so far away so close

i spent the night wrestling with a migraine then woke up foggy and went to work on a talk i'm giving in kenya next week.  it's on palliative care in the developing world.  as i pulled up some old talks i've given on what palliative care is, on suffering, on giving bad news, on pain management- and i realized how non-applicable much of it is here.  how different the issues are. i began to think about resources and capacity and choice.


we will all die.  we will all get sick.  we all experience suffering in life.  these are universal truths.  but.  how we do these things and our response to them, the tools we have to fight or stave off sickness or death, the cultural meaning of the illness and response to the suffering- that is not at all universal.  it's specific and unique and complicated. and it's really unfair.

it's just unfair that poverty holds hands with illness.  that poverty limits choices, that it silences people, that it keeps people in the dark, that it prevents access and diagnosis and treatment.  so the result is people showing up when it's too late- too advanced- too far gone.

like the woman in clinic.
"doc can you come see this lady, she says she has some ulcers 'down there'"
"sure"
i enter the little corner 'exam' room (or small area of privacy with a table and a curtain).  i can smell the problem before i enter.  she stands peeling off layers of undergarments wet and stained and climbs on the table. its a huge fungating oozing mass extending the entire area.
"okay" i say laying hands on her abdomen to feel for masses, "how long has this been growing?"
"five months."
"why haven't you come to see a doctor?"  i said nicely, but hoping it didn't sound judgemental 'who have you been seeing for this would have been better.'
"i've been going to the local clinic."
"what have they been doing?"
"giving me shots."
i bit my lip- wondering who exactly was giving her shots.  wondering what was in these shots.  wondering how much they were charging this poor woman to believe she was being treated instead of referring her to someone who could actually treat her.

i was mad mad. now we are dealing with a great big mess. 

sometimes it's even harder.  sometimes we find it before it becomes a big mess - but either the treatment isn't available, or it's too expensive, or the person is too scared to have surgery- (because they've seen so many people die 'from going to the hospital').  and then we're providing palliative care for something that would be cured if the person was born in another country.

this week i had an older woman come to clinic.  she was a cute little old lady who reminded me of my grandmother.  she was even dressed a little like my grandmother which is weird in uganda.

*random aside- there are people here who remind me of the ugandan version of people back home. it happens all the time. the other day i saw the ugandan megan marie (my second cousin); a ugandan kim manning; a ugandan bryn; it's weird!

so this older lady comes in with her right eye covered and it's paining her and i'm trying to get her taken care of, while needing to rush out and pick up my kids, and see two other people.  i'm fully stressed about making sure i give her the correct thing so she doesn't go blind.  i'm wishing i had an ophthalmologist nearby. i'm running through the rolodex in my mind to remember who i know who is an ophthalmologist in the US and debating calling them for a 'curbside consult'. i'm asking the nurses to find me the number to mulago- there must be an eye doctor on call.  they laughed. 



i felt like i was in a time machine, that had landed me back a few decades or centuries.


then i had a moment.  this lady doesn't exactly know how old she is, this lady is from the village.  this lady has been living with HIV, has lost many family members to HIV. this lady knows that so many people from the village don't ever get care- or they see the witch doctor or a traditional healer- so many people do just go blind.  this is life here.  she wasn't worried, but i was. 


it was moment of realizing that you do the best you can.  that this lady was thrilled to be seeing (at least with one eye) an actual doctor.  it was a moment of remembering the value of the group over the individual here- and how hard that is to wrap my mind around as an american.  the fact that poor people over 40 don't know their birthday is part of the same picture as the other health providers in clinic not getting riled up over her lack of access to an eye specialist- or the baby with the big head not getting a CT scan.

but there is a flip side. i see how some of the time what we do in american medicine is overkill, or 'cya' or even can cause harm.  i have been able to see simply that the body is a truly amazing machine- that people often do okay when all they get is 'the best i've got' and some prayer.


i've been here almost 6 months.  i love that i have much to give and also much to learn.  that practicing medicine here is a whole new deal.  that even when you can't treat it, or cure it, you can try, and care, and show love.  that in the trying, and the advocating, and the caring- that person feels valued as an individual.  that even in poverty and illness- we can relieve suffering.
so far away, so close.