Nipo hapa / I am here: Coping with suffering in Usa Village, Tanzania

The signpost at the hospital

The signpost at the hospital

This past Tuesday, there was a large crowd gathering around the minor theater, or emergency room, at the local hospital. We quickly headed over to see if assistance was needed in the ward. Professor Sullivan peaked her head around the entryway and immediately turned to me with alarm on her face.  “Do not go in there,” she stated forcefully.

I didn’t need to hear it twice, nor was my curiosity to look peaked by her panicked reaction. I stepped back, horrified to find out that a young boy lay on the table, about to have his leg amputated after his pikipiki (motorcycle) was hit by a truck. Also sustaining serious head injuries, he was mercifully unconscious. His leg was so severely damaged in the accident that there was barely any bone left to cut through.

In the tiny room, the doctors swiftly removed his leg. He was then transferred to a different hospital in Arusha, a half hour away. We would find out later that the boy had passed away.

In Tanzania, pain and death are an integral part of day to day life. Accidents happen, pregnancies happen, sickness happens—and managing these events takes a different kind of reaction from the one I’m used to. At home, we take great care to comfort people in their suffering and reduce pain as much as possible. We also have a myriad of drugs and interventions available to achieve these ends. Here, options are few and far between and pain management medicines—beyond paracetamol (a drug related to regular strength Tylenol)—are even harder to come by. Over the past week, I’ve come to understand the stoicism around pain and death here that was so confusing to me during my time at the hospital. Through the following stories, I will attempt to explain what I have seen in just a few days and how these experiences have moved me closer to acceptance of their seemingly detached version of compassion.

Later that day, we returned to the minor theater. There was a young boy there, James, who had cellulitis. His swollen foot was badly infected and needed to be drained of numerous pockets of pus. He was clearly terrified, so Professor Sullivan kneeled down next to him, face level with his, and comforted him softly in Swahili. He asked her to stay. The waiting adults were treated first, and we created a human wall around the little boy so he wouldn’t see the bone setting and wound treatments happening two feet from his bed.

This tiny room, typically used for pap smears, was where the diabetic ulcer patient was treated.

This tiny room, typically used for pap smears, was where the diabetic ulcer patient was treated.

In the side room, a young woman was having a diabetic ulcer attended to. She wailed relentlessly and I pitied the many, many sufferers of diabetes in this country. In the bed next to James laid a single mother with a badly damaged ankle. What she really needed was orthopedic surgery at a specialized hospital, but she would have to a) be transported a half hour to get there, b) have family members bring her food and water and be able to do so at least three times per day for the duration of her hospital stay, and c) have someone take care of her child during that time. The doctors grilled her on her resources and ability to make it work. Professor Sullivan made a particularly poignant comment: treatment here is not allocated by medical need but rather by the resources and lifestyle of the people requiring care. This woman lived alone. She would not be able to be cared for or care for her child if she had the surgery, so the patient and doctors had no choice but to risk permanent deformity by setting her ankle in the theater. They gave her a sedative, wrapped her ankle in a cast, pulled it with all their might away from her body, and checked the alignment of the bones with their fingers. Five minutes later, this woman moaned continuously in her sedated state. She had not been given pain medication, but due to the sedative, she would not remember the procedure. Over the next couple of hours, two more adults needing treatment for orthopedic injuries came in, and both vocally recoiled and winced at the pain of bone setting and casting.

Lastly, it was James’ turn. The doctor came over, and the boy immediately burst into tears. James was utterly petrified as his mother was sent out of the room. Multiple people held him down while he was also given a sedative (but not an anesthetic). Here, they only have one type of sedative, and it’s particularly risky to use on children; it can cause cardiac issues, and so the doctors only drew a very low dose for James. Seeing the needle, feeling the alcohol wipe on his arm, and knowing that something bad was about to happen, James started screaming at the top of his lungs. Amidst the screams he yelled for his mama, and Professor Sullivan reminded him that she was there, that she knew he was hurting, and that she wouldn’t leave his side.

The doctor moved down to his foot, where he had to make several deep incisions to drain the fluid. Despite the sedative, James let out resonating high-pitched sobs while fighting the nurses. After several minutes, or longer (I couldn’t even tell how much time had passed, as I was so wrapped up in the moment) the doctors stopped: not because they were done, but because James could not take anymore. This poor child will have to come again for the same procedure, and maybe even again after that. Hopefully, he also will not remember how much pain he was in. [Of note, this treatment would be similarly performed in the U.S., although they have other types of sedatives that are not as risky to use on children]

Throughout this scene, I stood transfixed against the wall and watched. I didn’t know how to comfort James, and I didn’t want to be in the way of the doctors who had very little room as it was. I was later glad that I wasn’t helping to hold him down: unable to endure the screams in my first experience of this kind, I had to step out. I was in awe of the staff and volunteers that calmly and empathetically inserted themselves—and do so day after day—to offer whatever comfort they could while not allowing James to wallow in his fear. (“Stop crying, stop crying!”) We all knew how much this child was suffering, but the doctors had to inflict this pain in order to make him better in the long run. It is a horrible reality that is part of the human experience.

The male ward of the hospital. In contrast, the female ward 's beds are in one room and close together. There are no wall separators for privacy.

The male ward of the hospital. In contrast, the female ward’s beds are in one room and close together. There are no wall separators for privacy.

