A Sixth Sense

You may wonder how Shirati Hospital cropped up in such a rural and remote area of Tanzania.  It turns out that there was an influx of Mennonite missionaries some 30 years ago and though they have long since left, their legacy remains with support and significant outside contributions.  The physicians and staff that arrive often have a link, at least by word of mouth, with the Mennonite Church.  With their influence the Hospital has grown and has essentially become the “referral center” for the district.  However, there are still very few fully trained physicians permanently stationed here, perhaps 2 or 3 in the entire hospital.  Most of the local medical providers are non-physicians, either Medical Officers (MOs) or Assistant Medical Officers (AMOs) who perform most general surgeries, cesarean sections, and deliver care on the wards.  Specialists arrive a few times a year to supplement the medical care they are able to provide.

All in all, I was impressed with how much care the local staff was able to provide with so few resources.  Yet, there were definitely still some 'what the heck' moments.  For example, intubations were rarely performed in the hospital since there were no working ventilators.  Even in the operating room most cases were performed under spinal anesthesia, perhaps augmented by ketamine.  It was somewhat disconcerting to see patients wide awake as their legs were being amputated or watch an orthopedic surgery drag on for 5-6 hours.  The whole time I was just praying that my spinal had taken full effect and would last for the entire procedure.  On the occasions that we were unable to use spinal anesthesia (abdominal surgery, etc.) we did end up intubating, albeit with sub-optimal conditions.  We used Ether through a pump (hand pumped through a device that looked like an accordion) since there was no ventilator. 

Ether Hand Pump

What's wrong with this picture?

Ketamine and/or Valium were used for induction followed by the paralytic succinylcholine.  However, the biggest problem was that there was no external oxygen source in the hospital.  No pre-oxygenation or apneic oxygenation here.  What generally would be a controlled setting for intubation essentially turned into a harrowing ‘emergent’ intubation every single time.  Presumably the patient was young and healthy and starting at 98-100% O2 saturation on room air.  After inducing and paralyzing the patient the oxygen saturation would immediately begin to drop.  It became a race against time to intubate the patient.  Even if intubation occurred within 10-15 seconds oxygen saturations would routinely drop to 40-60%.  No one informed me of this prior to my first intubation.  My first airway attempt would have been a standard affair back home:  young, healthy skinny man with no predictors of airway difficulty.  His epiglottis was a little floppy but I got a pretty decent view and slid the tube through the vocal cords in about 10 seconds flat.  I looked up at the tiny monitoring device and noted the patient was saturating around 80% which was not to be unexpected considering he had received no oxygen over the past 1-2 minutes during induction, paralyzing, and intubation.  However, despite “bagging” room air (we normally breathe 21% oxygen) mixed with ether, the patient’s oxygen saturation continued to plummet all the way below 40%.  I stared in horror since this was one of the lowest oxygen saturations I had ever seen in a living human being.  At this point I immediately thought of the potential for esophageal intubation (endotracheal tube going down towards the stomach instead of the lungs).  However, the patient had equal breath sounds with chest rise and no rush of air over the stomach.  I had multiple people check with the same result.  I then looked in the patient’s mouth again to verify the correct placement of the tube.  Nothing looked amiss.  At this point, I was still the only person in the room who was nonplussed.  The anesthetist was a quiet fellow and continued to bag through the ether accordion pump while I held a double-handed seal of the mask over the patient’s face.  Ever so slowly the oxygen saturation began to rise but it took over 5 minutes for it to reach 90%.  I would soon realize this to be a common occurrence.  Luckily I did not see any catastrophic consequences of these hypoxic events and patients were apparently none worse for the wear post-op.

The wards in the hospital, like much of sub-Saharan Africa, are big open air wards.  There are female, male, and pediatric wards that accommodate many more people than you think would be possible.  The beds are side by side and so close one could essentially roll from one bed to another and snake his way across the entire ward.  There are no levels of acuity, step-down status beds, or intensive care units.  Patients are sometimes even placed two to a bed.  Patient privacy does not exist and rounds occur with every patient hearing every other’s story.  Basic patient care such as feeding, bathing, and clothing is performed by family members.  Patients don’t get any food unless their family brings it for them.  There are no blood transfusions unless a patient can find a matched donor, usually a family member.  Despite all these difficulties, the staff provides care beyond which one would expect.  They work long hours, manage an unreasonable number of sick patients with unimaginably meager resources, all while wearing a smile.

Nevertheless, there were some tough patient cases and ethical dilemmas.  One particularly striking case involved a 23 year old HIV-positive woman (whom I will call Ms. Khadija) who had just delivered her 4^th child by cesarean section.  She had a post-operative wound infection that required a return to the operating room.  I don’t have the exact statistics for post-operative complications and infections; however, I suspect that the rates are significantly higher in rural Tanzania.  She was taken back to the operating room and found to have extensive infection and pus in her abdomen.  It was cleared out but she was still in dire straits.  Being HIV-positive certainly didn’t help.  Hers was bed #1, the first one you stumble across upon entering the morass that was the female ward.  It was unavoidable. It was the weekend and the on-call doctor had left for the day.  I was now the only physician in the entire hospital.  As I entered, the unmistakable stench of infection permeated the air.  I immediately stopped at bed #1.  Ms. Khadija looked acutely ill.  She was sweating profusely and had a glazed look over her eyes.  She was breathing very fast, upwards of 60 times per minute.  I checked her pulse and it was between 140-160 beats per minute.  Her temperature was 104+F.  Her blood pressure was tenuous.  She had disseminated infection with likely end organ dysfunction (though we did not have any lab tests to confirm), what we would call severe sepsis.  In the U.S. she would be in an intensive care unit with 1:1 nursing (not 1 nurse to 40 patients) with multiple physicians, specialists, and a host of other team members and resources.  She would likely be on a ventilator with central venous access and on many powerful antibiotics and medications to support her blood pressure and help fight the infection.  Here, she only had me and a handful of nursing students.  When I arrived there were no fluids running.  I had another IV line placed and started fluid resuscitation.  She was already on 2 antibiotics.  I added a third.  She was now on all the antibiotics the hospital had to offer.  She had no central lines for large volume resuscitation and we had no pressors to support blood pressure.  All I could muster was to wipe the pus that was still draining from her abdomen and wave the flies away that were slowly starting to settle all over her body.  I held her hand.  All the while, the rest of the ward, including the woman lying a foot away in bed #2 had to watch this cruel death struggle.

I walked over to the head nurse and said, “She will not make it through the night.  But try your best.”  She nodded.

