January 2005

Monday

At our clinic near the Bwindi Impenetrable Forest in S.W.Uganda near the border of the Congo an American mountain gorilla researcher presents with a diffuse erythematous rash and a swollen face. She relates that for the last several days she has noticed the slow but inexorable swelling progress from her face to her chest and abdomen. She denies any constitutional symptoms, no tongue swelling, no shortness of breath, no wheezing and feels well otherwise. On examination it is obvious that she has a systemic allergic reaction as she has uticaria covering most of her body and angioedema of the lips. I begin a search for the usual suspects: drugs, insect bites and stings, chemicals and cosmetics, typical foods but turn up nothing. I query about physical factors as she has been camping in the forest for several days but nothing unusual has transpired. After a period of reflection she offers that there has been something new in her diet; the gorillas she has studying have been feasting on an unusual berry-like fruit. She was hungry and decided to give it a try and behold it was quite sweet! She recalled that over the course of several days of munching on this fruit the rash did erupt and progress. She vowed that although this fruit was very tasty she would avoid it in the future.

Tuesday

Our laboratory technician excitedly bursts into my office urgently requesting that I come with him to the lab. He sits in front of the microscope and adjusts the slide and then motions for me to peer through the lens. At the tip of the pointer is a faintly visible thread-like creature wriggling among a myriad of red cells. We replace the slide with another-the original slide stained to search for the malaria parasite and there is the identifiable Bancrofti filaria amid several plasmodium falciparium parasites. I return to examine the patient, a 22 year old pregnant female, who although suffering from an acute malarious episode is otherwise healthy. She exhibits no signs or symptoms of filiariasis; no adenolymphangitis, no lymphedema and no wheezing. I silently wonder if over the years here in Africa I also may have acquired a fellow traveler in my blood-stream.

Wednesday

I am awakened by the persistent knocking at the door, it is a pygmy named Hope laboring with her first child. I had recently visited Hope at her newly constructed mud hut of which she was very proud. Previously she had been landless but through generous donations from the United States a piece of land had been purchased. Hope’s family and several other local pygmy families had been in dire straits, losing many children to malnutrition, but now relocated on their own land and living in their own homes they were headed toward self-sufficiency and a bright future. Tonight Hope was attempting to increase the pygmies’ depleted numbers. Nate, a visiting medical student from the United States, and I walked down to the hospital and noted that that Hope was in active labor and pushing hard. I cautioned her against bearing down until the head had descended further, but as soon as I turned my back there she was, feet entwined in the bars of the window and straining with all her might. Labor did progress smoothly though and eventually I instructed her that she should begin pushing. Immediately there began a chorus of encouragements from her mother, relatives and other friends in attendance. Although some of this encouragement consisted of helpful advice, it was also punctuated with yelps, cries and rip-roarious laughter. It seemed as if everyone was having a merry time excepting Hope. Nate readied himself for the delivery and suddenly with a mighty push from Hope he was cradling a newborn baby girl. Upon hearing the infant’s cry the pygmies began singing and dancing to songs of joy and Hope broke into a great smile. Nate and I walked back to our quarters up the hill under a canopy of stars. The Southern Cross was clearly visible in the south. Although the heavens appear different in Uganda, the joy of new life is the same the world over.

Thursday

My wife and several medical students had been conducting a mobile medical clinic at a distant pygmy settlement. The clinic had been busy with over 100 patients treated but had to be terminated early as several needed immediate attention at our hospital. The vehicle returned and discharged its contents of medical students, five seriously ill children, their parents and the medical supplies. We quickly hooked up the most serious children to IV’s. I was thankful that the hospital had expanded that day. Our pediatrics ward had been operational for only a few months and our bed capacity had proved inadequate, particularly during this malaria season. Seven newly constructed beds had arrived today and now we could accommodate 22 patients including 5 isolation beds for TB, meningitis and other contagious diseases. I reflected on my previous tenure on the board of a hospital in California. There we had expanded the number of beds but in the process had to jump through an incredible amount of governmental hoops, seemingly a word salad of acronyms; the process took years and was very costly. Our recent expansion of seven beds took a week and cost a total of $245; bed construction-$105, mattresses-$70, sheets-$35, and mosquito nets-$35.

Friday (Christmas Eve)

Christmas carols sung around a small plastic tree accompanied by guitar and drums. It was a simple but heartfelt gathering of fellow workers. We reflected on the fact that while we attempted to address the needs of those less fortunate we could never fully appreciate their vulnerability to poverty, deprivation and disease. Although always a stranger here love, hope and compassion binds us as one. Late that evening we returned to the hospital primarily to check on a three and a half year old girl admitted earlier in the day with seizures and anemia from severe malaria. The young girl had initially seemed to improve with IV glucose and parental artemether. Shortly before midnight Christmas Eve we found her apnic and pulseless. Her mother sat in silence at the foot of the bed. I informed her that her daughter had died and expressed my regret. I asked about the father, “killed in recent violence in the Congo” was her succinct response. We placed cotton in the nasal cavities and tied the jaw shut with gauze as is the custom here before rigor-mortis sets in. I helped lift the dead child onto the mother’s back as she secured her with a shawl. Our only exchange as she departed was my expression of sorrow and her returned silent gaze of deep sadness. She, with quiet dignity, returned toward the Congo and was slowly enveloped by the darkness.

Saturday

While living in the United States I found my life filled with a variety of projects which had the possibility to consume me. Balancing work, family, committees, chores and even exercise had the potential to become rather frenetic. Among the pygmies there is an expression “kumara obwire” roughly translated as making time. This consists of sitting and relaxing with friends and relatives. Although only a day might have passed since the last meeting, conversation is centered on catching up on recent events; how is the wife or wives, kids, crops, hut, etc. Much of the time though is spent in silence with no agenda. “Kumara obwire” has not come easily for me. Of late I have been motivated to hike up to one or another pygmy village and just sit. The pygmies will slowly gather around and we will “make time” together. Today while visiting a village a mother reluctantly approached and sat on a rock on the edge of the gathering. She had several children in tow but one I noticed was wrapped tightly in a dirty cloth and was held close to her breast. The bundle she cradled seemed larger than a suckling infant and then I noticed a swollen foot protruding from the garment. I asked if she would let me have a look. She carefully unwrapped the child and I noticed the telltale signs of Kwashiorkor-red hair, peripheral edema and dermatitis. I suppressed my initial thoughts of “how did this child become so ill and why he was not brought to our hospital for our feeding program”. Rather I reflected on how “making time” had somehow allowed this woman to quietly approach and entrust her child to my care.

Scott Kellermann