by Pamela Grim
“No.”
“Does he want medication, is that why he's here?”
More animated conversation. Then: “He doesn't want medication.”
“Then what the hell does he want?”
This time Yasha and the soldier talked for a long time. Finally, Yasha turned to me and said, “He wants a statement that says he's too sick to be in the army and then he wants a visa to leave the country.”
I closed my eyes and pressed them shut to ease the headache. When I opened them again I found Yasha gazing out the window to where a lonely light bobbed in the distance. Yasha had been a medical student before the war. He, too, was desperate to get out.
“Tell him,” I said, “that there is nothing I can do for him. Tell him we don't give out visas in the Emergency Department.” It's just a fact of life.
“He wants to know if we can write him something that would say he was too sick to fight.”
I looked down at this fellow, shivering on the gurney. He looked as fragile as a young girl. He just didn't want to die. What was the matter with that? As a doctor I should understand that. There should never be war.
I put one hand on his shoulder and reached out for his other hand. “I'm sorry,” I said. “He has to go to a military doctor for that. Maybe they can help him. I can't do it.”
There was, ultimately, so little I could do. I stood there asking myself, Am I really making a difference?
Then, I thought, well, vaccination.
Earlier in the afternoon, up in the mountains above Old Vetiz, back when I thought I was making a major contribution to the war effort (these things can turn on a dime), I had gone outside to take a break and sit in the sunshine. I sat on the steps of the schoolhouse and looked around. A dozen men stood talking in the yard, a few in uniform, or as much of a uniform as men wore in Bosnia. The others were dressed for farming. One young soldier flirted with a young girl with long hair. The women stood off near a fence chatting happily. The scene was utterly bucolic. It was then that I realized that these were the former Muslim inhabitants of Old Vetiz—the ones who held the siege as long as they could. They must have finally retreated to the surrounding mountains. I knew this was going on elsewhere. Territory was fought for and then finally abandoned when the townspeople melted into the mountains. This was a short-term solution only. It was only a matter of time before the Serbs or the Croats claimed this land as well.
Amir joined me and we walked up the hill. There was a field in front of us, and then above us stood what looked like an old barracks or stable. And there was some kind of statue, human sized, arms raised in a sort of benediction. “What is that?” I asked Amir.
He looked up. “It's a monument. To the war.”
I looked around at him. “The war?”
“Not this war, the other war. World War Two.”
We walked up the hill through the brush, stepping over mounds of dirty snow.
“That barracks there,” he said pointing, “that was used by the Ustasha during World War Two. A concentration camp. A death camp.” Amir stopped, reached down and plucked a stalk of grass. He chewed its end thoughtfully.
“This is where they killed—what is the word in English—you know, people who fight for freedom?”
“Partisans.”
“Yes, partisans. This is where they killed the partisans and tortured them. It used to be a slaughterhouse, a regular cow slaughterhouse. Then it became a human slaughterhouse. My uncle died here, I think. We don't know for sure.”
We arrived at the top of the hillock. There was a small memorial: a statue of a woman gazing at the ground sorrowfully, arms outstretched. Underneath her on the pedestal “1945” was etched in the granite. There was a coda in Bosnian carved underneath. I didn't ask Amir to translate it. I was afraid that somewhere it would contain that classic memorial phrase, beloved of survivors and those who remember, the ever hopeful
“Never again.”
12
HOW TO TREAT TETANUS
Also a sign for them is that we bear their progeny on the laden ship.
If we will, we drown them,
and there is no helper for them
nor are they saved, unless as a mercy from us…
—The Koran
IN NIGERIA WITHMÉDECINS SANS FRONTIÈRES, I, the lone American, drove the French crazy in many ways, but one way in particular was by taking photographs. “You are here as a doctor,” Pierre told me as he watched me rack down my camera lens on a child covered with necrotic purpura, “not a tourist.”
“I am also here to bear witness,” I told him, zeroing in with my camera now at a different angle, “to witness what I've seen.”
