Stories from Malawi

The following are excerpts from stories written by Elizabeth Fitzgerald MD.  
July 2018
Privilege and Burden

My day today began and ended with dead children. I walked in to the EZ in the morning to find the night intern doing chest compressions on a surprisingly chunky toddler in a yellow wool hat with embroidered pink flowers. Despite his robust size, he was beyond saving. It was unclear why he had died. Shortly after we declared him dead, after his mother dropped to the ground with guttural wails, they brought Christina to me. She was about 4 years old, and her face had the glazed expression of shock, with her eyes half-lidded and her mouth partially open. Her lips were dry and dusky; her hands were cool. She lay in her mom’s outstretched arms, limp and unresponsive in a faded pink dress. She had been laying essentially unnoticed in the hospital for days with bilious vomiting, the intern explained. Her mom had asked for help this morning because the child would no longer wake up. I lifted her from her mother’s arms and marveled at how light she was, her tiny limbs dangling at her sides.

The intern team and I spent the day resuscitating her with IV fluids, while tending to the approximately 50 other critically-ill patients in the Emergency Zone. An X-ray determined that she likely had a perforated bowel, and when she finally regained consciousness, her belly was tense. She thrashed on the bed, crying for water. The nurse, who was alone in the unit, tied her wrists to the bed with gauze to keep her from ripping out her IV. The team and I made multiple trips to the operating theater and had long discussions with the surgeon about the patient’s condition. He was alone, but he promised to come evaluate her after tending to other surgical emergencies.  At the end of the day, 14 hours into my 48-hour call shift, it was time to go home. I was already exhausted, had a patient’s bile dried on my pant leg, and had run out of water hours ago.  I stood at Christina’s bedside as she alternately pulled at her restraints crying with thirst and lay listless and panting. I had moved her into the HDU, to be placed on one of about 6 monitors for the 300-bed department. Her mom sat on a chair at the bedside as I looked at her vital signs, which had stabilized. 

“Don’t leave Dr. Eliza,” the mom spoke. “Don’t leave your patient. Stay with her.”
I was startled, and realized that the patient’s mom spoke English, had heard my name, and was imploring me not to go home.

Being a physician is both a privilege and a burden. In lifting that child from her mother’s arms that morning, I had taken on responsibility for her life. And despite her size, the burden was heavy. At KCH, where our team of 4 was covering more than 200 patients that night, I understood this mom’s fear that if I left her baby she might die. And yet, after 8 years of working at KCH in the EZ, which I sometimes liken to a war zone, I knew that I needed to go home in order to be functional for the rest of my call. The child had been stabilized, and she needed a surgeon. I explained to the mom that the 3 on-call interns would watch over her, and that she was in good hands; they could call me any time. I live only 5 minutes from the hospital, I told her, and the surgeon had promised to come. I drove home on the unlit streets with a feeling of dread.

I saw her empty bed when I arrived for rounds the next morning. The surgeon had never come.

In my writing about GH over the years I have tried so many different ways to describe heartbreak. Sometimes it is almost a physical pain, that leaves you momentarily breathless. 

I get asked a lot about why I do this work, and Christina and her mom personify my motivation. I am motivated by the weight of her body in my arms. I am motivated by the burden of her death because I had to go home. I am motivated by the wails of the mothers of dead children. 

I do not understand why we, as human beings, value some lives more than others, but I am faced with the evidence of our apathy every day that I come to work at KCH. It is not OK that 6 children died that night. It is not OK to have such different standards for ourselves than we do for other mothers and their children in the world. We, as global citizens, need to do better.

January 2018

He sits hunched on the bed with his knees bent, sharp angles against his rounded, swollen belly. He is cachectic.

He sits leaning forward with his head in his hands, his face wizened, his hair sparse and coarse.

He is exhausted.

His body is riddled with cancer. He has been given chemotherapy that has rendered him anemic and immunosuppressed but is his only chance at survival. In a hospital with no blood, few labs, and few medications, he has developed pneumonia. He struggles to breathe.

He is suffering. 

The room is bright, his sheets are filthy. He sits alone. In an effort to ease his breathlessness, I give him a dubious green liquid from a used plastic water bottle labeled “Morphine” and put a mask on his face. He is unable to speak but helps me adjust the mask over his nose and mouth with skeletal hands. When I ask him if he is OK his eyes meet mine and he nods and gives me a weak thumbs up. And then, as I stretch over from behind him to tighten the strap for his mask, he reaches up and places his hand on my cheek. It is cool and soft. He holds it there for a moment that lasts forever.

