Reflections

Two months ago I left Cameroon. I was exhausted and could rarely see the good and positive - though I knew it was there.  

Today - here and now - I am on the eve of my flight to return to Cameroon for the last time as a resident.  I am seeing snapshots in my mind - scenes of Cameroon’s lush countryside, of steep and rugged mountains, of sweeping vistas, of the black sand beaches of Limbe and the white sand beaches of Kribi.  I see the winding roads through the jungle.

I smell the scent of the wet jungle, I feel the sand and water between my toes, I hear laughter floating across the breeze.

Memories - times shared - conversations engaged - laughter, insights, dreams, trials, struggles, failures, successes.  Each image a story rich in culture, context, and sub-text.

Life is what happens when you aren't looking - or so they say.  But living and working in Cameroon for nearly five years I have been constantly aware of life in the making - here - and now.

I think of the people with whom we have shared this time: Cameroonians and non-Cameroonians.  People of similar faith and those with very different belief systems.

Images of my favorite places to hangout float through my mind: Arne’s; Capitol Hotel; A1-Complex; Gideon, the Shawarma guy; Bonga Juice; Clerks Quarters; and the Mediterranean.

I see Thanksgivings and Christmases and parties at our home and with friends at theirs.  I see quiet evenings and game nights.  I see failed game nights that turned into beautiful quiet evenings and spontaneous quiet evenings that became game nights.

I see church: fellowship meals, sermons, and energetic discussions.  I see the friends and colleagues who traveled far and near to visit.

I taste the many cooking experiments of our own making and that of our volunteers.  I can taste the oil and pepper in the black beans; the succulent chicken and tomato sauce; 

I remember the very day the first time I smelled the grass, February 14, 2010 after the first rain of the season.  I smell delicious food and the burnt aromas of forgotten popcorn or rice.

I feel the cold dampness of the rains; I feel the warmth of the sun and rejoice in the gentle breeze.  I feel the cool of each evening; 

My thoughts drift to the Health Centre, what was, what it has become, and thinking what it can yet be.  Much of this I am still processing.

Some speak of legacy - this time in Africa.  But it is only a drop in the bucket during a rainstorm in Buea.  The entirety of our life is our legacy: the good, the bad, and the ugly.

Each of us is a gift to humanity - a gift of our talents, our time, and our skills.  We gift our interests and efforts.  Sometimes it is appreciated - sometimes not.  The quality of the reception of our gift need not change the gift.  The quality of the gift of ourself is our choice, not the choice of someone external to ourself.  

Let us encourage one another.  Because there are many days of struggle.  

Be courageous! Love with genuine affection.  Love the lovely and the unlovely.  Bless all with the gift of a life lived in and through Love.  

Fit for Skyline Drive

The drive to Yaounde from Buea is about 322 km (200 miles). The fastest I made it was in 4 hours the longest included an overnight in Douala because the traffic really was that bad (coming back from Yaounde).  Normally, without feeling rushed it was between five and six hours.  The thing is a Nissan Terrano is an SUV and it drove like an SUV abused in Africa - with good reason - because it is.

When I picked up the Fit I was trying to think about a fun place to drive for an extended “get to know you” experience. The ONLY place that entered my mind was Skyline Drive in the Shenandoah National Park.  I mapped it out in Google to 207 miles with an estimated drive time of 4 hr and 35 minutes. 

It was a beautiful drive. I opened up the sunroof and put the windows down. I was able to work the car a bit more.  The drive to Front Royal was pretty standard but turning up Skyline Drive I immediately noticed the CVT trying to find the right place to be. What I was driving were some rapid up and down hills on corners. It was trying to anticipate what I might want or need but was not meeting with any success. So, I turned off ECON and put the car in sport mode, requiring me to use the paddle shifters. This turned out much more satisfying (admittedly however I am a manual shift guy and still wanted to shift that way).  In any case the CVT obeyed my command. I found the Fit ready to respond with some engine breaking on the down slopes and entering corners before adding power through the curve and up the hills.  It was quick to shift up or down.

The steering is light and precise, coming off the Terrano I simply wasn’t prepared for its accuracy, but that is one reason for me to do this drive. With the wind in my receding hairline, music emanating from the iPod through the sound system, with a “Fit” and capable car I was getting road therapy - salve for the soul.

It was all real good until I realized I went west on 33 rather than east. Oh well - I wasn’t lost just getting extra miles on the highway.  I went back via I-81 to I-66 an extra 60 miles or so.

My entire drive took me about 6.5 hrs with stops out vistas and animals.  I was reminded just how fun it is to drive a car that is so willing to be driven.  To be fair to the Terrano, the few times I found myself on muddy and challenging roads I was ever so pleased it was what it was!!

Everything has its purpose.  I enjoyed the Terrano and am now enjoy the Fit.  To fully enjoy each I have to remember each has a slightly different purpose.  

Everyone has a purpose. Sometimes it seems that our “things” are easier to see and understand purpose. In people purpose may be more difficult. However I would like to make it easier. I believe it is our purpose to love without condition or requirement.  Everything else we are or have is something else - perhaps gifts from God to be given in the service of love.  You are fit for service because you have a purpose and a very high calling: love others as you love yourself.  May the love of yourself and others grow more each day.

Let It Rain

“Have I not commanded you? Be strong and courageous. Do not be afraid; do not be discouraged, for the Lord your God will be with you where ever you go.” Joshua 1:9

~O~

Sometimes courage is in short supply.
Sometimes strength is found in weakness.
Sometimes the tears threaten to fall.