He had no response to this. But I did. Photographing made me queasy. I felt like a predator, even though, every time I would ask permission (not with words, of course, not with my ten words, max, of Hausa). I would touch the camera with an index finger and then gesture to my potential subjects. They would always nod, yes, but how could they do otherwise? We, who came with everything that saves lives, how could they refuse us? Worse was that after the first day in this land of infectious atrocities, I photographed only the worst of the worst, some terrible confluence of tragedies: the woman dead with cholera found one morning at the edge of the camp—she couldn't make it the last one hundred feet to the clinic; the boy who had lost half his face to meningococcal purpura; the old man dying alone and covered with flies; the baby already dead. There I was, checking different angles, trying to get the correct exposure. “I want others to witness this,” I told my medical colleagues, but my justification was something of a sham and I knew it. I was right, too. Most people back in the States would look through the first few images only, in my book of photographs, and then they would put them aside. Or I would show a couple at a medical lecture, to illustrate a clinical problem. The room would always go very quiet, and there would follow a collective sigh and a few amplified coughs. “Wow,” someone would say. Then we would move on. This was not for them. Nothing they had ever seen could be like this. Ultimately, the only one I really bore witness to was myself. I pasted the photos that meant the most to me into a scrapbook, and I would leaf through the book sometimes, late at night, after a bad shift in the ER, just to remember. There was the kid with purpura that had necrosed his entire right foot. There was that woman (me standing beside her wearing a ridiculous grin and a Hemingwayesque safari jacket the clinic staff told me only an American would ever wear) we brought back from the dead, who was now yaworeke, cured. Then there was the strangest picture of all, the backseat of a car—a little sedan—where a black man lay, pietà-like, over the laps of two other frightened-looking men, their black faces burned white in the false light of the camera flash. One of the men is holding up a glass bottle of saline, the other grasps at the IV site. The figure on their lap is rigid, stiff, as if he were badly painted, or rather, if you thought of him as a sort of Christ, as I thought of him, he was an immobile Christ of a twelfth century-triptych, no later.
This man had tetanus.
I was rounding one afternoon, out in the fly-infested “intensive care verandah,” when I stopped at a patient who had been puzzling me for days. He was a young man who, someone told me, was a policeman in a small village some distance from Kano. His three brothers were caring for him. He had been here on the verandah for three or four days. “Meningitis, fairly classic case,” I had told myself initially. (Of course, my workup consisted of lifting the man's head up to see whether his neck was stiff—it was.) I had treated him with oily chloramphenicol and when that didn't work, ampicillin. He was one of the few patients who didn't either die or get better; he just slowly, slowly kept looking worse and worse. Was this a weird case of meningitis, I asked myself, or was it something else? Occasionally we would find, after a day or two of symptoms that suggested meningitis, that in fact we had a cholera case in our midst. We would have to drag the patient off to the cholera camp and dowse the ground where he or she had lain with chlorine bleach. But
this wasn't cholera. Sometimes I would wonder—malaria? Cerebral malaria? I had no way to tell other than empiric therapy, so I went ahead and gave IV chloroquine. Sometimes when I did this, the patient would make a stunning recovery—but not very often. I tried chloroquine on this patient, but he only seemed to look a little worse, just as before.
That day I just squatted there, looking at him. The man was conscious but extremely weak, a strange type of weakness. He could gesture a little with his hands, but he had trouble speaking, or even swallowing. His brothers would try to feed him a little soup, but it was clear that for this man even opening his mouth was extremely difficult, almost painful. That morning the patient lay back stiffly, his head in the lap of one of his brothers. As I watched him, his hands made the pill-rolling gesture common to Parkinson's patients, while across his naked belly there were ripples of abdominal muscle contractions, a wave of fasciculations—tiny, chaotic muscle spasms. Whatever this was, it didn't look like any meningitis—meningococcal, malarial or otherwise—that I had ever seen.
