrator before the age of 18. As for transactional sex, multiple studies have demonstrated that school girls use money obtained from sex to pay for school, clothing, pencils, and even packets of peanuts. In other words, the insidious problem of HIV in young women is well-documented and pervasive. Why ignore this tragedy? I honestly don’t know. It has little to do with moral sensibilities, especially in deeply religious African countries. Does it have to do with a sense of defeatism on a continent that is awash in poverty? Or perhaps it is so common that these cases disappear in a large ocean of numbers? Do we ignore what we don’t want to admit exists? How do we break out of this cycle of infection that plagues many young women of sub-Saharan Africa?
On our last day, one patient in particular concerned us. Only twenty-two years old, she presented after developing difficulty swallowing, as well as vomiting and weakness in her legs. Unable to breathe on her own, she required a ventilator. She clearly had significant weakness in her legs, but her arms seemed perfectly strong and she understood everything we told her, but could not speak due to the breathing tube.
We diagnosed her with neuromyelitis optica (NMO), an autoimmune disease in which the body attacks certain channels on cells, leading to inflammation in the central nervous system. We gave her three days of intravenous steroids. Though she still could not breathe on her own, she already recovered some of her strength. We spoke with her mother who thanked us profusely for our help.
We ended the trip on a high note. Our decisions about the hundreds of patients we saw made differences. Moreover, we taught dozens of medical students and residents. As they furiously took notes on rounds, we showed them physical exam maneuvers, demonstrated physiologic and pharmacologic concepts, and explained the classic symptoms and treatments of disease. And they expressed their deep appreciation for us, too. We exchanged phone numbers and email addresses with the residents, who have since gotten in touch to ask questions. I have never experienced such profound gratitude. We made a difference in a way that did not seem possible in the United States.
Back at our guest house, the water pump was not working, so I showered and shaved using buckets of water from a faucet outside and took a cab to the airport. We zoomed past motorcycles, mopeds, huts, street shops, and women in traditional garb carrying large containers as dust and dirt from the road swirled in the air. Nearly a day later I landed back in America.
The chasm between our world and theirs seems unbridgeable. My unfettered access to internet, drinkable tap water, air conditioning, subways, restaurants, supermarkets, clean streets, a soft mattress, my own kitchen, relatively cheap MRI scans, CT scans, lab results, blood pressure machines, IV poles, computers, drugs for common illnesses, specialist physicians, family, and friends contrasted starkly with what I saw in Africa. Even the ability to walk across the street to the CVS and pick up a cold Gatorade seemed delightfully novel to me. I was home, in a society flush with resources and technology, thankful for this remarkable country.
That evening, however, I found out that the NMO patient had died the night I left. It is unclear why, but we suspect it was a pulmonary embolism — given that she was bedbound, she may have developed a clot in her leg that migrated up her veins and into her lungs, cutting off blood flow into her lungs from the right side of her heart. And as my appreciation for the accessibility of professional and personal resources in the United States waned over the next few days (how quickly one gets back into the rhythm of life!), I thought perhaps that our success was an illusion, an attempt to help gone awry. I could only hear the words in my head of the African physician, and now my friend, over and over again after the death of another patient earlier that month: “Welcome to Africa.” And my response to the voice echoed just as loudly, “I have to come back.”