(Please note: this blog post is not for the faint of heart)
I have no idea what to do. Nothing I do is right. Everything
here is wrong.
This blog post probably won’t make much sense as it is a
rant of fury and sadness and guilt and frustration. Life here can be so
incredibly horrible. I can’t imagine being an African woman living here. I
don’t know that I would survive or that I would even want to survive.
At one of our site visits today I met a woman who came for
cervical cancer screening. She is a widow. She is a mother of seven small
children. She came to the clinic today because she has had malodorous bloody,
watery vaginal discharge for the last three months. She has never experienced
these symptoms previously and she has not been sexually active for over one and
a half years (and yes, I actually believe this patient). She was seen at a
neighboring dispensary and given treatment for cervicitis (for a presumed STI –
which I don’t think she has) and told to follow up at the health center for
cervical cancer screening.
The instant she laid
down and spread her legs for the exam it was obvious that there were some much
bigger issues here. Her entire uterus was protruding from her vagina, raw,
infected, and exquisitely tender. She said she had been trying to push it back
in, but is kept prolapsing back out of her vagina and it was becoming too
painful to push it back in. My diagnosis: complete pelvic organ prolapse with a
secondary infection and irritation of the uterus/cervix due to environmental
exposure. I try to gently clean her with some sterile saline, but this is
clearly futile and a cervical cancer screen is clearly not going to be very
effective or useful at this point. She needs to get to a larger hospital to be
seen by a OB/GYN and be evaluated for surgery.
So what am I supposed to do? Do I just tell her she needs to
go to the hospital? I think she knows that already. The hospital is far away
(about 45 minute drive) and she doesn’t have money. I know that if I tell her
to go to the hospital that she won’t make it there. She will sit at home for
another three months, in pain, probably scaring away any potential help by the
ever-increasing odor that is emanating from her vaginal area. I don’t know what
to do. So I call the district hospital reproductive health guy that I know and
ask what I should do. He tells me to bring her to the hospital and that she
will get seen and treated there. Ok. I don’t think about things much farther
than that. I know that this woman needs help far beyond what this little health
clinic can offer and that she probably won’t get it if I simply tell her to go
to the district hospital. And I know that she shouldn’t have to live like this,
that if I were in her shoes, I wouldn’t want to live even one more day in this
condition. So I take her.
Of course I forgot about that little “law” about taking
people to the hospital. Apparently, if you bring someone to the hospital, you
are responsible for them – for their hospital bills, food, lodging, etc. I
begin to realize the error of my ways as we get closer to the hospital… as we
stand in line for registration… as it’s pointed out to me by a colleague. Now
what? I don’t know. I thought I just needed to bring her to the hospital and
she would be taken care of. That’s what I was told in simple terms and so my
mind was just working in those simple terms. Duh – forget you were in Africa?
Apparently so.
So I back peddle. I say, “hey, let’s get her evaluated by a
clinician here; they can come up with a treatment plan and estimated costs; I
will give her money for transportation home tonight; she can follow up at the
health clinic with one of the nurses who I can then communicate with about
creating a plan for her.” My colleague shakes his head and says to me, “You
knew this. You knew that if you bring someone to the hospital, you are responsible
for paying for them.” He’s right. I knew. I guess I was “supposed to” leave her
there and verbally refer her to someone else. But I just couldn’t imagine going
home and leaving her in that state. I tried to hold back tears the whole ride
home. How does one live with that? Abandoning the patients who clearly need
help? I just couldn’t imagine living like her. Or perhaps I could – and that’s
the problem. I could imagine how horrible it would be to go home at night with
a uterus hanging out of my body, raw and infected and painful and smelly, once
again turned away from a health center where I was asking someone, anyone to
please help me.
I finally arrive back home and climb out of my car, which
now reeks of infected vaginal secretions. I then remember that I didn’t just
irrationally make this decision by myself. I called the district hospital
reproductive health guy to ask what I should do. HE TOLD ME to take her to the
hospital. So I call him up and tell him how I was told that either I pay for
her treatment or she wouldn’t receive any care. He informs me that the hospital
policy is that patients will receive care regardless of their ability to pay.
They can get treatment and then bills can be sorted out later if the person can
pay. I call up the nurse and tell her that this is what I was told and ask her
to call me after the patient is seen by the clinical officer.
The next phone call goes something like this:
Nurse: “The patient was found to have pus in her urine so
she was told to get some antibiotics for an urinary tract infection, but the
pharmacy is out of stock and she doesn’t have any money so she was only able to
get Tylenol.”
Me: “She has pus in her urine because her entire
cervix/uterus/etc is infected because it has been hanging outside of her body
for three months! Did anyone examine her?”
Nurse: “Let me have you talk to the lab tech.”
Lab tech: “Yes, the patient had pus in her urine, so she
needs treatment with antibiotics.”
Me: “May I ask who saw the patient please? And what is their
phone number?”
Clinical officer: “Yes, the patient had pus in her urine, so
I prescribed antibiotics for a urinary tract infection.”
Me: “Did you examine the patient?”
Clinical officer: “She had pus in her urine….”
Me: “Did you examine the patient?”
Clinical officer: “The patient didn’t have money to buy
gloves so I could not examine her. If a person needs a speculum exam, they need
to purchase the materials. This is a district hospital – that is how it works
here.”
Me: “Did you even ask the patient what was wrong? Or the
nurse that I talked to about what this patient’s problem is? She has grade 4
pelvic organ prolapse. Her entire uterus is hanging out of her vagina. You
didn’t need a speculum to see the problem. You didn’t even need gloves to see
the problem. She just needed to lie on a table and open her legs a smidge and
you would have seen that the problem was bigger than a urinary tract
infection!”
Clinical officer: “She didn’t have gloves so I couldn’t
examine her. Don’t worry, I told her to come back tomorrow with money.”
FUCKING HELL! I’m sorry to curse on this blog, except that
I’m not. She can’t come back tomorrow. She lives miles and miles away and can’t
afford transportation and has seven kids at home alone and she was just treated
terribly by you. There is no way she
is just going to pop back in tomorrow with a bunch of money for gloves and a
speculum and whatever else you think you need. She needed you to listen to her
for a couple minutes and maybe just take a small look. She needed someone at
the hospital to HELP HER. But no, she was turned away because she couldn’t
afford to buy a fucking glove.
And of course now I feel like I should have stayed. I felt
like I had done too much and caused a problem and now I feel like I did too
little and abandoned my patient. But I still think she should have been taken
care of regardless of whether or not I was there to watch and make sure that an
exam was done and that an appropriate management strategy was developed. This
patient should have been taken care of at the hospital. But she wasn’t. She’s
wasted an afternoon, will arrive home late to her children, and will have
nothing to show for it expect maybe even less faith in her ability to get care.
Why bother going to a hospital here? You won’t get the care that you need.
You’ll just waste your time and money. Better to suffer silently at home.
That’s shit. That’s absolute shit. People shouldn’t have to live like this.
I’m pissed off at myself, at the clinical officer, at the
hospital, at the system, at the global community for allowing this to happen.
I’m sad that this woman will return home tonight, without any treatment and
without any hope. And I’m overwhelmed that she’s not the only one.