The glass facade trembles and nears dissolution into a broken heap of shattered remnants.

There are many things to appreciate about my life in Buea. I am surrounded by blessings in the form of friends, pets, smiles, and inspirational stories every day. I live in a people-oriented culture where people take time for people.

~O~

Sister Comfort dropped by the patient's room looking for a pair of baby's shoes. In spite of her busy schedule, she exchanged pleasantries with the new mother for a quarter of an hour before continuing on with her duties. She forgot the shoes.

~O~

A member in church is recovering from an operation at home. Each day a steady stream of brothers and sisters in Christ, visit her, delivering fruits, drinks, and companionship – distracting her from the pain and cheering her through discussions on the local events in town or reminiscing over enjoyable memories.

~O~

Even online, when I open my in-box, it spills over with messages and encouragement in daily snippet exchanges shorter than a tweet but filled with plenty of love.

Everywhere I look, I am blessed.

~O~

Still, there are the periods of loneliness, tiredness, discouragement – seasons of sadness. Or perhaps not an entire season but rather moments of melancholy? Periods in life that remind me I am human, not immune to the tribulations in life.

Sometimes the showers of blessing are showers of sadness too.

The rain outside my window tonight falls lightly, it drips in a steady flow – slow droplets from the sky sighing in their misty descent. Their melancholic liquid symphonies splashing to their death in a mournful rhythm of drip, drip, drip.

I want to join their chorus. I want to let my own tears blend and mix into the watery cascades, allow the sadness  to float away in the same rivulets as the falling water. The rainy splashes can drown out my sobs. My tears will vanish in the fleeting flowing eddies of swirling water.

I want to let the tears come and wash away  this sorrow.

~O~

Emotions are like the waves of the ocean's tide, ebbing to and fro. Sometimes content and happy. Sometimes disappointed and sad. My patience is in short supply these days. It's a thin line. I easily snap at slight provocations.

A new nurse did not know how to set up the quinine infusion for a small child properly yesterday. He almost caused a serious mishap through his ignorance by failing to ask for help in getting the dosage correct. He could have caused a major problem that might have hurt the child.

“How can you not know how to give quinine for malaria?” My voice was angry as I rebuked him for his mistake. “Haven't you worked as a nurse before in other hospitals? How is that you don't know how to set up the most commonly given infusion for malaria? You told us you could do all things. You told us in your initial interview that you were capable of all the basic duties required of a nurse.... ”

The new nurse maintained his composure. He couldn't understand my hastily spoken complaints but he understood that I was upset.

“I'm sorry, doctor,” was all he could add.

Later, I was reminded. “He's just a baby, doctor. He's new.”

It was true. In spite of his deceptions regarding his initial skills, now was not the time to deliver a lecture on his incompetence but rather move forward. Chiding his lack of abilities would not solve the issue. Berating him over his mistakes was not the solution.

I took him aside. “I am sorry for getting upset at you,” I apologized.

~O~

This morning I argued with the auntie and mother of a young child sick in our hospital. “Please, let her continue her treatment. Let her complete her medicine. She is too ill to go home.”

They were determined to go though. “Doctor, you are not getting us,” the auntie complained.

“I am getting you,” I answered. “I am just not agreeing with you.”

In the end, no matter what I said or offered, they left. Their minds were made up.

~O~

“It was the worm medication that the doctor prescribed. It was too much medicine. My doctor in Yaounde says I should not have taken it all.”

The recently bereaved woman who'd just suffered a miscarriage needed someone to blame. It didn't matter that the worm medication she believed to be the culprit for the miscarriage was part of the standard of care given to all pregnant women. She needed a reason. A reason so that she could avoid a miscarriage in the future.

“She has to blame the medication, doctor,” my astute nurse observed. “She cannot just say it happened like that. I could see that she already had it in her mind that the worm medicine was the problem. She has to tell her husband that so he doesn't blame her.”

She was correct, of course. I have to be brave and professional and accept the accusations. Arguing the scientific facts have not convinced her otherwise. She needs a scape-goat. I am that person today. Even though I know I'm innocent and haven't caused her harm, I am hurt. It is a terrible accusation to be blamed for the loss of one's baby.

I want to cry but now is not appropriate. Tears will not help. I continue on with my day. Even when I don't feel confident and brave, I can at least play the part – maintain my role as medical leader. My nurses need me.

~O~

Tonight, alone, the rain falls softly. The burdens on my heart feel extra heavy. I wish I could join the crying sky. I want to weep for all the pain and suffering I witness in my labors. I want to mourn for the tragedies that enter my sphere of awareness here in Buea.

The tears cannot come though.

Instead I let the sky do the crying for me.
Let it rain.
Let the tears from heaven come.
Cleanse away the sadness and the sorrow; make way for the sunshine tomorrow.

~O~

“My eyes fail, looking for your promise; I say, 'When will you comfort me?'” Psalm 119:82

“But those who hope in the Lord will renew their strength. They will soar on wings like eagles; they will run and not grow weary, they will walk and not be faint.” Isaiah 40:31

“This is my Father's world,
Why should my heart be sad?
The Lord is King;
Let the heavens ring!
God reigns;
Let the earth be glad.”
- This Is My Father's World.  Hymn written by Babcock

When the rains of Africa come to Buea

Right now I'm feeling…  I don't know what I am feeling - though I know I am feeling.  Phil Collins music is in my head and now playing through my iTunes.