The following morning, I went to the female ward to help out. I was asked to mop the floor, a useful activity that I was glad to take off the nurses’ hands. Nurses here do all of the cleaning in addition to patient care. Despite how seemingly simple a task it seemed, I still managed to struggle. As I mopped the ward (one room with beds along both walls), the women there stared at me with faces I couldn’t read. I wished so badly that I could talk with them. I always worry the patients think I (and all the other volunteers) am simply trying to profit from their suffering, amping up CV’s by observing them agonize in the hospital. I tried my best to communicate through empathetic facial expressions and gentleness when mopping near their beds. I also felt extraordinarily stupid because I didn’t know how the nurses would mop (around or under all the beds?) or even where they got the soap and water. At one point, I encountered a heap of vomit behind a bucket near the latrine, and had a long debate in my head over what to do about it. “If I clean it, I am making the water in this bucket a disgusting mess and I don’t know where/how to get new, soapy water. If I don’t, the vomit will sit there and someone else will have to find it at a later point, and the nurses would very well know that I had left it there.” If I could speak Swahili, or interrupt the doctors and nurses during their rounds, I would have asked. But I was left to my own decision-making, so I opted to clean the vomit and hoped the disinfectant was strong enough to kill anything in the mop water. It might seem like a silly debacle, but I kept having these dilemmas in my head throughout these tasks, dilemmas that I found very stressful.

I then moved on to the private ward, where individual areas of the same large room were sectioned off for those who could pay. I was told (in broken English) to go into these private “rooms” and mop. Thankfully, there was only one section with a patient. It was an elderly woman, hacking gruffly. She started speaking quickly to me in Swahili, her eyes watering and distress clear on her face. I finally figured out she needed a bucket to vomit in, so I ran off to find something, anything, that she could use. I found a bucket in the back that I’m sure was not used for that purpose, and rushed it over to her. The poor woman could barely hold it up to her mouth, and couldn’t decide if she needed it held or wanted it on the floor. I held it for her and she let go sputum into the bucket while continuing to cough violently. In my head, I’m frightened; I have no idea what this woman has, and I am two feet from her face while she coughs and vomits. But what could I do? Leave a woman to suffer? Ultimately, yes, that is exactly what I did. After throwing up, she starts saying to me “maji, maji!” (“water, water!”) I ran over to the nurse, disturbing her, and did my best to communicate the problem. Finally she simply informed me that the woman would have to wait for relatives to bring her water. The hospital cannot afford food and drink for the patients and has to pick their battles. I went back to finish mopping empty-handed, and the woman no longer called out to me. We both knew that the hospital had nothing to give her, and she suffered silently.

Back in the public portion of the female ward, I continued to finish up and heard wailing. I turned to the side to see a visitor sobbing as others held her up and guided her out of the room. It was only then that I noticed a patient in the far corner had passed away. I had been there for hours and not even realized there was a problem. I am reminded of the T.S. Eliot quote: “This is how the world ends / Not with a bang but a whimper.” A whole life with a story, a history, a family had ended—forever.  There was so little reaction around her death by anyone but the visiting family that I didn’t even notice she had gone.

Today, I had the opportunity to go to the hospital and volunteer, but I chose to stay home and catch up on work instead. I am anxious about going back there. I am afraid to see the cringing, aching faces of elderly and young women as we move them to change bed sheets. I am afraid to have them ask me questions, express their pain, and otherwise indicate misery in Swahili, to which I can offer no comfort or understanding. I wonder about all of the volunteers that come through here every month and how they feel, because those that I’ve met do not seem shaken by these events. In any case, I will fight my feelings and go back.

I don’t know if I would be capable of emotional stability while encountering such suffering on a daily basis. I don’t know if I would be capable of inflicting pain to bring healing, as these doctors have to do. They can’t even provide food and water, not because they don’t want to, but because they don’t have the means to and are forced to prioritize. As Professor Sullivan explained to me, there is an outward insensitivity about pain, suffering, and death here that is born of a different reality from ours in the U.S. As I cowered in the corner, watching James scream, I was also screaming in my head: “KNOCK THAT KID OUT! DRUG HIM! GIVE HIM ANYTHING!” But as aforementioned, there are few anesthetic options for children, and even fewer that are available here. Kids, adults, even laboring mothers, are told to buck up and quiet down. Tanzanians help each other cope with pain by not giving it a voice, by not letting it take over. They accept it as a natural process inherent to life. This coping mechanism leaves Tanzanians better able to move on from tragedy when it strikes; and it does, all the time.

On Saturday, dozens of motorcycles crowded the streets to lead a group of cars in mourning. There was a picture, surrounded by ribbons and flowers, placed visibly on one of the cars: a face Professor Sullivan immediately recognized. The procession was honoring the boy killed in the pikipiki accident. If I hadn’t understood the Tanzanian mentality before, I could clearly see then that the stoicism around pain and death here does not lessen the devastation from such an event.

What can we, in the U.S., learn from the Tanzanians? How can we better cope with our lack of control over life’s twists and turns? Through an openness to pain, suffering, and tragedy that acknowledges the inevitability of unfortunate events. Through acceptance that all we may be able to do is be there for each other, acknowledging each other’s tough times without judgment. Being present can be enough. So when I go back to the hospital, to the female ward or the minor theater, or any of the other places, I will go with that mindset: to be there, in that moment, with others as they suffer, not creating distance nor overstepping my bounds, but just to be. Taking Professor Sullivan’s advice, I will simply say “Nipo hapa.” “I am here.”

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