Just Here Trying to Save a Few Lives

by Pamela Grim

  I sat there, momentarily a scientist, watching the fasciculations with interest. The millions of tiny muscle cells, contracting chaotically, produced muscle spasms. The effect was such that the entire muscle leaped to tense life. I could see on the patient, as if he were a weight lifter, the well-demarcated rectus and oblique muscles of the belly; the sternocleidomastoid on either side of his jaw was tensed, straining to bring his head down. Then I looked up at the man's face. It was in full spasm now as well. His eyes were open wide; they seemed to stare, like some cartoon character, right out of his head. His lips drew back in a hideous grin so that all his teeth showed. Risus sardonicus. The broad grimace of tetanus—also seen in strychnine poisoning. Contracture of the masseter and other muscles of the jaw and mouth caused the lips to draw back in a “sarcastic smile”—really more like the hideous grin of a naked skull. How could they have refused him at the tetanus hospital?

  Oh, God, what to do. I thought back to the book last night. Treatment: Valium, penicillin, “horse serum.” Well, I knew we had the Valium—we used it to treat the seizures commonly seen in the meningitis patients. We also had a small supply of penicillin (differing slightly in chemical makeup from the ampicillin we used to treat the critical meningitis patients). The last drug I was not so sure of—rather I was sure we didn't have it in our supplies. The question was: could I get it elsewhere?

  There was a pharmacy nearby. I had never visited it, but patients would sometimes show me packages of medicine they had bought there: Cephazolin, neomycin cream, ibuprofen.

  I peeled the label from a liter of normal saline and wrote on it, “tetanus immune globulin.” Underlined.

  “Here,” I told one of the brothers, handing him the label. “Pharmacy.”

  The man stared down at the label in his hand, looked up at me, then got to his feet and fled.

  I started an IV in the patient's arm and taped over it with my usual sign:

  TOUCH THIS IV AND YOU DIE—DR. GRIM

  Simon went to chase the Valium down while I rummaged around in my portable supply box. There was a little bit of everything in there: angiocaths, IV tubing we used as tourniquets, vials of ampicillin and oily chloramphenicol. I found a syringe and plucked it out, cradling it in my hand. There was something comfortable in the feel of this plastic; handling it has been my life's work. The smooth cylindrical 10 cc syringe, as simple as water, the plunger working like a piston in my hands. I returned to my box, groping around, and fished out several 20-gauge needles in their little shrouds, half plastic, half paper. Comforting to touch.

  Simon returned with the glass ampule of Valium: 10 mg in 2 cc of saline. I broke the neck, dipped the needle in and inverted the bottle as I withdrew the plunger to fill the syringe. This must be how an addict feels when he gets his little kit out, I thought. The feel of the spoon, the warmth of the match. That knowledge of “I'm in control now; I know what needs to be done.”

  The patient's brother returned with an ampule labeled “Tetanus Immune Globulin.” There was some murky-looking liquid inside. Who knew what it was? I broke this ampule open and sucked up the contents with another syringe. Needles, syringes, ampules of drugs. I was in my element now. Even these few things were enough to make me think: technology. I was in a great mood. We were going to fix this guy.

  I injected 5 cc of Valium and then sat back to watch. It was like watching a choppy sea become calm. The muscle tremors and wavelets subsided, and a moment later the patient sank back with a sigh. His shoulders unclenched, and his head dropped to one side. How many days had he been tied up in muscular knots like this and I hadn't even noticed? Slowly the patient turned his head to look upward. After a moment he raised his left arm up and reached, stretched. There was no spasm. He looked up at me and reached out his hand as if to show me that his arm worked; he could control it. Then very carefully, as if he were afraid something would break, he smiled.

  The next step, I thought, was to find out where the Clostridium was hiding. In most people infected with tetanus, the portal of entry was a cut in the skin that had become infected. I asked his brothers. “Has he injured himself recently? A wound of some kind?”

  “No, no,” the brothers said. “Was he usually a healthy man?”