I picked up his hand. It immediately assumed a claw shape. I tried stroking it gently, but this only seemed to make the hand spasm worse. I checked his temperature, using the only thermometer I had, my hand on his bare chest. Maybe a low-grade fever. As I hunched over, looking at him, the medical director of the mission, Jean-Paul, a Zairian political refugee with a lifetime of experience in tropical disease, walked by and paused. He must have been puzzled by the sight of one of his doctors kneeling by a patient as if in prayer. He looked down at me, an eyebrow raised in question.
“What is this?” I asked him.
At this he looked even more puzzled. Thinking back, I realized that the expression on his face was incredulity. He couldn't believe I didn't know what this patient had.
“This man has tetanus,” he said, nodding his head at me, and then walked on.
I sat back on my heels and looked down at the man. “Tetanus,” I said in wonder. “Lockjaw!” To an American doctor this was a disease as mythical as the plague. There are, maybe, a handful of cases a year in America.
I jumped up and ran after the director, catching up to him out on the barren brown yard in front of the hospital. “Tetanus,” I said. “But what do I do?”
He looked at me as if I were daft. “Why, you send him to a tetanus hospital.” He moved on, shaking his head again.
I walked back to where the man was and gazed down at him lying there on the dirty floor. A tetanus hospital, I thought. For a moment I imagined a real hospital with real beds and real sheets and floors not covered with contaminated needles. Screens on the windows. No flies. I thought of my hospital back in the States. I saw before me, like a mirage of precious water, our supply room. The room was crammed with everything you could ever want to take care of a sick patient, shelves and bins filled with endotracheal tubes and Foley catheters, syringes, sterile needles, bottles of Pedialyte, triple-lumen central lines, Betadine, hydrogen peroxide, We Care hand lotion, suture kits: everything disposable, use once and throw away.
I found Simon, my nursing assistant. “Jean-Paul says we must send this man to a tetanus hospital,” I told him, “wherever that is.”
Simon gestured vaguely to the east. “By the old city,” he said.
“Do they have a way to get there?”
Simon shrugged. “I will find out.”
It turned out that they did. The brothers had a friend with a truck, an ancient Ford pickup, which showed up just at sunset. The three men loaded the patient into the flatbed and fastened the tailgate closed with bailing wire. The whole truck seemed to be held together by rust, baling wire and the Nigerian equivalent of duct tape. I could see it rumbling down the potholed, washboarded Kano dirt roads, shaking each bump into this man's bones. At least he would make it to a tetanus hospital, I thought, where people knew what to do much better than I. I hadn't thought about tetanus, other than to give the vaccine, since medical school.
Out of curiosity, when I went home that night, I stopped at the MSF offices to search our medical library. The library consisted of four books, three medical texts and one medical novel. (Called The City and the Covenant, it opened inauspiciously with the sentence: “The uterus of the woman on the bed contracted according to its cellular intelligence.”) The most recent book of the four was a textbook of internal medicine—published in 1964. I had to blow the dust off the top, just like in the movies, and when I cracked the book open there was that tropical smell of something ripely rotten. Someone had visited this chapter before me. I found a bookmark there, a clipping from a newspaper that crumbled when I touched it. I glanced through the text. The first thing that caught my eye was the phrase “horse serum”—the book was that old. In the middle of the page was a drawing of a “spore forming bacillus” shaped like a squashed cigar. Clostridium tetani. The tetanus bacillus.
“The bacterium surrounds itself with a protective shell,” the caption read, “that makes it resistant to heat, cold, floods and desiccation. Tetanus spores are everywhere, in the soil, on animals, in humans…blah, blah, blah…facultative anaerobes.” That meant Clostridia lived without oxygen.
“The disease is more common in the tropics than in temperate zones. In third world countries tetanus is a disease of the newborn; Tetanus neonatorum. Typically the infection occurs because the bacillus invades the umbilical stump at the time of birth, particularly if, as is common in underdeveloped countries, the midwife uses a dirty knife or a contaminated piece of glass to cut the umbilical cord. In some countries the infant mortality rate from tetanus approaches 50 percent.”