He is our responsibility.

Monday, September 24, 2012

My patient died last night.

What does an 11 year old boy think about while he is dying?  He lies on a plastic bed in the merciless fluorescent light, surrounded by the relentless noise of babies crying and machines beeping, with the occasional sound of mothers wailing when their children die.  He watches tubes inserted, seizures, and CPR in the surrounding beds. Does he have hope?  Is he afraid?  Is he thinking of football games he’s played, or his school friends?  Is he missing his dead mom? 

My heart breaks that his last moments were spent in that chaos and filth.  I pray that he just felt tired, and that he fell asleep, and felt no pain.  I am so truly, profoundly sorry that I couldn’t save him.  Please don’t write to me and tell me about how it’s not my fault.  I know with my head that there was a complicated path that eventually lead to his death, and I know that I am only human, and that we are limited here.
And yet, my son is 11.  He is solid, and boisterous, and robust.  He has dreams, and a future. ALL boys should be pestering their little sisters, and building forts out of sticks.  They should feel safe, and have faith that they will be protected and loved while they go about the work of growing up.  Instead, this sweet soul lay in that war zone, holding his grandmother’s hand for several days before he died. 

I wish I could have altered that path.  I am so sad that we, as human beings, have allowed this to happen to our children.  I pray for that little boy’s soul. I don’t have a great concept of heaven, and I don’t pretend to know what comes next.  But for him, I hope he is with his parents.  I hope that he died painlessly, and that he is now whole and strong.  I am grateful for the time I spent taking care of him. I am honored to have witnessed his quiet courage.  And I am so terribly sorry.

This is an excerpt from an essay written by Eamonn Fitzgerald, during a 2017 visit to Malawi.  Over three weeks Eamonn worked closely with the Mrs Harawa a clinical social worker at KCH.  Eamonn, at the age of 16, helped found MCI.

Our first house visit.

I go with the social worker to visit a family just outside Lilongwe on a particularly hot day. The temperature is strange and out of place in the customarily cool winter of Malawi. As we drive, we pass countless villages each like the last. Children run alongside goats, pigs and dogs, teens and adults work around the village or stand by the roadside selling things ranging from airtime to boiled and dried mice on a stick. That is how we find the young father of the patient, mice in hand on the side of the rutted road to the village. The patient is a 16 month old with cerebral palsy and malaria who’s mother continually attempts to leave the hospital without the permission of the doctor. Despite his age the child looks to be only 3 or 4 months, no doubt a result of his various illnesses combined with the malnutrition that is all too common in Malawian children. This malnutrition, while partially due to limited food consumption, is also due to the poor nutritional quality of the staples of their diet. One such staple is Nsima, a dish made from maize flour and water that is typically served with greens and a protein source. When these greens and protein sources are not available however, it serves little nutritional purpose, providing only empty calories.
We arrive at the village, a small collection of mud and brick houses with grass or tin roofs and are met by the village children, amused by my red hair, no doubt a rarity in Malawi. The patient's house is a tiny rectangular building with a bare cement floor and a single cabinet holding all of their possessions; a makeshift radio and battery, a panga knife, and several cans of baby food. They are a stereotypical set of Malawian parents, extremely young by Western standards, the father being 23 and the mother 19. Despite the language barrier they are very courteous as they discuss their conditions with the social worker. We ask what they do for a living and learn that in addition to being a roadside vendor, the husband also works as a brickmaker. This is a difficult and physically taxing job that he hopes to turn into a business. This is but one example of the industriousness that I have encountered in Malawi. After the visit the social worker tells me that she hopes to find a way for the mother to contribute to the household. One of her ideas is selling vegetables from a home garden. This is a way by which many Malawians earn money, however they are far outnumbered by the subsistence farmers of rural Malawi.

Malawi has a high child mortality rate. Many of these children's deaths are due to preventable illnesses that could easily be dealt with if they occurred in the United States. However a lack of access to reliable health care in these rural villages makes these illnesses fatal with an astounding frequency. Outside we meet the husband's grandmother, 74 years old and mud plastering the side of a new house. She smiles toothlessly at us as she poses for a multigenerational picture with her daughter, her daughter's son and her grandsons son. Although the life expectancy in Malawi is slowly rising and currently standing at 62, this is low compared to 78 in the US and 81 in the U.K. This low number could be drastically improved if hospitals in Malawi had support for their infrastructure and increased clinical capacity.

By Eamonn Fitzgerald, 2017