  “Yes, yes. Very healthy.”

  I did a quick physical—nothing was obviously abnormal, no hitherto-missed festering wounds. I squatted there for a while, musing; while I did, the brothers told me a little more about the patient.

  They were all men of the Hausa tribe, the largest tribe in this area. The patient served as a local sheriff in a town about twenty miles away. (Apparently, although he was a government employee and therefore on the national payroll, he didn't receive enough salary to go to a private hospital for treatment.) A week ago he had become very sick. His brothers had heard that they might find a hospital here that treated sick patients for free. In order to get to the hospital, the brothers managed to get a ride part way and then they walked the rest of it, another four or five miles, carrying their brother.

  The patient had a wife and two sons. Three other children had died last year.

  Cholera.

  At noon I stopped and sat at the old wooden table we wrote charts on, to eat one of my oranges. Simon sat down next to me, and together we went through the numbers: sixty-two patients in house today. Nineteen patients admitted in the last twenty-four hours, ten discharged and eleven dead since last night. Our mortality rate was averaging about 20 percent. Not great.

  Why was I here? I asked myself for the tenth time that day. Sure, we could give these people antibiotics and all, but look at how many still died. All these deaths preventable with just a vaccination. What this country really needed was a workable public health system. Everything we were doing now was just a temporary bandage, not a solution.

  I sat there glumly peeling my orange and when I finished, I split it open. Nigeria, hell for people, is a paradise for oranges. When you open one, there is an immediate citrus smell so rich as to seem distilled. Never had I eaten oranges like those sold at every crossroads in Kano. Pyramids of beaten-looking, overripe fruit attended by girls of eleven or twelve, this their last year before the everlasting banishment to womanhood, house arrest and the Muslim veil. Sitting there, eating that orange and looking around, I had the momentary thought that we were doing better, or at least it seemed that way. Last week deaths were running closer to 30 percent of all patients admitted.

  Maybe we were accomplishing something here.

  There was a rustling in the bushes. I looked up. This was usually when a little girl I knew would come to beg at the camp. She would sneak onto the hospital grounds by climbing between the slats of the fence and then through the bushes. Once inside, people left her alone. She was the only beggar whose presence on the hospital grounds was tolerated.

  It was her, coming to beg. From a distance she seemed to be just a normal little girl dressed in rags, but as she came closer, you could see that something was wrong with her face. She had normal eyes but a protuberant muzzle-like nose and enormous malformed lips that gave her face a dog-like aspect, as if it were half human, half basset hound. This was because the girl had leishmaniasis.

  Leishmaniasis—in this case cutaneous leishmaniasis—is a scarifying disease caused by a protozoan, L. tropica. The protozoa in her case affected a localized area of the lower face. Her face was normal from the forehead down to the cheeks and the superior part of the nose, but the disease had eaten through everything beyond this. The tip of the nose had become tubercular and looked snout-like. Her upper lip had become huge, elephantine. It was purplish, and encrusted with oozing sores. Her lower lip had partly rotted off and what remained was necrotic, avascular, black. Her jaw dangled open; she had lost the ability to close it. Drool seeped perpetually out of one side of her mouth. I don't know how she ate.

  Yet her forehead and eyes were those of a very pretty young girl.

  She was a feral thing. Once, one of the other doctors had tried to examine h
er. The moment he put his arms around her she kicked, bit, screamed, until he let her go. Personally I couldn't even imagine touching her without gloves and a mask, her face was so obscene.

  She lives in a world, I thought, where almost everyone feels that way. No one could imagine touching her. And she can't be more than ten.

  I had long ago given her my last American dollar, so today, when she showed up, I fished out some Naira and held it out to her. She grasped at the notes greedily. Besides the Naira, I also tossed her an orange. She came forward to grab it and then leaped back out of my reach, squatting on the hard ground, turning it over and over, monkey-like, in her hands.

  I went back to writing on a chart but found, after a few minutes, that the girl had crawled under the table and was playing with my shoelaces. She whispered up at me unintelligibly. Simon bent near her and said something rapidly in Hausa to her. She scurried away.

