Many people have moments when they are reminded that they can make a difference in someone's life. For me, the month I spent in Niger, West Africa, helped to refocus and shape both my personal and professional life. This wasn't my first visit to a developing country or my first trip to Africa. This was, though, my first time practicing medicine in Africa.
I had been in the country about 10 days when I met Saratou. The previous days had been filled with adjusting to tropical medicine diagnoses, performing innumerable lumbar punctures during evaluations for cerebral malaria or meningitis, and trying to learn to cook with the only vegetable available: onions!
Saratou was a 14-year-old girl who presented with acute abdominal pain and fevers. Through an interpreter, I learned that she was newly married without any history of pregnancy. Her pain had started 3 days earlier and had become progressively worse. She hadn't eaten or had a bowel movement in 2 days. The physical exam showed a distended abdomen with mild guarding and no rigidity but very significant pain on diffuse palpation.
In the States, my differential would have included a ruptured appendix, PID, or ectopic pregnancy, but the most likely diagnosis in this setting was typhoid. When I first saw her, Saratou's bowel hadn't perforated, at least by physical exam, so I treated her with antibiotics and bowel rest. She received IV antibiotics and remained NPO for a number of days. She eventually began to improve and was ultimately discharged from the hospital in stable condition.
Another case that defined my time in Niger involved a 2-month-old with cerebral malaria. He came in seizing and with slow pupils. After 2 days of treatment, his seizures had abated but there was no neurologic improvement. He was unable to breast-feed, so I broached the subject of placing a nasogastric (ng) tube for oral nutrition. Through the interpreter, I explained why I was requesting the procedure. The mother initially agreed to have the tube placed, but the nurse told me that she would change her mind because the people of Niger associate a nasogastric tube with death. (This is logical because most initially refuse the tube until very late in the disease, and their children die.) I returned later that day to see that the ng tube had been placed, and I was elated that the mother trusted me. A couple of days later, however, the child still showed no neurologic improvement, and I had to explain to the mother that he was going to die. I was thankful for the trust that had been built between the mother and me over the proceeding few days.
During these patients' hospitalizations, I was overcome with the feeling that "I just have to save one." In reality, a child died of malaria the very first day I was there and every subsequent day as well. Usually, multiple people died every day. I saw cryptococcal meningitis ravage the body of a 21-year-old AIDS victim. I became familiar with the signs and symptoms of extrapulmonary tuberculosis. I learned that you can never fully understand statistics until you experience them firsthand. I kept wondering what untapped potential was being lost in the deaths of so many children and young people.
The approach to medicine in Niger was drastically different from how I had been trained, but still I noticed some key similarities. In my job in oncology in the States, as in Niger, I have witnessed the journey of grief that patients travel from diagnosis to treatment and finally to the transition to supportive care. A big difference, though, is that many Americans respond to cancer or chronic illness with surprise or a sense of personal injustice. They think about the loss of the future. In Niger, women expect to lose children. The question is how far they should walk and how much it will cost to save the child. Their focus is in the present as there is no guarantee of the future. Their focus comes not from lack of a mother's love but rather from a realistic view of the hardships that they face daily.
Both cultures deserve good communication from their health care providers so that they can understand the medical decisions that are recommended. Just as I dress professionally in the States, I wore a head covering and long skirt in Niger, which increased the level of trust and opened the doors of communication. Using an interpreter was not easy, but I pressed them to disclose all of the information I was communicating. The combination of teaching, as well as smiles and eye contact, made the difference in the mother entrusting her child to my care and proceeding with ng tube placement. In the States, if I am accessible, honest, and compassionate, it also fosters mutual trust.
The time I spent in Niger refocused me. It improved my diagnostic skills and it led me to reevaluate my communication skills. Most importantly, my appreciation of the value of each individual life was enhanced. We can play a major role in our patients' lives no matter where we practice. JAAPA
Heather Carlson practices in gastrointestinal medical oncology at M.D. Anderson Cancer Center, Houston, Texas. She also works at a free clinic that caters to the indigent Spanish community.