Apollo at the front

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Apollo at the front
Ellen M Einterz

Some time in my mid-40s, shortly before the turn of the century, I finally got used to patients calling me grandmother. Children, young adults, and even those who themselves are grandparents and greatgrandparents started doing that. My greying hair and sagging skin aside, I like to think of it as a term of endearment or sign of respect in this society in which elders are still revered and old age is coveted, not feared. It is unusual in most of Africa to find a doctor in his or her 50s still practising primary care, or what we call front-line medicine, in underserved areas. Most new graduates man the trenches for a few years and then hitch rides on the first transport out. Some specialise and settle in cities already glutted with specialists. Others emigrate to more comfortable climes. Many others retreat to bland bureaucratic posts in ministries of health or non-governmental organisations, resolutely and gleefully tucking their stethoscopes and tuning forks away forever. The money is better, usually, and the rhythm of life is more regular, and there is a sense that one’s professional prestige depends on moving to the rear, getting out of the line of fire and away from the blood-splattering messiness of the battlefield. The front-line doctor sees just about everything, just about all the time, or so it often seems. A pickup truck loaded with jerry cans of fuel and the local football team overturns and catches fire, and all 11 players in various states of unconsciousness are brought to hospital with third-degree burns. A man in a remote village dies of acute diarrhoea, and the next day two of his neighbours die, and by the third day half the village is prostrate with cholera. A 30-year-old woman, a nomadic herder with missing fingers and the heavy facial features of leprosy, presents with putrid ulcerous excavations on the soles of both feet. A farmer clearing his field blinks too slowly to stop a centimetre-long splinter of millet stalk from spearing his cornea. A woman who has buried her first three children arrives in labour with the fourth, and the baby’s umbilical cord is prolapsing through her dilated cervix. A village elder suddenly loses his ability to urinate. There are no MRI scanners on the front line. No third—usually no second—generation drugs, no libraries of books or stacks of journals or computers with internet access. There is no laser or laparoscopic surgery, no lithotripsy, no serology for uncommon diseases, no banking of blood. There are no referral systems, no colleagues older and wiser or even just there to discuss a case or offer an opinion. Ears, eyes, and hands reinforced by a stethoscope, a sphygmomanometer, an otoscope and ophthalmoscope, and a watch with a sweep second hand, are the front-line doctor’s most valuable diagnostic tools. The history and Vol 365 June 18, 2005

physical examination are bolstered by whatever laboratory investigations can be done with a decent microscope, a minimum of glassware and a few reagents, while imagery in the best of cases is limited to plain films and ultrasound. The doctor in these circumstances knows how to do the tests, produce the images, and interpret the results. Medical treatment draws on a pharmacy of a hundred or so essential generic drugs. The workload is relentless because the demand is constant and because it involves not only care of patients but also hospital and health-service management. A leaky roof or a rusty lock must be fixed. A faulty generator is a nuisance, but it also imperils the cold chain that protects the vaccine supply. Disgruntled government nurses stage a go-slow. The minister of health and the national chiefs of this and that and the representatives of the big non-governmental organisations all want their reports, bound and in triplicate if you please, today if not before. For the front-line doctor in Africa, there is no typical or untypical day, and our patients are the whole community. We treat the young and the old, the poor and the well off, men and women; we manage the socalled western but in fact universal illnesses such as hypertension and diabetes and asthma, but also the parasitic and nutritional diseases associated with poor and tropical or semitropical zones. We are usually dealing with ten or twenty more or less urgent problems at once: a malaria patient in a coma, an epidemic of meningitis in three villages, an ailing ambulance, a new snakebite patient bleeding unclottable blood from multiple sites, a district administrator calling an immediate emergency meeting, a woman in labour with a breech. We enter the life stories of each of our patients. John Mortimer relates that Dr Salter, his salt-of-the-earth village doctor in The Rapstone Chronicles (London: Penguin), gave the newborn Dot Nowt “a slap on the bottom and told her to get on with it, which is the most you can do for anyone embarking on life”. But of course birth is only the beginning of the journey, and the frontline doctor finds himself at every port of call as his patient’s ship navigates its most turbulent waters, through sickness, recovery, new birth, the fading and loss of a loved one, good news, bad news, injury, disability. We sense not only the duty but also the privilege we are accorded, to be present at the most lifechanging, the saddest, and the most exultant moments of a person’s life. Every encounter is a chance to learn something new. Traditional beliefs often vie with the physician’s more Cartesian tendencies, and patients’ ways of expressing

Lancet 2005; 365: 2147–48 Hôpital de District de Kolofata, BP111, Mora, Extrême-Nord, Cameroon (E M Einterz MD)



