It Shouldn't Be Like This

(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.