I paused considering the sentence. “Approaches,” what a delicately euphemistic term. But what that coy sentence meant was that in underdeveloped countries one half of all babies born died of tetanus. I knew this fact after reading through an MSF report on health care in Nigeria. Things were no better now than they were in 1964. Worse probably.
“The tetanus syndrome,” the book continued, “is not caused by the bacillus per se but by an exotoxin.” I looked up from the page. I remembered this from medical school (the memory accompanied by the faint perfume of formaldehyde). An exotoxin is a poison that bacilli, under the right conditions, manufacture and export to the body of the host. In some lungless part of the body—say a necrotic wound or a cut—the conditions become just right for the Clostridium to flourish, multiply and manufacture exotoxin. The exotoxin makes its way to the circulation and is disseminated throughout the body. The toxin is called tetanospasmin—one of the strongest poisons known to man.
Tetanospasmin mimics the neurotransmitters that govern our muscle system, causing muscle cells to fire. The bacterium itself doesn't do this; only the toxin does. When the body is awash with tetanospasmin, the muscles depolarize—contract—chaotically. This produces the tonic-clonic movements and the muscle seizures that are the hallmark of the disease.
I went back to the text. “The first signs of tetanus are small muscle spasms that involve the muscles of the neck and the jaw. Patients become unable to swallow normally or even open their mouth. Hence lockjaw, as the common name for the disease.”
This was the stage my patient was in now.
“Treatment.” The essential part. I lingered here because I knew tetanus was treatable, quite treatable, even in 1964 and even in Nigeria. Not much magic here. Just penicillin, Valium and “horse serum,” (now replaced with cloned tetanus antitoxin). Penicillin kills the tetanus bacillus, Valium reduces the muscle spasms, and the tetanus antiserum deactivates the toxin. One, two, three. This is the regimen they would use in the tetanus hospital.
I went back to my room and looked through my own library. Somehow I had lost my book of W. H. Auden's poems. This reduced my library from four volumes to three, one of which was a textbook of tropical disease. This book had pages and pages about traveler's diarrhea but nothing in it about tetanus. My other two books were the Lonely Planet Guide to Africa on a Shoestring, and The Complete Poems of John Berryman.
John Berryman did seem more relevant to Nigeria than Auden—in his claustrophobic, paranoiac, boozy sort of way. His mood matched more the political situation here. Throughout the week, there had been riots in Lagos and in some of the upriver towns. There was no gasoline; this despite Nigeria's position as one of the top oil exporters in the world. In Kano people stood for hours in line waiting for a liter or two. The cholera epidemic in Bauchi was even worse than the one we had here; we had no resources to do anything about it, and nobody else seemed to care. Meanwhile, the newspapers featured headlines such as “Abacha Honored by the Federation of Trolley Conductors.”
And so I turned to my Berryman. I sat up that night, reading him by flashlight:
I am, outside. Incredible panic rules.
People are blowing and beating each other without mercy.
Drinks are boiling. Iced
drinks are boiling. The worse anyone feels, the worse treated he is.
Fools elect fools.
Nigeria pinned down on paper.
The morning after I sent the patient to the tetanus hospital, I started rounds and found him in his usual spot, still surrounded by his three brothers. They looked as if they had never left.
“What happened?” I asked the brothers.
“The hospital had no beds.”
“No beds? Did they give him anything?”
The brothers shook their heads.
“Did they say when they would have beds?”
The brothers shook their heads.
“He's much worse,” the brothers told me. One of them showed me how badly the patient's muscles spasmed by attempting to flex and extend his right arm. The arm was stiff as a board.
I squatted down next to the patient and momentarily put my face in my hands. “Iced drinks are boiling.” When I looked, up I saw Simon, the brothers, even the patient, gazing back at me expectantly. I was the doctor; I must do something. I reached out and patted the man's shoulders. This set off a ripple of spasms that spread across his chest onto his neck and belly. His arms rocked stiffly, his legs extended, quivering, tensed. His whole body shook, and you could see under the skin his twitching muscles: fasciculations. His arms twitched as well. His belly was as tense as a drum. This could have marched right out of the textbook I had read last night.