Take me home; We said hello goodbye; we fly so close; Another day in paradise; Both sides of the story; 

Of our expat friends in Buea we are the "old-timers".  Those who came before us have returned home.  Some came about the same time and are now leaving.  And long time volunteers who came after we did have left.  We have enjoyed so many short term volunteers (over 60 from 11 countries just at the health centre since the beginning of 2010, to say nothing of the many American, Australian, Belgian, Czech, Dutch, English, French, German, and so on, coming independently or through other organizations).  We have truly have been blessed by each person.  

The rains of Africa have come. 

When the rains of Africa come to Buea the days are indeed gray.  Even the brief sunshine of the early or late sun is muted.  The fog rolls in and out and the mist settles on the furniture and linens.  The dampness of nature mirrors the dank and dampness of the loss, one by one, each wave of the expat Buea family.

When the rains of Africa come to Buea, there are no tourists and university students go on holiday.  When the rains of Africa come to Buea some shops close.  Like winter in America it is like the season of endings.  

When the rains of Africa come to Buea I am reminded of the cycle of life.  Here the cycle of people coming and going seems faster than "real" life in America.  At the very least those who come and go faster don't usually outnumber those who remain.  And so life in American felt more "stable".   That is to say the people coming and going in our lives, the closeness of our space and time changed much less frequently and in seemingly smaller numbers.  Life in Cameroon, while having local friends who remain with us the percent of turnover of close friends seems higher.

As I continue listening to Phil these songs play: Two worlds; Find a way to my heart; Dance into the light; You'll be in my heart; and The Same Moon.

When the rains of Africa come to Buea we know the rains will not last forever.  I know we have two great PCVs already in Buea.  We know more will come.  We continue to meet and greet even more very cool expat volunteers.  With the new season more volunteers will be coming to Buea.  In an interesting twist we actually have six volunteers and a friend visiting during the rainy season this year.

When the rains of Africa leave Buea the dry season comes -- the sun returns, students return, tourists return, out-of-door dining returns, and long walks return.

[see our Facebook page for some of our volunteers]

Universal Male Sporting Rituals

“Guys care about sports teams. I'm not talking about simply rooting; I'm talking about a relationship that guys develop, a commitment to a sport team that guys take way more seriously than, for example, wedding vows.”

― Dave Barry, Dave Barry's Complete Guide to Guys

I am not a ‘sporty’ person. I can count the number of sporting incidents like baseball games and American football matches that I’ve attended on one hand, I think. The last time I watched a football match was the world cup in 2010.

~o~

“So they left the subject and played croquet, which is a very good game for people who are annoyed with one another, giving many opportunities for venting rancour.”

― Rose Macaulay

“There will be traditional wrestling up at the Pala-pala field today,” our Cameroonian friend informed us one Sunday.

“What time?”

“Four O’clock but you can come at five,” he replied.

“We should go.” I turned to Bill next to me. “Something different. Might be interesting for a while. I’ve never seen traditional Cameroonian wrestling.”

So the three of us found ourselves up at the Pala-pala field that Sunday. Curiosity about the sport took precedence over my usual reservations on watching male testosterone-touting athletic feats.

The wrestling field is a natural amphitheatre. The grassy slopes surround a more or less level circular playing arena below. Wooden pickets with white crosshatches that have the village name painted on them and look like the white crosses of marking graves dotted the edges of the field. Villages grouped themselves accordingly to show support for their wrestling representatives. A gigantic oak-like tree that appeared as if it had had witnessed many hundreds of events on the field loftily stretched its thick branches over the upper corner of open expanse. Perched on the wooden supports fastened to the tree’s branches were three enthusiastic ‘sport’s announcers’. They pounded tirelessly on their traditional drums in an upbeat, intoxicating rhythm that added spice and vibrancy to the atmosphere of expectation that permeated the jostling, talking crowds. Women and children wove through with snacks balanced perfectly on their heads – peanuts, chin-chin, plantain chips, fruit slices. The perfect sport’s event – crowds, sweat, shouts, laughter, music, and food.

“One, two, three…” the referee counted down on his fingers and on the count of three the two young boys hunched over and eyed their opponent. They looked to be about ten years. Small. Sturdy. Muscular. Slender.  Apparently the young boys start before the adults kick-off the game officially. The two young boys waved their arms over their head in a pawing manner as if they were getting ready to pounce on their prey. They concentrated on every move their opponent made trying to anticipate and outmanoeuvre. As they each reached forward toward the other, they circled within the confines of the white wrestling circle.

“The goal is to get the other person on their back,” our Cameroonian friend leaned over and informed Bill and I. “As soon as the back of one touches the ground, the other person wins.”

One of the boys lunged forward. His opponent skipped sideways and dodged the outstretched arms of the other. They circled around each other for another round. Suddenly, the shorter of the two reached out and caught the shoulders of the other. Instantly, the two locked into battle. Muscles bulged and ligaments strained. The boys danced left, right, and all around each leveraging to get the other one to fall over. The grimaces on their small faces matched the effort they were expending to try and win this match.

“Do they have to hold their opponent on the ground for three seconds in order to win?”

“No, any touch of the back to the ground constitutes a win for the other person.”

I watched as the two boys used all their strength to try and unbalance their opponent and get him to flip over. Each crouched low and kept a wide stance. They were equally matched.