I told the students back at the hostel what was happening in the hospital.  They didn't believe me at first, “Oh she will be okay.  Don’t worry.”  I didn't say anything.  When we returned the next morning the ward was bustling as usual, with nursing students running every which way and a sea of patient faces greeting us as we walked onto the female ward.  All the beds were filled and there was already a new woman in bed #1.  I glanced at the woman in bed #2 and our eyes locked.  We did not speak the same language but her eyes told me the story of Ms. Khadija’s final hours.

Being an Emergency Medicine physician certainly helps one differentiate sick from not sick and we are pretty good at it.  However, working in a resource limited setting such as Tanzania forces one to take gut instincts to an other-worldly level.  In my previous visits to South Africa, I had heard the sentiment before but could never foretell the events myself.  How did they all know a patient was going to die?*  Here there are no lab tests or fancy imaging or complicated diagnoses to hide behind.  No lactate or white blood cell count or CT scans with contrast.  It is just you and the patient.  And you just know.

*A shameless plug for a previous publication in the Lancet-Student regarding end-of-life-care in South Africa told from a medical student’s perspective:

http://www.thelancetstudent.com/legacy/2010/12/10/doctor-please-don%E2%80%99t-leave-me/

Just Another Day in the Village

After an eventful journey from Nairobi to the Tanzanian border I settled into the sleepy village of Shirati for a much needed respite after 48 hours of travelling.  It took an additional two hours over dirt roads and paths winding through various villages to finally reach our destination.  Dr. Esther Kawira had a piping hot meal ready for me when I arrived.  Her story is remarkable.  She is a U.S. trained Family Medicine physician who married a local and settled in Tanzania 30 years ago.  Twenty of those years she spent running the only hospital in the village and has since opened her own rural clinic serving the underserved population for nominal fees.  It is to work with her and the individuals in the hospital that I have journeyed here.

First a little about the village of Shirati.  When I was trying to research the area I could not find it on a map.  I have since only seen it listed on a single map (blown up to include only this province) which belongs to the local historian.  Homes are primarily mud huts with thatched roofs or made from tin.  The wealthier folks can afford small brick houses.  Small bumpy, dusty roads connect the farms in the surrounding area.  Animals roam freely and still see people infrequently enough to stare intently at you as you pass by.  Whenever I ran through the village, children would cheer and join me from each community of huts, slowly forming a flying-V entourage around me.  It reminded me of the Muhammad Ali movie where the whole town in Zaire started running with him yelling, “Bomaye Bomaye” (“Kill him, Kill him” prior to the ‘Rumble in the Jungle’ against George Foreman).

Shirati’s central area is located by the hospital.  It consists of the hospital compound and then a row of shops and fruit/vegetable stands across the road.  Each shop contains essentially the same 10 items with an occasional oddity thrown in.  These include (in no particular order):  peanut butter, medium fat spread, dilute hot sauce, bread, shampoo, coffee powder, washing powder, and fluorescent orange drink concentrate.  One or two shops have a rare refrigerator where you can purchase “cold drinks.”  Fanta gone wild, flavors abound.  Orange.  Black currant.  Pineapple.  Passion fruit.  There is also a fruit and vegetable stand and some streetside grillers of meat (what I have come to call “danger meat” but can never resist since I love street food).  What you absolutely cannot find is anything dairy related.  No milk.  No yogurt.  No cheese.  I repeat, no cheese.  I can survive without tv, internet, electricity, and other niceties of modern life, however, I do not know if I can survive without cheese.

Our village Gas Station

Fruit & Vegetable stand

'Danger' meat

Dr. Kawira’s new clinic is still a work in progress (no power yet) but is shiny and expansive and the patients have started flocking from near and far to see her.  The pathology seen here is distinctly different from that seen in the U.S. and there are very limited resources with which to diagnose and treat many conditions.  Our rapid testing at the clinic was limited to the following:  HIV, syphilis, malaria (P. falciparum), hemoglobin, urinalysis, and urine pregnancy.  We also had a small storeroom of medications, much of which was donated or procured from Nairobi.  After a few days of training under Dr. Kawira I was set off to run the clinic on my own with a band of medical and PA students.  We had a nurse to translate from Swahili (or Luo) to English.  At our disposal was a stethoscope, flashlight, measuring tape, Doppler for fetal heart tones, lubricant, and gloves, but most importantly our clinical acumen.  No imaging or ultrasound.  No CBC or electrolyte panels. 

