"I'm Not Driving Anymore" by Rob Dougan
A/N: Obviously, the title of this story foretells certain things, but
putting that aside, what images does your mind envision when you hear the
words, “African mission hospital”? Laparotomies by the dim light of a torch?
Crowded wards of mothers with their children on quinine IV drips resting on
flimsy mattresses? Psychiatry probably isn’t the first thing that comes to
mind. And, to be truthful, it is still an underrepresented area of care in most
of Africa. As the populations become increasingly urbanized, some mission
hospitals in or near the cities must be willing to adapt to the ever-increasing
variety of ailments. It isn’t all malaria and typhoid now. What follows is one
of my experiences trying to navigate psychiatry in a foreign culture.
“Hear my prayer, O LORD;
let my cry for help come to you.
Do not hide your face from me
when I am in distress.
Turn your ear to me;
when I call, answer me quickly.
For my days vanish like smoke;
my bones burn like glowing embers.
My heart is blighted and withered like
grass;
I forget to eat my food.
Because of my loud groaning
I am reduced to skin and bones.
I am like a desert owl,
like an owl among the ruins.
I lie awake; I have become
like a bird alone on a roof.”
Psalm 102:1-7
I remember the first day I met Pat*. Petite.
Poised. Precise. Unlike the many inhabitants of Buea, she was strikingly distinct
in her appearance. A slender bone structure with elevated cheekbones, light
brown skin, and shiny curly black hair coiffed in immaculate braids tracing
ribbons on her scalp indicated her foreign heritage.
*(names, places, and certain other details have been modified)
If her external appearance hadn’t given her
away, her accent of soft, distinct syllables, clear and musical, would have
revealed her outside ancestry. “Where are you from?” I inquired, curious as to
her origins.
“Botswana,” she replied in refined English
tones that were easy for me to understand, a rarity during my earlier days in
Cameroon. She smiled mischievously. “Do you know where Botswana is?”
“Well, I must confess that I do not.” I
gave her a wry smile and bent over my world map on the desk between us to
search out a new country and expand my geography knowledge.
She chuckled and rearranged her purse,
setting it aside on the rusty chair next to her. “Here,” she pointed out the
small African country nestled next to its domineering neighbour in the southern
part of Africa all the while gazing at the map upside down.
“Ah, I see,” and nodded in recognition of
the country. I raised my head and took in her facial features again. Very
similar to the Ethiopian aquiline beauty oft admired in fashion magazines. Her
eyes crinkled upward at the corners and smiled back at me, amused at my meagre
geographical knowledge but obviously pleased at the interest I showed.
“Someday you should come visit,” she
invited pleasantly.
“Maybe I will,” I replied with the cautious
enthusiasm of one who loves to travel and experience new cultures yet realises
there are only so many places one can see in a lifetime. However, Botswana now
stood a much higher chance of getting on that list!
“How did you come to Cameroon?” I asked the
next logical question as she obviously was still fond of her motherland.
“My husband,” she replied matter of fact.
Then her mobile buzzed and she motioned an apology as she flipped it open to
answer the caller. “Yes, mama…I’m at the hospital…I’m coming…” Tone and body
language indicated the person on the other end of the conversation might not be
the most amiable caller. With a tired sigh, she concluded the conversation and stashed
away her phone, turning it off as she turned her attention back to our consult.
“Sorry,” she shrugged her slender shoulders with an apologetic gesture. “It was
my mother in law. She has to know where I am. If I’m gone for more than an hour
she calls.”
I nodded a sympathetic gesture.
In reply she returned to my original
question, “My husband is a business man and travels a lot. He was in Botswana.
We met and fell in love there. He’s Cameroonian. All his family is here. So,”
and she gave a poignant look of accepted destiny, “that’s why we’re here. We
are building a place up in Buea Town.”
After our introductions, we eventually came
around to her medical reason for consulting. Although I cannot recall the
problem, I assume she was content with the advice as she continued to remain a
client of our health centre and brought her children when they were sick as
well. . I remember exchanging emails and finding myself intrigued by this
lovely lady who painted a picture of poise and grace under pressure. Smart.
Modern. Managing as best she could in a new culture. Fascinating.
~O~
Life goes on. Events happen. Time marches
forward. One day, Pat showed up in my clinic in order to consult again. Nausea.