The referee blew his whistle. One of the boys had pushed the other outside the white line. Instantly the boys regrouped in the middle and returned to a their former locked-limb configuration. One boy stumbled and almost fell. The crowd cheered and shouted. The referee’s helper in a red-knit hat watched the boys closely for any sign of foul play.

“What are they doing over there?” I turned to my friend and indicated a group of young men kneeling on the ground in front of a table under a canopy. The young men with traditional cloth wrappers knotted around their loins formed a semi-organised half-circle in front of the elderly gentleman writing names down on a sheet of paper.

“They’re registering their names for the match,” he answered. “They have to show their respect by bowing before their elders when they ask to participate in the wrestling.”

“Oh,” I said. Now that is something different from American sports events that I’ve attended. Respectfully kneeling before one’s elders/leaders. Not a bad concept. It was interesting to watch these same young men, after paying their respects to the presiding elder, later mingle in their groups. They were otherwise your typical free-spirited young male species boasting big male egos, loud laughter, beer, and cigarettes – not to mention the sagging jeans that always look as if they’re going to fall off and give a full view of the underlying colourful boxers/underwear.

“Any game becomes important when you know and love the players.”

― W.P. Kinsella, Shoeless Joe

As the men registered, the young women did what young women typically do at athletic events. They strutted and giggled. High-heels, sparkling dresses, and flirting laughter punctuated the crowd as the ladies threaded their way among the crowds in pairs of two or three – sometimes five or six. Male and female eyed each other from a distance. Yes, I thought, a rather universal activity at sporting events – testosterone meets oestrogen.

I turned my attention back to the youngsters in the ring. Each boy fought with all his might. A fierce determination registered on each of the their faces. Back and forth they gyrated locked in their wrestling. The drummers thumped out an encouraging beat. The crowds cheered. Eventually, the one boy was momentarily thrust off balance so that his left shoulder touched the muddy surface. The whistle blew. The other boy had won.

A group of mature women in matching cabas danced enthusiastically onto the field and trampled all across the boundaries of the wrestling circle. The referee blew his whistle and waved his arms to redirect them elsewhere in vain. He was absolutely hopeless in his efforts against these solid and joyful dancing women. No itty-bitty young pom-pom waving cheerleaders here. Mothers and grandmothers of solid-build and genuine enthusiasm danced a congratulatory, winner’s dance for the boy. A man, perhaps a coach, with greying hairs and strong muscles, rushed out and hoisted the winning boy onto his shoulders. The boy punched the air with a big smile on his face.

People cheered. The women yodelled. It was a big moment for the small boy. All around the field, the papa figure carried him. Clearly, he was proud of the child as he raised his own hands in a gesture to generate more cheers and clapping from the crowds. The younger men in his village that had registered to wrestle in the match gave the kid high-fives and backslaps. Some of them, in their excitement over the win, gave each other hugs and chest thumps. Very male bonding-ish. The same behaviour is observed everywhere among the masculine species at sport events.  I smiled. The enthusiasm was infectious. It was very uplifting to see a village come out and show such sincere support.

And what about the boy that lost? He was picked up by his village papa and given a big hug. Although he didn’t get a winner’s congratulatory stroll around the field, he was walked back to his waiting teammates with a comforting hand supporting his shoulder ensuring him that he was still part of the team and his mates were not disappointed in him. He pulled up his traditional cloth wrapper around his waist and strutted back with his chin up – perhaps a little disappointed he hadn’t won but not discouraged. Next time… One could see it in his posture and face. He was a determined chap.

“In the dust of defeat as well as the laurels of victory there is a glory to be found if one has done his best.”

― Eric Liddell

The adult-version of the traditional wrestling was much the same as the kids. Suddenly an extra-excited hum of chatter filtered round the watching fans.

“The white-man is up next,” my friend answered my unspoken question.

I strained on tiptoe to see. A very white man with an even paler white chest strolled out to the middle of the wrestling circle, Cameroon wrapper around his waist and all. His opponent was a very black Cameroonian. They appeared to be about the same size – same height and general build.

The two opponents faced each other and shook hands. The referee checked their mouth and hands for any foreign objects. Satisfied, he blew his whistle. Black and white men circled and quickly locked arms.

“How long do you think he’ll last?” I asked my husband, referring to the white volunteer.

“Not long,” he answered knowingly. My husband had once tried to toss a small five-year old boy up in his arms at the orphanage during playtime. The boy was slender and appeared lightweight. Not at all! My husband almost sprained his back! The youngster was solid muscle. Much heavier than he looked.

My husband’s predictions were barely out of his mouth before the white man’s opponent lifted him up and almost gently flipped him onto his back. Oh well… kudos to the white guy for trying. The crowds cheered and laughed. No one really lost on this match. The Cameroonian proved his strength and the foreigner had an unforgettable experience. Everyone was happy.

Cultural curiosity satisfied I headed home as the sun was setting. “Interesting,” I commented to Bill. “It seems to be rather universal that at sporting events there is an unspoken code of manly display. Enthusiasm, joy, mutual encouragement is shown through certain physical bonding rituals rarely witnessed any other time – hugging, chest thumping, fist pumping, back slapping, and high-fives. Perhaps it is part of the global language of testosterone brought about by the atmosphere of adrenaline-charged sporting competitions?

~o~

“It seems that soccer tournaments create those relationships: people gathered together in pubs and living rooms, a whole country suddenly caring about the same event. A World Cup is the sort of common project that otherwise barely exists in modern societies.”