Sota Clinic

Our Pharmacy

On my first day alone we diagnosed new cases of HIV, tuberculosis, syphilis, malaria, schistosomiasis, dysentery, CHF, and asthma.  There were a few days when we diagnosed half the patients at the clinic with malaria (of the P. falciparum variety) often with varying and very different presentations.  In addition to these “bread and butter” cases I saw even more interesting pathology including lymphatic filariasis, known more colloquially as ‘Elephantiasis,’ hepatocellular carcinoma secondary to chronic Hepatitis B in a young unimmunized man, and even diagnosed my first case of leprosy.  Acutely ill patients could be “admitted” overnight essentially for observation and treatment at the clinic or they could be “transferred” to Shirati Hospital.  Care in resource limited settings is often fraught with ethical dilemmas.  A typical case follows:

~~~~

Case:  65 yo M PMH CHF (congestive heart failure) and PUD (peptic ulcer disease) presents with pitting edema to thighs, diffuse crackles bilaterally.  Previously treated with Hctz, digoxin, and Lasix but lives in extreme poverty with inability to afford meds and has poor access to health care as he lives several hours away from the nearest clinic.  Still has some Lasix remaining but no digoxin or Hctz.

Physical Exam  

Vitals:  37C  HR 120s  RR 20  BP 200/100

Gen:  Appears uncomfortable and short of breath.

HEENT:  PERRL, EOMI, +conjunctival pallor

C/V:  S1S2 present.  Tachycardic to 120s.  Normal rhythm.  III-IV/VI holosystolic murmur loudest at the LUSB

Resp:  Diffuse crackles bl; decreased air movement

Abd:  Epigastric tenderness.  Mild abdominal fullness.  No rebound.  Mild voluntary guarding.  +Fluid wave.

Ext:  Diffuse 3+ pitting edema to bl thighs

Ethical Dilemma:  This patient would clearly benefit from admission to a hospital with aggressive management for decompensated heart failure.  However, in TZ most care is fee for service and this patient is unable to afford admission to the local hospital.  In fact, he is unable to afford observation overnight at your clinic or even HIV/syphilis tests.  The total cost for overnight observation and IV medications and tests would amount to less than $10.  What do you do?

This was a case that I had on one of the days I was running the rural stand-alone clinic by myself.  This is a common example of an ethical dilemma that may arise during a global health elective.  Diagnostics and therapeutics in this patient would normally be straight forward however the waters are muddied when resources are limited.  Issues raised in this case include resource allocation, poverty, and access to care.  Since it would cost just a few dollars to get medications, tests, and an admission the thought of pulling out a few bucks from one’s pocket immediately comes to mind.  We are fierce patient advocates but must be cognizant of the downstream effects of our actions.  How do you decide whom to help and whom not to help?  Will treating this man for one day change the course of his disease?  There are no right or wrong answers but each case is worth analyzing closely.

In our case, the man was able to afford several vials of IV Lasix (40 mg) which I administered to him prior to his discharge.  I was also able to increase his oral Lasix dose and restart his digoxin and hydrochlorothiazide.  The patient promised to return for admission the following week after he returned to his village and gathered more funds.

Monday Market

Open Air Market

Highest point in Shirati (Aboke Hill)

Coming Soon:  Life at Shirati Hospital

Deadly First Day Back in Africa

And so it didn't hit me that I was actually going back to Africa until the night before I left.  The NSICU was a busy month and left me little time to think about the trip.  The last 24 hours were a flurry of activity as usual with various errands, “procurement” of medical supplies, and packing.  I am heading to Tanzania in East Africa, a country that I have visited before, but am hoping to become more intimately familiar with.  Cincinnati to Paris to Nairobi took about 24 hours.  The company supposed to pick me up at the airport never showed so I hailed a random taxi and headed to my lodging around 1AM.  The guard didn't have my name on the books but I got lucky and snagged the last room for a couple hours of shuteye.  At 6AM I headed to the bus station.  As part of the trip I had been encouraged to hire a private car for the long journey to Shirati in rural Tanzania.  However, it would be about $350 for a single person one way.  I thought this was outrageous (I could probably buy a motorbike and drive myself for less than that).  Perhaps a bit of an exaggeration but I opted instead to take a local bus for $10...In addition to the obvious cost savings, the cross country bus is the usual test for any intrepid foreign traveler and I wanted to see if I could still hang.

The cab driver was skeptical when I stated that I wanted to go to the bus station.  I asked him to drop me off but he refused and said he would take me in personally.  “There are bad people here,” he whispered.  I initially thought this was ironic considering the number of cabbies I had been cheated by through the years.  The bus station reminded me a lot of an Indian bus or train station.  A mass of humanity and chaos.   The driver almost immediately got into a fight as the parking ‘managers’ (none official and mostly self-appointed) did not let him park and forced him into the morass of buses and people in the terminal.  After we got to a dead-end jammed by buses on all sides we turned off the car.  I was about to get out but the driver yelled, “Stay here!”  He locked the doors and scurried away.  He resurfaced a few long minutes later and said he had found a bus.  He grabbed me and started running zig-zag patterns through the crowd.  “Follow me!”  The crushing waves of people surrounded me and the hawkers hit me from all sides.  There was even one guy who pointed and yelled, “Mzungu, Mzungu!”  I was incredulous.  Through all my previous African adventures I had largely avoided such designations.  Despite my nearly native dress and confident walk this guy had found me out.  Mzungu literally means ‘foreigner’ but is generally reserved for individuals of much lighter complexion than myself.  This guy was pretty good or maybe it was the long hair that was the giveaway.  Luckily no one else really seemed to mind.

(aerial view of Nairobi bus station) 

As we approached the bus, I tried to hand the ticket guy a $20 bill (I hadn’t gotten a chance to exchange any money since I had only arrived a few hours prior).  He looked at me like I was crazy:  “We don’t take that.”  The taxi driver started to look worried now.  He grabbed my money to go exchange it for Kenyan Shillings in the back alley:  “Stand right here.  Do not talk to anybody!” By now a crowd had started to surround me and the ticket agent.  There was yelling and shouting and pushing.  I was starting to get nervous.  Just then the taxi driver returned with the cash.  He thrusted it upon the ticket agent and then pushed me onto the bus.  “There are no more seats left.  Do not lose this ticket or they will kick you off the bus.  Do not buy anything.  Do not eat anything.  Do not talk to anybody!  I will make sure your bag gets into the boot (aka ‘trunk’).”  Looks like they saved the last seat for the mzungu.  With that the taxi driver turned to leave.  I yelled after him, “Wait!  What’s your name?”  He looked puzzled.  “My name is John.”  I smiled.  “Asante sana, John.”  He nodded and then hurried towards the loading crew.  I've realized through the years that I often have to implicitly trust many of the people I meet in my travels.  And yet I never cease to be amazed by the kindness of random strangers who go out of their way to help and often protect me.

As I began to walk down the aisle I was intensely aware of everyone staring at me.  My trekking pack did not fit down the aisle and I lifted it above my head and scrambled over various packages, bundles of produce, and the errant child.  Much to my dismay there were no chickens or livestock, always the gold standard for a true local bus.  However the bus was packed and at first I did not see any seats available.  I walked all the way to the back and realized the last seat was on the bench at the rear of the bus.  I climbed over several people and squeezed in between 8 other people (7 adults and 1 child).  There was nowhere to put my back (which contained all of my worldly possessions) so I placed it on my lap.  The windows were shut, the heat was stifling, and I was physically sticking to the two individuals beside me.  I finally felt at home.