Vomiting. Loss of appetite. Weakness. Dizziness. Hum? I asked her when her last
menstrual cycle had been. “Any chance that you’re pregnant?” I inquired as we began
our conversation in the office to go over her history.
“Yes, I think I am,” she gave a shy and
happy smile in spite of her ill health.
A urine pregnancy test a few minutes later
confirmed our suspicions. Pat was quite pleased. It would be her third child.
She had two other biological children in addition to three older adopted children
from her husband’s previous liaison.
It was a good thing that Pat was so delighted
about the new addition developing gradually, in the perfectly controlled
process of time, inside her womb. In spite of our best efforts, she struggled
in an endless battle against pregnancy-induced nausea and vomiting and the
resulting fatigue. Each antenatal
check up ran along similar lines. “Pat, you’ve lost a kilogram. What happened?”
I was concerned at how this already tiny, forty something kilogram, Botswana lady
could manage to grow a healthy baby in her nutritionally compromised state?
“I know, doctor.” She always gave me a brave
apologetic smile. “It’s just so difficult. The food here…” her voice drifted as
she remembered her native traditional dishes. With a wistful expression, clear
almond brown eyes staring off into unseen places and senses smelling her
homeland dishes, she related her struggles with getting used to the very
different foodstuffs her Cameroonian mother in law cooked. “She is constantly
telling me to ‘eat’. She tries to force me.” She related her recollections of
such with a shudder. “She doesn’t understand…” her voice faded into silence.
I empathised with her and gave her the
freedom to voice her frustrations and grievances against her current situation
in the privacy of our consulting room. “For the baby’s sake, try to eat more.
Small, frequent meals. Small snacks. Groundnuts, perhaps?” I spoke with concern
for both mother and yet-to-be-born infant. As she left her antenatal
appointment, we hugged. A hug of encouragement and hope. A small infusion of my
strength and concern to bear her up against the daily struggles of dealing with
an overbearing mother-in-law, an absent husband, a demanding job of supervising
the building of the family home, all in the face of a medically difficult pregnancy.
It was not easy.
Somehow she survived her third and most
difficult pregnancy. The resiliency of the human spirit against earthly
antagonistic forces is extraordinary. There are certain people that seem to
glow all the more brilliantly in the polishing harshness of reality. Pat was
one of these people. In spite of her mother-in-law’s harassments, constant
phone calls tracking her every movement, and pregnancy fatigue – in spite of
everything – she made it through all nine months of pregnancy and delivered a
beautiful, healthy baby girl in the middle of the rainy season. A two point
nine kilogram beam of sunshine and joy breaking through the billowing storm
clouds that stacked up against the mountainside of Buea. Since I was away on
annual leave during the momentous event, it wasn’t until a month later that I
was introduced to the new addition. It was a joyous reunion consisting of
pictures, smiles, congratulations, and thanks all around.
~o~
After the birth of her daughter, Pat
slipped from my mind. I occasionally thought of her and wondered how she was
coping but I rarely heard from her. On her part, the construction on their
family home, the new baby, the routines of daily life and raising six children,
kept her preoccupied.
It is the unfortunate fate for one who
works in the medical field that patients typically only reappear when a health
crisis hits. (An occupational hazard that comes with the profession). So it was
that several months later, I glanced out at our packed waiting area, not
unusual for a Monday. Men and women, old and young, squeezed together on our artificial
leather padded benches situated against the walls. Small children dashed here
and there, some grasping small plastic baggies of chin-chin or groundnut snacks
in their grimy palms leaving trails of crumbs for the sparrows wherever they
toddled. Glancing out into the sea of familiar organised chaos and trying not
to calculate how far behind I was in seeing patients, I caught sight of Pat.
She met my eye and gave me a quick smile. She looked alone - and tiny. Dressed
neatly in jeans, ruffled blouse under a wrap-around sweater, and perfectly
applied make up with a delicate head scarf draped around her face, she
presented the epitome of style yet her face held a haunted look of vulnerability.
I was shocked at her naturally
slender, petite body that had now shrivelled past thin. Perhaps not emaciated
but definitely underweight. I wondered what happened. She didn’t look healthy
from my briefest of assessments.