  “What did you say?” I asked Simon.

  “It's an Islamic prayer of good riddance. She must stop begging now.”

  Sixty patients to round on; the day broken only by the few minutes I spent with my oranges and the Kano Times. There was really no escaping the weight of the days. It pressed down on me like a heavy stone on my chest. I would get short of breath sometimes thinking about how many dead I had seen and how many there were in the future. Probably there were people dying right now, and if I got up and walked over to the acute tent I might even save a few. I knew Jean-Paul was up to his ears in the cholera camp. But still I lingered on, trying to garner some strength. I was tired; I could see it in myself. I could feel that I was cutting into my personal reserves.

  Someday those reserves would be gone.

  At the end of afternoon rounds I went back to see my tetanus patient. He had stiffened up somewhat since the first dose of Valium, so I gave him another. I wondered how long it would be until the penicillin would do the trick. His third dose was due at 8 P.M. The nursing students would administer it. The brothers were going to try to feed him now. I checked again before I left. He was resting more comfortably.

  I went home that night thinking, Tetanus patient: Treatment Day 1.

  In the morning the man looked a little better. He sat up, braced in the lap of one brother while his other brother spoon-fed him some soup. The man managed a weak smile at me and even lifted one arm a little. I bowed my head over him. Praise God but pass the penicillin.

  I looked up from my bow. The two brothers were bowing their heads in return to me.

  Tetanus patient: Treatment Day 2. Pt doing well, eating soup. Plan: continue penicillin and Valium.

  Sometimes the deputy minister of health came on rounds with us. He always wore a snow-white jubbah that gave him a regal air. He would walk with me making suggestions for better therapy—usuallythis involved drugs we did not have. One day he stopped in front of my tetanus patient and gazed down on him. I presented the case.

  “You know,” he said, “metronidazole is currently the preferred antibiotic.”

  “Where can I get metronidazole?”

  “Perhaps MSF has it stocked?”

  I shook my head. MSF was here to treat meningitis.

  “Then I suppose penicillin will have to do.”

  He liked doing rounds with the nurses and the medical students. Just like a lot of doctors in the States, he liked showing off what he knew. After an hour or so of this, in which nothing of substance would get done, he would then get back into his chauffeur-driven car and drive off to whatever important meeting deputy ministers of health had to go to in Nigeria.

  He's a physician, I thought. Why isn't he here with the rest of us? What the hell was I doing trying to save the lives of people in this country when that man isn't willing to do the same?

  I had nightmares about him, about his chauffeur-driven car, about the enormous compounds with walls and guards and security entrances. In my dreams I always wanted to know—why was I here? Nigeria is a wealthy country. It leads the world in oil production. Shell Oil generates millions and millions of dollars in revenues a day. But the Nigerian people, the Hausa and the Ibo and the Origoni tribes, people who have lived atop these fabulous oil reserves for a millennium or more, get nothing, or less than nothing. The rich, the few fabulously wealthy families, live in well-guarded compounds and, when they get sick, go to private hospitals or fly off to the U.S. for their medical care. Everyone else, the other 99.9 percent of Nigerians, lives as vulnerable to meningitis, cholera, tuberculosis, leprosy, as in the nineteenth century.

  Sometimes, though, an epidemic catches the attention of the “international community” and various aid organizations. People from these aid organizations go to the Nigerian government and persuade the powers that be that “something should be done.” So the outside aid organization rides in to the rescue. We arrived in Nigeria with seven tons of medication and supplies, but seven tons means nothing here. It's hardly even a fraction of what is needed.

  But we come anyway. We even save a few lives, but only a fraction of the lives that need to be saved. Soon, we will leave and when we leave there will be nothing to take our place. The meningitis epidemic, cholera, measles, typhoid fever, all preventable diseases, will return and continue as before. The only solution is a political solution, national public health programs, responsible corporations who reap only as much as they sow. Shell Oil with a conscience. Nigeria doesn't need us. What we do here is less than nothing. We take the pressure off the powers that be, making it easier for those who plunder to keep on plundering. This is the humanitarian aid paradox.