It took nearly an hour to get out of the literal parking lot the bus terminal had devolved into.  Buses were pointing every which way and interspersed were random cars, motorcycles, and people.  It took hundreds of back-and-forth maneuvers to get out of the bus station without striking any other buses or vehicles.  The bus ride would take 10 hours from Nairobi to the Kenya-Tanzania border.  From there I would have to get on a jeep to make it the rest of the way to the remote village of Shirati in Tanzania near Lake Victoria.  The additional 2 hours were mainly on dirt/mud roads through various villages.

The bus ride started with what I thought was the conductor getting up and telling everyone the rules of engagement.  I thought this was peculiar since I had never heard anyone giving rules/instructions or even names of bus stops during previous African bus trips.  It was all in Swahili so I couldn't make out exactly what he was saying.  However, he continued on and on, getting louder and louder by the minute until he was screaming.  He had the entire bus in a frenzy and everyone had their arms raised.  I finally realized that he was preaching.  This continued for over an hour until his voice was hoarse and sweat profusely dripped from his brow.  He was succeeded by another individual and then another.  I was beginning to wonder what kind of bus I had gotten onto.  Everyone was in a trance and even the little children had their arms raised.  It felt like some kind of cult.  Bits of English would occasionally filter through.  “Today will be the start of a new life!”  “This is a new beginning!”

This would be a fateful day as in the midst of the sermon we heard a loud crash and the bus came to a screeching halt.  Everyone stood up simultaneously.  I heard murmurs at first and then screams as the bus emptied.  I scrambled out into the midday Kenyan sun.  Immediately in front of our bus, a motorcycle had hit a matatu (mini-bus known by various names and seen across sub-Saharan Africa) head-on.  It had been nearly 48 hours straight of traveling and I was dehydrated and delirious.  It felt like a dream.  Despite the glare of the sun, I could make out a body lying spread eagle in the middle of the road.  It was the motorcyclist and he was clearly dead.  Blood and brain matter were scattered everywhere.  I dragged his body to the side of the road while trying to avoid oncoming traffic.  I then ran to the other side of the road.  At first I couldn’t even see the matatu.  It had apparently struck the motorcyclist, swerved, and tumbled off the ravine to the side of the road.  I was horrified.  I had taken such vehicles innumerable times in the past across several countries.  They are generally stuffed to the brim with people, as many as 15-20 at a time.  While usually uneasy when travelling in one (the drivers are generally erratic and speed mercilessly), I routinely do so because it is exceedingly cheap and is the mode of transportation for the common man.  

 (typical matatu)

This particular matatu had rolled off the side of the road and lay about 20-30 feet vertically down in a ravine.  It had tumbled through thick brush and was lying upside down.  As I got closer I could hear the wails of women at the edge of the road crying in despair.  I pushed through the crowd that was quickly forming and started climbing down.  It was incredible to see how quickly people came together to help.  Women who had been working the fields came with machetes and began to cut a path for the men.  As we made our way down the scene turned even more grim.  There were additional fatalities and bodies were strewn everywhere.  We began to carry each bloodied and mangled body up towards the road.  In addition to the dead there were several critically ill passengers.  I quickly began to triage in my mind.  Several black tags already.  Several ‘green’ tags.  One man had clearly broken both legs.  He calmly looked at me, his eyes pleading, and asked, “First aid?  Please?  First aid?”  I put my hand on his shoulder and said, “Please wait.  Help will come.”  In fact, I did not know if any help would come.  I moved on to the ‘red’ tags, critically ill people that had a chance to survive with appropriate intervention.  There were several people that were minimally responsive or altogether unresponsive, likely with severe TBIs (traumatic brain injuries) or intra-thoracic injuries.  Blood was pouring from scalp and other wounds so I had bystanders hold pressure.  Another man was gasping for air as blood was pouring from his mouth.  I didn’t have a stethoscope but he potentially had a pneumothorax (collapsed lung) and or hemothorax (blood in the chest cavity).  In fact I didn’t have any supplies whatsoever.  The motorcyclist could have used a thoracotomy (cutting open his chest) since he was found pulseless within a minute or two after blunt trauma.  All the critically ill likely would have been intubated (with breathing tubes).  The man with the pneumothorax could have used a needle decompression or finger thoracostomy (cutting the chest to relieve pressure from the collapsed lung) and chest tubes.  Many of these patients would have been helicoptered to level I trauma centers in the U.S.  Instead here they were languishing on a rural Kenyan road with no EMS system and no help in sight.  I was reduced to assigning GCSs (Glasgow Coma Scores).  Despite all my years of education and medical training, I felt completely and utterly helpless. 

In the midst of despair the situation somehow worsened.  The crowd surrounding us had enlarged and was growing angry.  They were trying to stop vehicles and buses to help transport the victims as I presume they knew that no ambulance was going to come.  They started banging on cars with windows and windshields beginning to shatter when people refused to stop.  Our bus driver, fearing the growing mob, began to drive away.  All the passengers who were milling about ran after the bus.  Suddenly I was faced with a horrifying split-second decision.  Do I stay or do I go?  In my haste to get to the accident scene, I had left everything on the bus.  I did not have any money, my passport, or a phone.  In fact I had no idea where I was (some 4 hours away from Nairobi and still 6 hours away from the border) besides being somewhere in the rural Kenyan countryside and I did not entirely know where I was going...

...There were again stares as I walked down the aisle (as the bus sped away) but this time it was because there was still fresh blood dripping from my hands and clothing.  I slowly returned to my spot at the back of the bus with a sinking feeling in the pit of my stomach.  I looked out the back window and could still see the blood stain in the middle of the road from the motorcyclist.  I could also see the victims I had left behind, perhaps to die?  Waves of nausea struck me and all I could do was clutch my face in my hands.

Today I failed not only as a physician but also as a man.  Hopefully tomorrow I will do better.

Hailing an Auto-rickshaw for Dummies

What is at once the most endearing and yet equally reviled symbol of India? Why the autorickshaw, of course. The cute, little yellow 3-wheeled contraption fascinates much of the Western world, yet local Indians complain endlessly about the ever-increasing fares and the general predilection of auto-wallahs (auto guys) to cheat you like a Bernie Madoff ponzi scheme. Luckily for you I have included a fail-proof method for hailing an autorickshaw in Chennai. Read on or scroll to the bottom if you are really desperate.

I was originally planning on commuting to the hospital by motorcycle but this was almost immediately shot down by my entire family both in the U.S. and India. When my relatives in India threatened to hire a private car daily I quickly settled for taking an autorickshaw instead. I could still sense their uneasiness. How bad could it really be? I had lived in South Africa for a year by myself, bought a car there, taught myself how to drive stick, and even maneuvered away from charging elephants...