See Lancet 2001; 358: 596

those beliefs offer useful insight into their understanding of health and illness. “Tell me truthfully, doctor,” the husband of a woman wasting from tuberculosis asks in a quiet aside, “is my wife suffering from sorcery or sickness?” A mother presents her sick baby: “Please, what is eating my child’s body?” and another explains that her son caught malaria from the morning dew. A man with an upper respiratory tract infection complains, “Air is entering my nostrils”. It is regarded as obvious that the membranes and fluid of the amniotic sac discharge through the mother’s mouth when a woman in labour vomits. Outbreaks of infectious conjunctivitis are called Apollo because one such outbreak occurred when Neil Armstrong was on the moon, and pinkeye ever since has been attributed to man’s shenanigans in space. Chest auscultation often requires first lifting aside an amulet necklace of shells, coins, stitched leather pouches, bird beaks, and rodent paws. Elizabeth Molyneux of Malawi has said that “nothing beats good clinical medicine for challenges, stresses, glorious successes, and miserable failures”, and nowhere is this clearer than on the front lines of health care in Africa. Sometimes there are frightening cases. I am called at midnight to receive a barely conscious woman who delivered earlier that day in her village and then failed to expulse the placenta. She is pouring out blood as if her uterus has a spigot with a cross-threaded tap that will not turn off. I get her on the table and note her colourless tongue and her unseeing eyes, and blood is flooding everywhere. I reach in to empty the womb and as I do, terrifying thoughts pound in my head, and as always in cases like this it is like being in a raging thunderstorm all alone in the middle of nowhere, and sometimes I have to look up to realise that in fact the room is so still and quiet I can hear a graceful lizard brush against the floor, and my thoughts are along these lines: am I watching this woman live the last five minutes of her life? If I don’t do something or do do something else, will her children never see their mother again? And all the while I am giving orders to the nurse—position the patient, give the injection, start intravenous fluids—and going through the motions of clamping down on the uterus and reaching in, finding the edge, grasping and withdrawing, all with a methodical deliberateness that just camouflages the fear and dread I really feel. In the end, the placenta is removed and the haemorrhage is stopped and the patient is stabilised, and when I leave the hospital at two in the morning I feel drained, as if half that blood spilled on the floor had been my own. There are sad cases. The scrappy 1-year-old we have been treating for several weeks turns out to have AIDS,

and I realise again that of all our AIDS cases the ones I most dislike facing are newly diagnosed children, because the implications for the family are colossal. Almost always, the child has it because the mother is seropositive, although she does not know it yet, and the mother is positive because her husband is positive, and as often as not it is a polygamous household so other wives are involved as well, and maybe other children; and in an area where there is little hope yet for adequate treatment, it is wrenching to break this kind of news to parents. One can only imagine how instantly devastating it must be to receive it. There are also wonderful cases. One Friday night in the middle of a dust storm I am trying to start a transfusion on a gasping 7-month-old boy who appears to have not a single vein in his body. Suddenly the lights go out—I will learn later that the storm toppled three electric poles and knocked out power and that the power will stay out for 5 days. In the darkness the boy, his eyes rolled back into his head, is struggling for every breath. I could send someone into town to fetch the man who is in charge of the back-up generator, but that would take 45 minutes, or I could go out to the generator house and start the engine myself, but that would take half an hour, and I do not know whether this child has even 15 minutes of life left in him. So I ask someone to light a kerosene lamp and we carry on trying to find the elusive vein in time to keep that life under my hands from going out like the electricity. We do find it at last, and it is not too late. The blood starts flowing and an hour or so later the bony chest starts heaving less desperately and the grey cheeks lose their ghostly pallor and finally the mother’s solemn face relaxes and streams with tears of silent joy, and surely that is one of the most beautiful things it is possible to witness anywhere on earth. The practice of clinical medicine precludes almost nothing else in the field. Indeed, research, public health, writing, and teaching should be integral to the job, and they should enhance not exclude patient care. The temptation to remove ourselves from the pulsating heart of the struggle is great, but the front line is exactly where the best, most experienced, most dedicated doctors should be. It is where the majority of a nation’s citizens are served and where the breadth and depth of a physician’s knowledge are most critical. It is where the first sparks of an outbreak are either extinguished by practised hands or left to ignite an explosive epidemic. It is where good, veteran leadership is most needed and can make the biggest difference. Most importantly, the front line is the best place for any doctor to be engaged, through commitment to the wellbeing of individuals and to the welfare of populations, in the ultimate and universal fight for peace.

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