― Simon Kuper, Soccernomics: Why England Loses, Why Germany and Brazil Win, and Why the U.S., Japan, Australia, Turkey--and Even Iraq--Are Destined to Become the Kings of the World's Most Popular Sport

Dyspnea

I’m supposed to write something inspirational. Something uplifting. Encouraging to the soul.

I don’t feel like writing anything cheery.

She’s dead.

I knew she was going to die. I could see it in her eyes. The heaviness. The weariness.

Pleading.

A resigned exhaustion.

Haunted by her existence.

Yearning for her release.

The look of death.

Yeah… this isn’t turning into a bright and happy piece of writing, is it?

Madam H was 50 years old. She came early in the morning. Too early in the morning. Concerned relatives had packed her into the car and shuffled her from hospital X to our health centre after she failed to respond to the treatment regime she was receiving.

“Coming,” my husband unlocked the front door. We were both trying to rejoin the land of wakefulness at the early hour. Jordan, our dog, had alerted us to the nurse on our front porch with her usual energetic barking. (No need for a doorbell. Most visitors don’t even realise we have one)

“It’s the nurse,” my husband called back to me.

“What does she want?” I inquired. I sighed. Already? Couldn’t the consults wait for another hour until the clinic actually officially opened?

“I don’t know. She wants to see you.” My husband relayed the message.

“Tell her I’m coming. I’ll be over in the hospital in a few minutes.” I hurried to finish dressing. Mornings come too early.

With a growing sense of trepidation, I threaded my way to the hospital through the milieu of animated visitors who invariably come along with a sick patient. It’s actually a little intimidating to walk past the crowds of them… all waiting and watching with expectant gazes for the white doctor. Their heads turned in unison as I passed them. I ducked away from their intense stares into the general adult ward in the hospital.

Madam H was positioned in a semi-upright position with the head of the bed cranked upright. She gasped like a trout out of water for air – hungry, mouth-open, inhalations -- without finding relief from her oxygen deprivation.

“What’s the story on Madam?” I turned to the night duty nurse.

“Difficulty breathing, doctor,” the night duty nurse gave me the very abbreviated version of the patient’s medical history.

“Anything else?” I pushed for more details.

“Doctor, the family says she can’t breath. She’s been taking medicines to no avail. They brought her here because of severe neck pain.”

“Oh?” I bent over and placed my stethoscope on Madam H’s chest, listening to the air enter, listening as some unseen force halts her efforts at breathing – preventing her from taking a long, deep, satisfying, lung full of air. No crackles. No wheezes. Just rapid, gasping breathes… not shallow but not deep and gratifying either.

“How long has she been like this?”

“Ten days.”

I stared incredulously at Madam’s troubled breathing. “She’s been breathing like this for 10 days?!” I raised my eyebrows, not quite believing.

The night duty nurse looked at Madam’s medical book in her hand. “Yes, doctor.”

“And what has the family been told is the problem?” I counted Madam’s respirations. Forty breaths per minute. Not as bad as I’d initially thought. Her heart was beating regular with a pulse of about eighty. She had a little swelling in her legs but not much.

“They said she has pneumonia, doctor.”

“Can I see which medicines she’s been taking? Do they have the other lab results from the hospital?” I turned my attention to the plastic sack of medications at the bedside cupboard. Augmentin. Tot’heme. Terpone cough syrup. Ventolin inhaler spray.

I addressed Madam and held out the Ventolin spray to her. “Take,” I instructed, “then tell me if it helps you breath better.”

Without wasting air to reply, she deftly took the Ventolin asthma spray and inhaled a few puffs.

“Did it help?”

“She looked at me with vague eyes and gave a noncommittal nod of yes.” I wasn’t impressed. Certainly not a dramatic improvement. She still put enormous effort into every breath.

“Doctor, she complained of neck pain and chest pain,” the nurse reminded me.

I nodded at her words. “Any fevers?”

The sister shook her head, “No, doctor.”

“Cough?”

“No.”

“Headache?”

“No.”

“Any pain anywhere besides her neck and chest?”

“No.”

“Does she have asthma?”

“No.”

“Has she ever had diabetes or hypertension?” I noticed that her blood pressure was up. The last reading on the blood pressure machine was 160/105 mmHg.

“No, she has never had high BP,” her sister looked around at the other members of the family who offered nothing to the alternative.

“Did her breathing problem come on slowly or did she get difficulty breathing quickly?”

“It just came like that,” her sister tried to explain. “It has never happened before.”

“So, she just woke up suddenly with difficulty breathing?”

“Yes, doctor,” the sister answered with hesitation.

“Has the treatment improved her breathing at all?” I looked around at Madam H and the rest of her family. Madam was busy breathing so I relied on her entourage to fill me in on the details.

They all shook their heads empathically. “No, she has only been having this difficulty to breathe, doctor.” The sister spoke on behalf of the crowd.

“Can I see her medical books and laboratory tests?” I sat down at the nurse’s station with an assortment of papers, receipts, several paper booklets, and a chest x-ray.

HIV negative.

Random blood sugar, 117.

Malaria negative.

Chest X-ray report read, ‘bilateral pneumopathy’.

‘for right breast biopsy’… huh?

“Did they do a biopsy of her breast?” I was confused. Why was there a work up for a breast lump going on in the middle of a hospitalization for shortness of breath?

“I don’t know, doctor,” the sister answered with a shrug.

Strange. I would peruse her books a bit more but for the moment Madam H, her family, and the night-duty nurse were anxiously awaiting a plan of action.