Let me review some of my experiences from the first two weeks. First off the guys couldn't understand a single word I was saying, whether it was in Tamil or in English (cover blown immediately). My accent was apparently that bad. I knew the target price (100-120 rupees, approx $2-$2.50) yet still asked them what their fare would be. My goal was to use this as a gauge for how foreign/how much of a sucker I appeared. I was routinely asked to pay 170-200 rupees for the 6.5 km to Apollo Hospital. The government set price of 5-6 rupees/km would come to about 40 rupees max. Locals are generally willing to pay around +/- 10 rupees/km depending on the time of day and route. I clearly looked like a guy ready to be taken for a ride.

A lot of roads are one-way in Chennai due to construction for a new rail system. The autorickshaw drivers use this as a ploy to ask for extravagant prices. After offering 100-120 rupees for a return journey I was told that this was the price "back in 1986, 1987, 1988." Interestingly, I only paid 110 rupees the previous day. I'm pretty sure I could get someone to pull me the whole distance on an original style rickshaw for half that price back then.

Now as an aside I should comment on relative pricing as a Westerner. While the actual difference between $2 and $3 is very little for me, the fact remains that they charge as much as 10 times the standard price because they think they can. Even for locals they try to gauge how wealthy a person is and in general how much a person is willing to pay. They will make every effort (regardless of how many twists of the truth it takes) to extract as much money as possible. With this in mind it becomes a matter of principle to avoid becoming a "victim." I have never seen a "working" meter and each auto driver sets his own price as he sees fit. While I joke about the exorbitant prices I certainly wouldn't be opposed to paying the higher price if it was uniformly employed. Just imagine if you were jumping on a bus in the U.S. and before sitting down the driver sized you up and decided on a price between $2 and $15 for you to pay (even though you know it costs $1.50).

I think I'll save my descriptions of the roads/traffic in India for another post. Let me just say that I breathe a sigh of relief at least once a day after escaping yet another death defying stunt.

Below is a dialogue from a book my friend Matt is using to learn Tamil. It's humorous but at the same time very accurate. I have had almost the exact same conversation with auto drivers several times already.

From: "Colloquial Tamil: The Complete Course for Beginners" by R.E. Asher & E. Annamalai

AUTO DRIVER: enge pooriinga?

MURUGAN: rayilvee stationnukku.

AUTO DRIVER: ukkaarunga. nuuru ruubaa ku∂unga.

MURUGAN: enna? nuuru ruubaayaa? pattu kiloomiittardaan

irukkum. miittar poo∂u.

AUTO DRIVER: miittar rippeer, saar.

MURUGAN: aattookkaaranga ellaarum ip∂idaan solriinga.

janangale eemaatturiinga.

AUTO DRIVER: petrool littar muppadu ruubaaykki vikkidu.

pooliskaarangalukku maamuul ku∂ukkanum.

MURUGAN: sari, sari. embadu ruuba ku∂ukkireen. poo.

AUTO DRIVER: Where are you going?

MURUGAN: To the railway station.

AUTO DRIVER: Sit down. Give me a hundred rupees.

MURUGAN: What? A hundred rupees? It’s only ten kilometres.

Set the meter.

AUTO DRIVER: The meter’s under repair, sir.

MURUGAN: All you auto drivers say this. You cheat people.

AUTO DRIVER: Petrol costs thirty rupees a litre. We have to give

bribes to the police.

MURUGAN: OK, OK. I’ll give eighty rupees. Go.

And now what you've all been waiting for...

Hailing an Auto-rickshaw for Dummies

Rule 1: ALWAYS bargain.

Rule 2: Pretend to be a local (if you’re White you are probably S.O.L…please skip to the final rule)

Rule 3: If you are not a local, pretend to be from another state in India (tip #1: Instead of saying “yes” say “ahh” and learn to do the Indian head-bobble nod)

Rule 4: Never hail an autorickshaw from an auto stand.

Rule 5: Act like you know what the fare is

Rule 6: If you have no idea what the fare is, divide the given fare by 1.5 to 2 (depending on how well you hide your foreignness) and make an offer.

Rule 7: Always lowball (you will almost certainly still be offering more than the government fare of 5-6 rupees per km). Try to meet at a price somewhere between the autokarren (auto-guy) high price and your “lowball” offer.

Rule 8: If you don’t agree with the price, walk away (physically). Surprisingly effective.

Rule 9: If all else fails, point and yell “eemaatturiinga! po da nai!” (cheater! Get out of here, you dog!) to voice your displeasure. Now run away before you get stabbed.

Rule 10: Know that no matter what you do, you will still be cheated (even the locals admit this).

Back to the Homeland (not Africa this time)

It has been a while since we danced but I have once again picked up my pen. Don't get too excited though, as I only write when I'm on an adventure and yet I am usually too engrossed in my adventures to write extensively or in a timely fashion.

4th year of med school has flown by. Sub-internships followed by applications, personal statements, and interviews accompanied by extensive travel. The last few rotations were painful but finally the end is looming near. This is both good and bad I might add. Closer to being a real doctor (as opposed to a glorified scut monkey that is a medical student) but also closer to the reality/pressure of the responsibilities of an MD.

I stacked my 4th year rotations and even managed to squeeze in most of my interviews without taking many months off during the year. This was all in an attempt to end medical school with a grand adventure. I had at one point or another applied for and/or scheduled rotations and travel in Vietnam, Cambodia, Laos, and the dangerous refugee camps of the Burma/Thailand border. After hearing that my grandmother was sick in India I changed my schedule instead to include a Infectious Disease rotation in Chennai. From there it slowly morphed into a tour of the Indian subcontinent. I convinced 3 of my childhood friends to join me for 2 weeks in Kerala's rainforests/backwaters, Delhi/Agra/Taj Mahal & my cousin's wedding in Chennai. I then joked with another college friend (currently residing in New Delhi) about climbing in the Himalayas and he promptly set up a month long foray into Nepal with a trek to Everest's base camp.

This schedule is probably a tad ambitious but I've always espoused the philosophy (which some look at with disdain) that there is no point in living if you're not continually pushing yourself to your limits. The next 3 months should hopefully continue to expand my horizons.

Last U.S. rotation. check. Rank list complete. check. 7 round trip flights booked. check. Learning how to hail an auto-rickshaw without getting swindled. Priceless.

December Holiday Part 1 (Sterkfontein Dam & Durban)

I hope nobody was holding their breath waiting for another post from me. It's been so long since my last post that I think I have defeated the entire purpose of having a blog. Nonetheless, I will try to catch you up (slowly) on how my year panned out.

The December holiday hit at just the right time. Other foreign students staying for prolonged periods in South Africa have described hitting “the wall” after 3-4 months abroad. While I made quite a few local South African friends, at this point I had not seen another American in Pretoria in nearly 4 months. Most of the people I interacted with on a daily basis only spoke English as a second language and I slowly began to feel the toll of not being able to communicate at the level which I had been accustomed to. In addition, my sub-study was still a no-go with issues of funding and problems with getting the local laboratories setup.

It seemed that much of South Africa goes on holiday in December and students generally get the whole month off and often part of November and January. I had to remind myself that this was the summer holiday for the Southern hemisphere. Luckily my professor in SA assumed that I would be taking the whole month off as well. I certainly couldn’t complain. I didn’t have concrete plans for the first couple of weeks but everything would soon fall into place.

Now let me go back to how I met some of the locals. I initially found it difficult to make friends. Most of the residents of Hippokrates (my dorm, which locals pronounce Hippo-krat-us) were upperclassmen and had their own groups of friends and busy schedules. So for the first 2 weeks I left my door open and had a case of beer and wine ready to share with anyone who might be passing by. These attempts were only moderately successful, though I did manage to introduce myself to most of the students on my floor.