Life has a funny way of tossing all sorts
of unexpected hurdles across our would-be smooth path. Sometimes it seems
certain people get more than their fair share of these bumps and potholes. Pat’s
circumstances were not going smoothly at all. As I listened to her recap a few
of the events evolving over the past months, my heart ached for all the pain
she was coping with. Emotional turmoil due to an endless string of unfortunate
events twisted round her mind and squeezed the peace from her daily routines.
The living situation with her mother-in-law remained a continued point of
conflict. The stresses of dealing with the problems associated with managing
the construction of their new house fell daily on her slender shoulders, each
new problem added to the pressure. The support she’d previously received from
her husband had now collapsed. She no longer trusted him and more and more he
ignored her pleas for help and instead fell under the spell of his mother. A
stranger in a strange country with little time to find friends or outside encouragement.
She was clearly homesick. Far from her own family in Botswana, she felt
abandoned, a sheep among a confusing pack of Cameroonian cultural wolves that
preyed upon her weaknesses.
“I’m so tired,” she confessed bleakly. “My
mother-in-law keeps pushing. She has to know where I am every moment.” As if on
cue, her phone buzzed. She glanced at the incoming caller ID. “That’s her,” she
shrugged with a knowing look at me.
I nodded in sympathy. “You need a break.”
“I know, doctor,” she affirmed, “but it’s
impossible right now. I can’t interrupt the children’s education. It’s the
middle of the school year for them.”
I shook my head at her determination to
provide the best for her children. I admired her for it but still worried as
she left the office.
Not long afterward, she came to see me
again. “I don’t sleep well at night. I can’t eat. I’m constantly tired,” she
admitted. “I don’t have any energy.” A few tears welled up and threatened to
overflow. She dapped at them with a tissue, careful to avoid smudging her make-up.
As she poured out her sadness and
frustrations to me, I brought up the topic of clinical depression. She
tearfully acknowledged that she fit the description. “Yes, I know I’m
depressed, doctor,” she affirmed with a sad gesture of her hands. After more
discussion, she decided to try a small dose of an anti-depressant drug called, fluoxetine,
the only option I had to offer her from our limited pharmaceutical supply.
She was faithful to follow up with me for a
short while afterwards and admitted that the medication did help. She managed
to eat enough despite having no appetite. “I know I have to eat so I can
breastfeed the baby,” she acknowledged, “so I force myself to take something.”
“You’re doing the right thing,” I confirmed.
Eventually the school year ended and Pat
was able to fly home to Botswana to soothe her tired and homesick soul. I lost
track of her after she left.
~O~
It was several months before I saw her again.
When I did though I was even more taken aback by her poor health. “I was fine
in Botswana,” she informed me. I ate the food I liked. I didn’t need to take
the medication.” Without emotion she continued. “But then I had to come back.
The children needed to start school again and everything. Now I have too much
stress.”
“Are you still breastfeeding?”
“Yes,” she nodded.
I was a bit surprised she still had milk
enough to feed her daughter. Yet now the question arose of what to do. There
are so many facets to clinical depression. How much is due to external
circumstances? How much to internal imbalances of brain neurotransmitters? Each
person is unique. There are no easy solutions. Each day was a struggle to
survive for Pat. She felt alone and hopeless against the forces of fate. She
didn’t have the energy to make new friends or even connect with old friends. I often
imagined it was the strong thread of love for her children that anchored her
enough to maintain her grasp of reality. Her reason for existence reverberated
around them.
Depression is impossible to comprehend as
an outsider trying to peer through the impenetrable murky glass wall of dark
logic. I couldn’t understand all the strange thoughts and memories that
surrounded her. She couldn’t verbalize the tumultuous emotional details that
tortured her existence. Instead she gave me the external symptoms. Eternal
fatigue. Isolation. Inability to eat. Constant anxiety. Poor sleeping patterns.
Feelings of guilt.
The cycle of depression rolls along predictable
reinforcing patterns, each building upon the other in an ever-expanding,
darkening cloud of hopelessness. Since she couldn’t change many of the aspects
of her situation that were unhealthy for her, Pat eventually resumed taking an
anti-depressant. “I don’t want to medication because I’m breastfeeding,” she
worried. She acknowledged that being alive for her baby was probably more
important though.