“Check the Hb (haemoglobin level). She looks a bit pale.” I instructed. “Then tell the family to repeat the chest x-ray.”

Surprisingly, the Hb came back normal – 12.2 g/dl. The chest x-ray, when compared with the picture from 10 days ago, looked very similar. This time the report read, ‘bilateral pneumopathy with small pleural effusion’.

I wrote orders for IV antibiotics and furosemide (diuretic). The underlying question remained though – why was Madam having pneumonia that wasn’t responding to appropriate oral antibiotics? Where was the pleural effusion coming from? Why wasn’t she having any fevers? Was the neck and chest pain related to the lungs or the heart or something else?

Time is a funny thing in medicine. It can pass in what seems like one blink of the eye or it can drag on forever, counted second by endless second with each laboured breath.

“How is she?” I came to check on madam in the afternoon after most of the consultations on the outpatients were finished. “She’s ok, doc,” the nurse shrugged without enthusiasm. “Her blood pressure is high.”

“How is her breathing? Any better?”

“Not really, doc. She’s complaining that the Lasilex makes her chest pain more when I give it.”

“Ok,” I acknowledge this odd factoid.

On examination at the bedside, I found madam sitting up. “Does she breath better when she’s sitting?”

“Yes,” the sister confirmed.

Her oxygen saturation was 99%. Her pulse and blood pressure were relatively unchanged. Respirations were still laboured. Her lungs on auscultation with my stethoscope sounded the same. No change. And, she still didn’t have even the faintest hint of a fever. I examined her conjunctiva. White.

“Check her Hb again,” I requested.

I searched through her records again. I found evidence for a ten-year history of breast pain and a small surgery with excision of a breast lump several years ago. Otherwise, I could not find anything new. I didn’t know what to think.  Her symptoms did not add up to equal simple pneumonia. They didn’t fit a simple pleural effusion either. In spite of producing plenty of urine, her breathing had not improved at all. My mind stared grasping for other explanations. Pulmonary embolus? Heart attack? Cancer? Pericardiac effusion? Pericarditis? Parapneumonic effusion? Questions; no answers.

I felt like an idiot. The family stared at me like I was an idiot too. How come the white doctor couldn’t tell them exactly what was wrong with Madam H and fix her? Their silent stares and background animated chatter felt eerie and accusing every time I passed the hospital entrance.

“I feel like I’m missing something.” I lamented to a friend online. “What is it?”

She graciously messaged with me and helped alleviate my insecurities. I felt somewhat more confident that at least my line of reasoning was logical, medically speaking, afterward.

I plunged forward with my questions and investigations while Madam H continued to struggle to breath. She was able to sleep and relax a bit when we gave her oxygen. I left the oxygen concentrator next to her bedside. Anything to alleviate her air hunger and discomfort even though it wasn’t the solution.

I took photographs of her chest X-rays and emailed them to another friend for reassurance that the local radiologist and myself weren’t missing anything significant on the films.

An ultrasound doppler study of her leg veins failed to show any blood clots. The sonographer didn’t feel there were any signs of a dilated right heart ventricle or atrium. “It just looks like congestive heart failure.” She gave her opinion of the ultrasound study as I discussed it with her.

So… no definitive answers.

“What was the repeat Hb?” I stood at the nurses station trying to decide what else to do. Nothing seemed to be helping.

“Her Hb was 13.3 g/dl,” the nurse informed me.

“How can that be?” I asked, still not believing. “She’s white. You’ve seen her, right?”

“Yes, doc.”

Madam H’s conjunctivas were white, her tongue was pale, her fingers appeared bloodless. I searched my memory banks for anything that would make her Hb falsely elevated. And yet, her pulse was not tachycardic. Her blood pressure was high; not low. The haemoglobin metre had churned out appropriate low values of 8.7 g/dl and 9.9 earlier.

“How are you?” I walked over to Madam H’s bedside and addressed her. During her entire stay, she’d barely uttered more than a yes or no. All oxygen was savoured in favour of expending her efforts to breath.

She stared at me with tired eyes. I didn’t need her to tell me. She wasn’t better. She was worse.

I checked her oxygen saturation. Sitting straight up with her legs dangling over the side, the oxygen saturation levels rose to a meagre 89%. When she leaned back into the bed, in spite of the inclined head of the bed, her saturations dropped to the 70s. Not good.

“Can you think of anything else?” I turned to my nurses at their station.

They shook their heads. “Doctor, I think we need to transfer her.”

Wearily I agreed. She was clearly not improving.

“We’ve tried everything we can here at our small health centre…” I began as Madam’s relatives sat opposite me in the make-shift family conference room. “I don’t know what all is causing her difficulty breathing. It’s more than a simple pneumonia though. She needs to go to the big hospital in D_____ where there are more specialists and capabilities to treat her.”

“You’re right, doctor,” one of the male relatives spoke and nodded.

“Don’t waste your time going to the other small hospitals. Just go to D_____ now. You’ve already been to one other hospital and I know the hospitals here in Buea are not big enough to do anything more than we’ve done for her here. Go to D_____.”

“Ok, doctor.”

We wrote up the appropriate paperwork and helped the family load Madam H into the waiting taxi.

I was relieved that she was going somewhere that could do more for her. I was frustrated that I couldn’t help her. I felt drained and apathetic. Discouraged. Empty.