I finally decided to try my luck in the TV room which I discovered was a haven for all the hardcore soccer fans (most people in SA refer to the sport as soccer or football interchangeably). After introducing myself to those around me I started blankly at the screen, not knowing who was even playing. A few people asked me who my favorite team and who knows what stupid, fumbling response I managed. After they realized I was American they asked me if I at least watched MLS to which I could only laugh. I tried to explain that as far as the hierarchy of sports in America goes, you were more likely to see competitive fishing or hunting and certainly Nascar before you’d see MLS. Most people in SA seemed to fall into two camps…those that loved Manchester United and those that hated ManU. It seemed like they followed European soccer much more closely than any team or sport in their own country. This was difficult for me to grasp considering our insulated sports scene in the U.S. and the fact that we all rep our hometown teams as if our lives depended on it. But I could be wrong since I’ve seen some crazy local soccer matches as well (fans carry full loaves of bread and heads of lettuce…and if their home team scores a goal they proceed to stuff the entire food item into their faces. Pretty scary stuff. Cue up video of Kobayashi at a hotdog eating competition.)

As luck would have it, a young chap by the name of Yash (final year dental student) introduced himself and asked me if I’d like to join him and a few friends for a drink. Months later I would ask him what made him think that I was looking for fun. He replied, “Well I knew if a Yankee was sitting here watching soccer that he must be really freakin’ bored.” Dead on. He took me to Pireshin’s (a final year med student, 6^th year) room where I would meet some more students: Yash’s girlfriend Yuvthi (also a dental student), Jeff (qualified doc, finishing up his community service year), Bhavna (Jeff’s fiancée, med student), Caiphus (med student, from Botswana), and Yassir (med student). They had a tight-knit group and readily accepted me. They would honestly become like a family to me, helping me in every way imaginable and keeping me out of harm’s way. Not to forget Bhavna’s and Yuvthi’s splendid cooking as well as Pireshin’s constant braais (aka bbq, SA’s national pastime), which all served to keep me constantly fed.

Now I had the last few weeks of the December holiday figured out but the first 2 weeks were still up in the air. As the holiday was approaching, Pireshin asked me if I would like to join him and the boys on a fishing trip. How could I refuse? We all piled into his backkie (pronounced buckkie, equiv to a pickup truck) and Yash’s car and made the journey to Sterkfontein Dam in the middle-of-nowhere, KwaZulu Natal. We brought enough meat and booze to feed a small army. It was like the Spring Breaks of college days past, except with a little African twist.

The setting was idyllic with long unpaved roads winding through the mountains alongside an immense dam. The closest town was perhaps 40km away and we were truly in an isolated part of the province. Our chalet was well equipped and comfortable and it overlooked the dam itself. It was peaceful beyond words and the sun rising and setting over the water was magnificent. It was an ideal holiday. Early morning fishing preceded an all-day braai, lounging and drinking beers. I even taught the boys how to play beer pong, which they enjoyed but led to the consumption of all our beer. We had to go back to town midway through the week to replenish our stores. Though we didn’t catch a single fish it was fun to drive the backkie off-road to the water’s edge and spend a few hours casting and reeling back giant wads of seaweed. It took me back to my childhood where a few friends and I would adventure to nearby creeks with our homemade fishing rods (made from sticks & fishing line) and spend the day chasing elusive fish and playing in the water. Oh and I completely forgot to mention the baby cobra I stumbled upon. I saw a tiny snake while we were fishing and of course I had to go provoking it with a stick. It reared its tiny body up and its head flared into that unmistakable cobra shape. Luckily I was able to run away before any of its larger friends decided to show up.

After this awesome start to the December holiday, I was invited by Yash to spend time at his house near Durban. He stays in Umhlanga Rocks which is a beautiful community on the coast north of Durban. It is walking distance from the Gateway Mall, the largest in Africa. While Yash promised me a quiet and relaxing week (I believed him since he spent more hours in bed than awake during the fishing trip), he kept me busy every day and every night. I don’t think I had ever seen him get ready so early on so many consecutive days. Nevertheless it was a great week spent hopping around Durban, the beach, Gateway Mall. At night we hit up different bars/clubs in Durban. At one of the clubs we got the full VIP treatment. One of Jeff’s friends was a businessman and knew all the owners of the clubs and all the bouncers. We got free entrance into an exclusive club and continued making our way up winding staircases. By the time we had reached the 4^th story (and passed quite a few fire code violations), we had bypassed the separate VIP dance floor and were escorted into an invite-only section. It had couches and basically a catwalk overlooking the entire VIP dance floor. Jeff’s friend proceeded to buy about 5 different bottles (whisky, tequila, vodka, etc.) from the bar. Whenever he asked you what you wanted to drink, he would buy an entire bottle instead of a mixed drink. Bhavna asked for a Red Square (which is an energy beer) and he misheard her and brought a bottle of Johnny Walker Red Label whiskey instead. We partied late into the night until the sun was rising. This was much better than Boston where last call usually happens at 1:30 or 1:45am at best.

It was a great holiday atmosphere in Durban & Umhlanga Rocks. Durban seems to be the playground of South Africans, as Joburg & Pretoria pretty much empty out in December. It was still hard to believe that it was December and it was weird seeing reindeer and sleds on people’s roofs when it was 90 degrees outside. Yash’s family made me feel very welcome and his mother cooked delicious Indian food daily. They definitely helped me ease the homesickness that was starting to creep in at this point. His parents were also very interested in what it was like being a first generation Indian in the U.S. They asked me how it was like growing up there and what kind of Indian community existed. They also asked me about racism and race relations in the U.S. and what if any barriers I faced as a minority. His parents helped me understand what it was like for an Indian growing up in South Africa during Apartheid times. It was only then that it really hit home that if I had been born in this country how different life would have been for me. This was not some story from a history book or even as recent as the Civil Rights Movement in the U.S. This occurred during my lifetime.

This was around the time that I began reading Nelson Mandela’s autobiography, “A Long Walk to Freedom.” I must say that it is one of the best works of literature (fiction or non-fiction) that I have ever read. I have read many autobiographies in the past and though many were interesting, they were usually slow-moving and difficult to get through. This, however, was an 800 page page-turner. I knew Mr. Mandela must have been brilliant, but to actually read his story was mesmerizing. Even more remarkable is to think that he wrote it in English, likely his 3^rd or 4^th language. His book really put my time in South Africa into perspective. It helped me see how far South Africa has come in such a short time, but also how far South Africa still has to go. While his story was for the most part chronological, the way he wove small vignette after vignette really made me feel like I was walking in his shoes, learning from each defeat and triumphing in each victory. Some stories he told made you angry, others made you want to cry, and still others made you laugh. It is remarkable to think that a man who spent a greater part of his life in jail was able to come back to society and forgive those who took everything from him. I think we can all learn a great deal from Mr. Mandela. I believe everyone on this planet should read this work. It is that good.