Sadly, her emotional depression weakened
her physical resistance to illness. We saw each other more often than I’d like
to report. An endless succession of stomach problems, sniffles, coughs, fevers,
and infections. She finally was forced to wean her little girl, as she no
longer had the strength to eat enough for two. Mainly I was the spectator and sounding
board for her as I watched her spiral hopelessly toward the grave. Her weight
dropped alarmingly. She came to me complaining of always being cold, never
being able to feel warm. “Everyone tells me it’s because I don’t eat,” she
said.
“Well, they’re right,” I reminded her. She
wrapped herself in her cardigan a bit tighter while I wished fervently I could
take off my white coat and try to cool off a little. A persistent cough took
hold of her lungs that refused to disappear in spite of everything. She vomited
up normal meals and was reduced to eating baby cereal and yoghurt. “You need to
go home to your family in Botswana,” I informed her, quite frankly, one day at
our appointment.
“I know,” she conceded. “That’s what
everyone is telling me. I just don’t know if I can with the children.”
“If you don’t go back to your mother’s
house, you won’t be around for your children,” I reminded her.
She thought about this a moment. “Yes, it’s
true. I am working on it. There are so many things to take care of before I can
go though.”
“I can write a prescription for you to take
holiday in Botswana.”
She smiled at my offer. “I know I need to
go back to my mother’s. I was well when I was there before. I could eat and I didn’t
need to take medications.”
“You should go sooner rather than later,” I
mentioned. Her homesickness, far from the comfort of her culture, in addition
to the enormous pressure of building a home and raising six children was too
much for her frail health now. “Please go,” I repeated. “You need to for your
health. It’s no good here.” There were times when we’d conclude our appointment
and I’d wonder if I would see her again – alive.
One day, Pat came to see me. As she coughed
her way through our conversation, she related how her husband had recently
returned from his most recent trip. “He was surprised at my condition,” she
said.
I nodded.
“He agrees that I should go back to my mom
in Botswana. Last night he said, ‘what are you doing? You must go back to
Botswana…otherwise you want me to send a corpse back to your mom?’”
Rather a blunt statement but essentially
true.
“So, I’m going back home,” she continued
with the first glimmer of hope in her voice that I’d heard in a long time.
“I’m glad,” I said, genuinely relieved. I
didn’t want to have to send a corpse back either. I was thankful that whatever
his failings might be as a husband, at least he realised the severity of the
situation and agreed with my recommendation.
~O~
The end of this story remains to be seen.
Perhaps there isn’t an end. For now though, I am happy to report that she is
doing better. I recently received an email from Pat. What follows is an excerpt:
“…As for me, thank God I am doing OK.
Better than last time you saw me. I am taking my medication and it helps a lot.
Thanks to you…. Any way just to let you know that we are fine…”
What will happen next? I don’t know. Her
children remain in Cameroon. Her family home is still being completed and will
be here. The pressures of her mother-in-law will return when she comes back
from Botswana. There are no easy answers. For now she is full of hope again and
I can rejoice with her in that. One day at a time…
~o~
A/N: One might argue that Pat was only
experiencing severe homesickness. The line between simple homesickness and clinical
depression is not always so easy to clearly define. Perhaps closer attention to
such ‘homesick’ symptoms in those living in a new culture might be beneficial. A
recent survey of over 300 medical missionaries, who have been in their foreign culture
for more than two years, revealed significant stress levels and self-reported anxiety
and depressive symptoms: “45.3% of
respondents have experienced anxiety to self-reported degree of 4 or 5 and
30.6% of respondents have experienced depression to a degree of 4 or 5 (scales
both from 0 to 5) (1).”
Psychiatry and the issues involved might
not be so remote from African mission hospitals as was once imagined. My prayer
is that we can all acknowledge the existence of mental illness in Africa,
accept the fact, and work toward a more supportive environment. Perhaps if this
article simply makes you think…become more aware…that’s all I can ask.
1.
“PRISM Survey 2011 - Christian
Medical & Dental Associations,” accessed March 18, 2013, http://www.cmda.org/WCM/CMDA/Navigation/Missions/Center_for_Medical_Missions/Prism_Survey_2011.aspx
A very insightful and interesting "lived experience" story and analysis; thank your for sharing with us.
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med_cat from LJ
Thanks for reading. I'm encouraged that you found it insightful.
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