I couldn’t even figure out what the real problem was. She was dying and I didn’t have a clear picture of what was really happening. There could still be a pulmonary embolus. Perhaps it was heart failure from a recent heart attack… maybe it was complications from breast cancer…. a resistant pneumonia… anaemia (even though our metre pointed to an alternative diagnosis she still looked very very pale). Too many questions. My mind wouldn’t stop processing Madam’s case. In spite of my musings, the meagre facts of the case swirled around without coalescing into any solid diagnosis. Like a computer trying to open a bad file, my brain whirled endlessly and fruitlessly. No program loaded. No answers popped up.

These types of medical cases are difficult. They drain my psyche insidiously and poison my confidence. So much effort with no return on the investment. I knew I’d probably never hear from the family again. I’d sent them off into the mysterious depths of the system of specialists in D_____. Historical experience informed me that there was a 95% chance I’d never know what happened.

Postscript:

The family took Madam H to another nearby hospital in Buea. They did not go to D____. At the hospital, they were again referred to D___ but instead chose to remain. Madam died at in the hospital the next day. The impression by the doctors at the other hospital was that she died of congestive heart failure brought on complications from breast cancer.

One may be tempted to lay blame on the family for not transporting her to a big, expensive specialty hospital where she’d have the best chances of survival. However, perhaps the family, like myself, saw the ‘handwriting on the wall’. Knowing that she was near death, they chose to let her die in her hometown and save the resources it would have cost just to get her through the front gate of the D____ hospital. Contrary to certain cultural attitudes in other parts of the world, there are financial limits and medical care is not an unlimited resource.

 “Who comforts us in all our troubles, so that we can comfort those in any trouble with the comfort we ourselves receive from God. For just as we share abundantly in the sufferings of Christ, so also our comfort abounds through Christ.”

2 Corinthians 1:4,5

More Moments...

Do I dare

Disturb the universe?

In a minute there is time

For decisions and revisions which a minute will reverse.”

― T.S. Eliot

Not every moment is golden with a residual warm glow trailing after it. Would be nice, but, if that happened, one might wonder if they were really practising medicine.

Sweat beaded up on my forehead, partly from the desperation of the situation, partly from the physical exertion. It is not always easy – physically speaking – to treat sick patients, especially when it involves attempting to manually extract a placenta that remained stubbornly attached to the womb after delivery. In fancy medical terms, one could say, “retained placenta”; in not so fancy pidgin terms one could say “placenta ee no de com out!” Both descriptions are adequate, though pidgin is much more flamboyant about it and probably expresses the angst of the situation more appropriately.

“Out! Out! Out! Out!” Madam A shouted with great ardour and volume.  “In the name of Jesus, I command you, come out!”

Many of our patients have strong ties to their religious community. Many belong to churches that are ‘evangelical’ in their worship style – very exuberant; speaking in tongues; casting out demons; etc. Apparently Madam A belonged to one of these congregations. At least her energetic prayers helped to distract her from the pain.

For myself, I prayed silently for strength and knowledge to stabilise her situation. Trying to remove pieces of retained placenta from a distressed woman who was more than a little “fluffy” in her middle portions was not easy.  I typically consider doctoring to be fairly cerebral. There are a few times when muscular strength becomes quite useful though. This was one of those times.

“Doctor, please stop!” Madam pleaded and shifted away from me. My nurses gripped her arms and held her steady with unrelenting determination.

I wanted to stop; but I wanted her bleeding to stop more. This was one of those moments when one must suppress natural human inclinations to comfort and relieve suffering in order to accomplish the greater good. One looks past the immediate pain to the future benefits. In the midst of the struggle, these future benefits can appear rather murky and uncertain though.

A storm of self-doubts blew in and threatened to impede my efforts. Was I doing the right thing? Why did the placenta not detach like it was supposed to? Should I have done something differently? Was it even possible to manually remove the placenta? What about more anaesthesia? Infection? How could I know when I should stop and refer? Would my efforts help her or not?

Such thoughts, as you can imagine, are not conducive to performing a task with precision, skill, and mindfulness. The moment is difficult to explain. Certainly it was not a bright epiphany, nor was it a shining heroic inspiration. It was simply a moment when one chooses to forge ahead and put aside all that detracts from the effort. A narrowing of the visual field to include only the pertinent information required to remove Madam A’s trapped placenta. Doubts, external noises, the faces of Madam and my grim-faced nurses faded into the backdrop as I focused on winning the battle of doctor versus placenta. I suppose, in a sense, it was one of those times when new depths of human capacity are forged.

Suddenly, I felt a firm, strong hand on my head. “Doctor, stop,” the patient groaned. I was momentarily startled. It is not often that patients grip my entire head in their hand.

“Almost finished,” I consoled. “Just persevere a little bit more.” I shifted my head out of her reach.

“In the name of Jesus, I know you will succeed, doctor,” she prayed vehemently channelling her pain into intense pleas toward heaven.

“Keep praying,” I nodded to her.

“Bless you, doctor,” she continued. “I know you will help me.”

I attempted to ensure that all the placenta tissue was completely swept free of the uterine walls with my fingers. Internally, I begrudged my short fingers and small hands. 

“Stop, oh, doctor! Just let it be. It will come out. I know God will make it come out. Just leave it. Let me rest.”

The patient reached out her left arm to grasp my upper arm and pull me away. My nurse intercepted and valiantly held her back.

“Ok, done,” I straightened up and stretched my aching back. I surveyed the scene. Certainly having a baby is not a very clean process. Add in a retained placenta and haemorrhage and the mess multiplies exponentially. “I wonder if they make sterile gloves with longer sleeves?” I pondered this question briefly when I washed my hands in the sink.