“I dare not linger, for my long walk is not yet ended.” In any case, I think I will sign out with a few more quotes from “A Long Walk to Freedom.”

"Any man that tries to rob me of my dignity will lose."

"The authorities (at Robben Island) liked to say that we received a balanced diet; it was indeed balanced – between the unpalatable and the inedible.”

“A nation should not be judged by how it treats its highest citizens, but it’s lowest ones…”

“A man who takes away another man’s freedom is a prisoner of hatred, he is locked behind the bars of prejudice and narrow-mindedness. I am not truly free if I am taking away someone else’s freedom, just as surely as I am not free when my freedom is taken from me. The oppressed and the oppressor alike are robbed of their humanity…. For to be free is not merely to cast off one’s chains, but to live in a way that respects and enhances the freedom of others.”

"I always knew that someday I would once again feel the grass under my feet and walk in the sunshine as a free man."

Have Your Cake and Eat it Too

While the first day was immensely stressful, my South African PI (principal investigator) Dr. Makin would make the next week or so run a lot more smoothly. I had initially rushed to get a car because I thought I would need to get to Kalafong hospital (out in Atteridgeville one of the largest former townships of Pretoria) the next day and by myself. However, it would turn out that I wouldn’t even need a car for about a week. Dr. Makin drove me to the hospital and showed me the quickest route to get there. She also took me around to run errands and get settled: cell phone, internet, groceries, etc.

The other reason why I wouldn’t need a car to get to Kalafong hospital initially was because of the government workers strike. This led to complete chaos among government services but was especially detrimental in the health care sector. All nurses and cleaning staff were employed by the government. They were part of the unions (representing 1.3 million workers in SA) demanding some 8.6% increase in salaries. Once they left, the public hospitals essentially shut down.

Even in the U.S. I feel we often undervalue nursing staff (and ancillary staff). It generally comes with the territory of training as a physician. We complain that the nurses have better hours, better relative payscales, and better benefits. On top of that we lament their constant incompetence and complain when we are woken up in the middle of the night for trivial reasons. It’s like a rite of passage in medicine; if you don’t have anything better to do, complain about the nurses. However, we often understate the fact that if all the nurses decided to walk out of the hospital (for whatever reason), the hospital would have a tough time operating.

In South Africa, this is magnified even further. Many health care facilities are essentially run by nurses. For example, most routine deliveries (even in the city and its surrounding areas) occur in clinics or midwife-operated-units (MOUs) without any supervising physician. Kalafong which happens to be a “tertiary” care center generally only receives complicated deliveries. Even here most deliveries are conducted without an obstetrician present, though the care of all patients is overseen by a medical team.

SA Medical Hierarchy

Consultant = Attending (completed specialization)

Registrar = Resident (specialist in-training)

Medical Officer (MO) = completed intern year(s) and community service years

Intern = first year after qualifying (2 years of internship now required for new graduates)

Qualified doctor = completed medical school

*All physicians must complete 2 years of internship as well as 2 years of community service after qualifying before they can apply for specialization

Now back to the strike situation...so when South Africans decide to strike, they really mean it. I remember when I was in SA 2 years ago there was a mini-strike and even that one brought the country to a halt. This strike (though I wouldn’t know it at the time) would last 3-4 weeks, and would be a harrowing time for all involved.

“A strike culture

Strikes are an almost yearly occurrence in South Africa, and have become part of the culture for a nation ruled by a liberation movement – the African National Congress of Nelson Mandela – that enjoys strong support from labor unions.

There is even a “strike season,” in which everyone from police officers to electric utility workers to members of the country’s Army march in protest for higher wages."

--Africa Monitor, 8/18/2010

The first day of the strike also happened to be the first day that I was attempting to drive to Kalafong hospital on my own. You can see Kalafong from the main road (Church Street) as a sprawling flat compound of buildings that seems to envelop the countryside. From far away it reminded me of a child playing marbles who sweeps his arms out to capture his bounty. I couldn’t help but think that once you go in this place you might not come back out. I was told later that the former ‘white’ hospitals (i.e. Pretoria West) were ‘fancy’ and built upwards with many floors and elevators, while the ‘black’ hospitals were built as flat expanses.

As I approached the main entrance of the building, I noticed stalled traffic (more than usual) and obvious commotion ahead. There was a mass of people singing and dancing in the street, and interestingly they didn’t sound happy. It looked like it would be tough trying to get into the hospital. Luckily, just as I was contemplating my next move, Dr. Makin called me. She sounded frantic and told me to turn around right away if I was on my way. I wanted to say, “Well, it’s a little late for that,” but I held my tongue. I listened intently as she told me that the research assistants on our team were barricaded inside the research building as strikers were trying to force themselves into the building. It turns out that not only were the workers going on strike, they were going to make sure that no one else was going to work (whether they were employed by the government or not).

Most of the stories I will tell are hearsay but from individuals directly involved (and reliable sources, of course): Our research assistants were able to get out relatively unscathed. However, not everyone was so lucky. The first day of the strike at Kalafong some members of the mob broke into one of the theatres (aka operating rooms, ORs) wielding machetes and guns and forced everyone out, including the surgeons who were already scrubbed (sterilized). The patient was left on the table already anesthetized, though apparently he hadn’t been cut open yet. All the students I spoke to said they were also forced out of the wards by the strikers. No physicians were left to care for the patients. Resistance was futile. If you didn’t leave on your own accord, you were carried out. One of the nurses who tried to enter the hospital compound by car was recognized by the mob, pulled from her car, and dragged through the streets.

“And there have been widespread incidents of workers who did not strike. Strikers marauded through a major Durban hospital, brandishing whips and threatening doctors and nurses. In Johannesburg, women in the final stages of labor and even a man with a severed hand were turned away from public hospitals, while fragile newborns had to be moved to private hospitals from wards barren of nurses.

After many such reports, the government set up special courts to deal quickly with strike-related violence.

A nurse working at a public hospital in the city of Pietermaritzburg was stabbed in the shoulder by three assailants whose faces were covered, said Chris Maxon, a spokesman for the provincial health department. And a nurse who works at the largest public hospital in Johannesburg is in intensive care after being attacked in Soweto.”

--New York Times, 9/6/2010

http://www.nytimes.com/2010/09/07/world/africa/07safrica.html

Within a few days, a large military force was called into action at Kalafong. It was safe to return, though a few harrowing moments were felt each day as you slowed to enter and exit the compound. If you looked the wrong way or someone mistook you for someone else, you could easily become the next victim. A few weeks into the strike I heard gunshots as I was exiting the compound. I didn’t slow down to see where they might have been coming from. Though my driving was improving, I certainly wasn’t stall-free yet and I wasn’t willing to take any chances. Even within the compound there was still an uneasy feeling walking about the hospital. I felt on edge every time I had to pass a soldier carrying an automatic weapon or shotgun through the narrow corridors of the hospital.