  Tetanus patient, Treatment Day 3: Patient looking much better. Eating soup but still can not feed self.

  Treatment Day 4: About the same. Requiring more Valium.

  Treatment Day 5: About the same.

  Treatment Day 6: Spasms well controlled but requires Valium every four hours.

  That was what I wrote down. What I said was considerably more upbeat. Every morning I would tell the man's brothers, “He's getting better. Look! He's getting better,” and they would smile and bow their heads. By Thursday, though, I had to admit that he looked worse, not better. If I laid my hand on his shoulder, it would produce an earthquake-like spasm just as it did when I first saw him.

  I went back to the 1964 textbook of internal medicine, looking for more advice. I thumbed through the parts of the chapter on tetanus I had skipped the first time around, back when I was sure that all the man needed was a little penicillin. There on page 872 was a list of the dead-end part of the disease: myocarditis, inflammation of the muscles of the heart, which leads to heart failure; respiratory embarrassment from spasms so fierce the patient cannot breathe. Pneumonia, thromboembolism. Bad things, all.

  “Environmental stimuli must be minimized. The patient should be placed in a dark, quiet room. Adequate analgesia must be maintained, as the muscular spasms are extremely painful.”

  Extremely painful.

  I ran my finger down the page and stopped it at a sentence I had missed when I read this before. “Survival rate is about 50 percent.”

  Fifty percent! I thought. It can't be that low. Then I thought, well, that was in 1964. The survival rate must be higher now that we have better medical technology. I paused at the thought. Not that I had any access to medical technology. Monitors, scanners, surgical procedures. Where was I going to find those in Nigeria?

  I went to bed that night and lay awake thinking about the humanitarian aid paradox. I must have fallen asleep, because I awoke suddenly with the confused noise of a hundred voices, talking, talking, talking, all about medicine. The voices disappeared in an instant, almost before I heard them. I lay there sweating in the darkness, wide awake now, and I knew why I was awake. I knew what those voices were; no translation was called for. They were the sounds of my own self, the darkest part of me babbling like mad, as I grimly wrestled with my conscience.

  The next morning I reexamined the patient as best I could, but just palpating his abdomen set off fit after fit of m
uscle spasms. Noise, too, set him off and the noise level on the verandah was terrible; children were screaming, women shouting, patients moaning, nurses calling to each other across the ward. Dark and quiet, the textbook had said. There was enough noise to keep this man shuddering and shaking almost constantly.

  I sat back on my haunches and looked down at the patient as he looked up at me. He tried to smile at me, but instead he triggered off a set of spasms. His lips drew back in a rictus of pain. There it was again, risus sardonicus.

  The spasms are extremely painful…

  What is the furthest extreme of suffering? I wondered. Where is the endpoint of agony? Is there a place where, if you are in severe enough pain, greater pain doesn't register? Is that point far away? Does anyone return from there? Can they ever tell us what they have felt? Is there a language for it? Would we, under any circumstance, ever want to know? And why the suffering? Why this man? Why this dead end here, a mat on the floor of a tent. The paroxysms are associated with excruciating pain. I looked at him, shaking my head. Christ only suffered as all men suffer. There was nothing new on the plains of Calvary.

  I searched out Jean-Paul again. Today he was supervising the outpatient clinic. This was part of the old hospital, which had real rooms with real beds. Unfortunately the real beds were really just bed frames and rusty coiled metal springs, the floors were filthy, there were no screens on the windows, and generally the place had such an air of haunted filth that most of my tent patients refused to transfer over once a “bed” became available.

  I found Jean-Paul on the back steps of the intake office, examining a measly child.

  I told him everything. I told him about the constant spasms, the failure of the penicillin, the excruciating pain that we could assuage for only a little while. Jean-Paul listened and as he did so he passed a large handkerchief over his broad face, nodding his head.