“Thank you, doctor. God bless you.” Madam A sighed. Her forehead was drenched in sweat, more so than my own even.

“We will pray that all the bleeding stops now,” I held her hand briefly. “I’m sorry. Ashia!”

“I know I will be fine, doctor. Thank you.”

She was tired. I was tired. I wished I had as much confidence as she did. She was pale and had lost more than a reasonable amount of blood. I thought I had removed all the placental tissue but I wasn’t one hundred percent sure. I’d never dealt with a situation such as hers before.

I sighed. My shirt was soaked in sweat. The storm cloud of questions returned. For now, there was nothing more I could do. I turned and walked out of the labour and delivery room while the grey clouds let loose a torrent of mixed logic and sentiment. I felt overwhelmed and a bit numb from the onslaught. Not my most shining moment. Yet, even as the rain is necessary for new growth; so too, the moments with Madam A led to renewed courage, comfort, and confidence eventually. Even the dark times have their value.

“And He has said to me, “My grace is sufficient for you, for power is perfected in weakness.” Most gladly, therefore, I will rather boast about my weaknesses, so that the power of Christ may dwell in me. Therefore I am well content with weaknesses, with insults, with distresses, with persecutions, with difficulties, for Christ’s sake; for when I am weak, then I am strong.”

2 Corinthians 12: 9,10

The Source of all healing

This was a presentation to the Buea Seventh-day Adventist Church on May 5, 2012.

Matthew 4:23-25

23 Jesus went throughout Galilee, teaching in their synagogues, preaching the good news of the kingdom, and healing every disease and sickness among the people. 24 News about him spread all over Syria, and people brought to him all who were ill with various diseases, those suffering severe pain, the demon-possessed, those having seizures, and the paralyzed, and he healed them. 25 Large crowds from Galilee, the Decapolis, Jerusalem, Judea and the region across the Jordan followed him.

The medical missionary work reveals the Good News of the Kingdom of Heaven - the great truth of the Bible:  That God, in Christ, was reconciling the universe to himself.  The universe has experienced a grand rebellion and God has been portrayed as arbitrary, vengeful, and severe.  These are the very attributes of his chief adversary.  Many beings trusted Lucifer and in doing so revealed their distrust of God.  When God created the earth it was designed for joy, peace, and love.  It was designed and purposed that we might have an intimate and trusting relationship with God.

The work of Jesus was to reveal the truth about God - the Good News of the Kingdom of Heaven.  He said "You have seen me you have seen the Father."  Jesus healed and restored all who asked, both Jew and Gentile.  Reread the gospel stories.  Jesus healed and restored everyone who trusted him.  It was not by force, fear, or intimidation that he gained disciples.  No, it was by living a life in union with God, meeting people where they were, not breaking off the bent reed, or snuffing out a flickering candle.  He proclaimed freedom to the prisoners of deception.

At the Health Centre our mission statement is this:  "As Jesus loved and served, it is our mission to serve and love the people of Buea by providing access to world class health services and education; and to encourage our clients to total health: spiritual; physical; emotional; and intellectual."

I encourage you to review the work God wants to see accomplished in your own life.  Consider your beliefs.  Why do you believe what you do?  What kind of God do you worship and admire?  Consider how God has led you.  Has your relationship with God always been the way it is? What unique joy is yours because you believe what you do?  How has what you believe improved or otherwise benefited your life (not just for the future, but in the here and now of today)?  Can you value what you believe apart from a legal obligation of obedience? If so, why? 

In our interactions with each other, in our church and with those outside, I encourage you to hold fast to the knowledge that each one of us is a precious child of God.  Let me remind you that God is already at work in every person's life:  you; me; and each person we meet.  Our role is not to make people into our image.  Our role is not even to make people into God's image.  Our role is to meet people where they are, without judgment, without condemnation, being very aware and sensitive to them as an individual and to stimulate spiritual inquiry without pushing our beliefs on to them.  When we do this well, we will bring the joy of our intimate relationship with God and all that it is producing in our lives in a systematic and very personal response to the questions of each other and our neighbors.

Our full and complete healing and restoration is not found in health education or medical ministry work.  It is not found in our denomination's 28 fundamentals or the vows we have taken at baptism.  These are not the truth, but they bear witness to the truth.  Our healing and restoration is a trusting relationship with God.

Jesus is the truest revelation of the character and nature of God.  God is not the kind of person his enemies have made him out to be.  He is not arbitrary, vengeful, or severe.  Rather God is all life, all love, all forgiveness, all the time.  To be apart from God is to not trust him and so we  will be sick and dying.  To be at-one with God is to trust him and we will be healed and restored.

We must care about the entire person.  As Seventh-day Adventists surely we already recognize that every person is of infinite value to God.  Regardless of his or her circumstances (race, tribe, language, position, financial status, beliefs, and religious affiliation, just to name a few), each person is of infinite value to God.  Our methods must be in alignment with Jesus.  Or else they are in alignment with his adversary.

As we close turn with me to Matthew chapter 15 and I will read from verse 29

29 Jesus left there and went along the Sea of Galilee. Then he went up on a mountainside and sat down. 30 Great crowds came to him, bringing the lame, the blind, the crippled, the mute and many others, and laid them at his feet; and he healed them. 31 The people were amazed when they saw the mute speaking, the crippled made well, the lame walking and the blind seeing. And they praised the God of Israel.

Depression

"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