I heard gunshots again one day when I was on the labor ward. They sounded close by. As I came out of the operating room, people were a bit more talkative but otherwise there weren’t any signs of commotion. People were acting like hearing gunshots in the hospital was an everyday experience. Later I would hear the story. Apparently some guys robbed a store adjacent to the hospital and then thought it would be a good idea to jump the fence into the hospital compound. Of course the military forces stationed at the hospital responded and a shootout ensued. I don’t believe anyone was injured in this incident.

A few weeks later, another nurse who was well known and had continued to work during the strike, had her house burned down with all of her belongings. As we were travelling to the various clinics and hospitals in the outskirts I began to hear more troubling stories. I heard one such story when I went to visit Laudium hospital with Sister (title for a nurse) Rachel K and Sister Rachel M. These retired nurses were now research assistants who took me under their wing and treated me like a grandson. This was about a week into the strike and there were still people singing and dancing and blocking the entrance of the small hospital. When we went to the labor unit we found only a single nurse (the Sister-in-Charge) and a brave nursing student left to run the entire department. The nurse told us about her struggle to continue working in the face of angry co-workers and other government employees. While she grappled with this issue, she said she was willing to sacrifice her own personal safety to help take care of her patients. It was very powerful to see real-life heroes in action.

Meanwhile, the healthcare situation of the nation was becoming dire. Court injunctions demanding essential personnel return to hospitals were going unheeded. And in actuality, care of patients was being impeded and leading to untold numbers of deaths in an already resource-poor setting. Stories in newspapers highlighted how entire wards were left unattended and how abandoned infants were left to die because there were not enough people to feed or hold them. Even with military personnel in place, the strikers were finding ways to meddle in unconscionable ways. The Laudium nurse mentioned above told a story of how she had been at the hospital the previous weekend at night, again alone. When the police and military left for the day they locked all the gates with heavy duty chains to keep the strikers out. During the course of the night she had a patient that became unstable and required transfer to Kalafong for a c-section. However, when the ambulance arrived to transport her, the guards found that the locks/chains at the main gate had been filled with glue and other debris. The strikers had decided that if they were not going to be allowed in then they were going to make sure that no one else could get out. So there was no way for the ambulance to get in and no way for the patient to get out. The military forces had to be called in to cut the chains because the locks were unworkable. In an obstetrical emergency where every minute literally counts, this would be too much to overcome. By the time the chains were cut and the patient could be transferred to Kalafong, it was too late. The patient and the fetus expired en route.

‘The health minister, Aaron Motsoaledi, who last worked as a doctor 16 years ago, stitched up the wounds of at least a dozen stab victims during a night shift at Chris Hani Baragwanath hospital in Soweto on Friday.

He spoke out angrily against strikers for invading a sterilised area of the hospital to toyi-toyi (an apartheid-era protest dance) and, at another hospital, for interfering with an operation on an anaesthetised patient.

"In other words, they were saying: 'Leave this one to die'," Motsoaledi told South Africa's Sunday Times. "You can't have a health worker who is also a killer. A health worker, by definition, must be a person with a very deep conscience who, regardless of how he feels, will never arrive at a decision where they are prepared to kill a human being." '

--The Guardian, 8/23/2010

http://www.guardian.co.uk/world/2010/aug/23/south-africa-public-sector-strike

Every few days there would be an update, an ultimatum for a certain percentage increase in wages, continued balking by the government, and then the strike would continue. Children were no longer in school. They had had about a month off because of the World Cup and were now missing another month. Matric final years (high school seniors) were complaining that they would have inadequate preparation for their qualifying exams. There was one story from Capetown where students were striking and demanding an automatic starting score of 25% on their final exams. There were also threats that the police, traffic controllers, and prison officers would strike as well.

“A strike by 1.3 million South African state workers may descend into “anarchy” if police, traffic and prison officers join the wage dispute tomorrow, the secretary-general of the ruling African National Congress said.”

--Bloomberg, 8/25/10

http://www.bloomberg.com/news/2010-08-25/south-african-strike-to-widen-as-council-workers-plan-walkout-on-aug-27.html

In the labor wards at Kalafong there were very few nurses and care was being diverted. The MOUs and clinics were overwhelmed. Many patients were delivering at home, fearing that there would be violence at the hospitals or that they would receive inadequate care. This led to many complications among patients because of delay in receiving care. On my first day in the antenatal care clinic I saw the results of the stress to the system. There were over 80 patients waiting to be seen and only 2 students and an intern to care for them. And I of course I had no clue what was going on. There was a long corridor with curtains dividing it into “rooms” and a small pathway along the side to walk through. I was thrust into one of these cubicles and a patient promptly walked in through a door on the other side. I was able to hash from the patient (who spoke very little English) that she had been sick the previous week and had been given antibiotics at the clinic. The patient was 26 weeks pregnant and I looked in shock at her medications. She had been given doxycycline. If I remembered anything from my obstetrics rotation back in Boston it was DON’T give tetracyclines (i.e. doxy) to pregnant women because of possible tooth discoloration or bone formation problems in the fetus. Luckily, the patient hadn’t started taking the doxycycline. Her logic was that she thought she was supposed to finish her vitamin supplements first before starting these new tablets. I wasn’t about to argue with her. We prescribed a new antibiotic and sent her on her way. The second patient I saw had severe pre-eclampsia. Her arms and legs were swollen. Her blood pressure was hovering above 180 systolic and she was also having symptoms like headaches, etc. I went to the intern to present the patient and request a transfer to the inpatient ward. However, she stopped me dead in my tracks. There were no available beds for the patient. Her condition was not ‘severe’ enough. I thought to myself, “So this is the kind of day it’s going to be...”

And the situation on the labor ward dictated what happened in the antenatal clinic. Students and physicians alike could be seen cleaning the wards as well as the operating rooms. Supplies were low and at times nonexistent. At one point I remember there being no fluids left. There were no gloves. I saw one nurse hand-suture an episiotomy (cut made to the vagina to aid passage of fetus during delivery) without gloves and the bare needle (small) in her hand. She would thrust the needle deep into layers of muscle and then reach for the tip on the other side and pull through. When the nurse saw my astonished look, she said, “We don’t usually do this, but the times are desperate.”

The strike would end uneventfully after three weeks and it seemed like people went back to work like nothing ever happened. All in all I learned some important lessons, especially that though we like to keep up appearances, our societies are almost always on the verge of chaos.