Outside apartment 13C the street is empty. It is early in the morning, and yet sounds echo from the metal shop beside the lake, roosters crow and the children upstairs patter back and forth across the tiles. I roll up my yoga mat, shaking dead cockroaches from its rubbery bottom. Through the grated windows, I catch a glimpse of Lake Victoria, shimmering out from the cluttered shore of shanties and deconstructed docks to eventually blend with the blue of the morning sky.
Half an hour later, I step outside the door, engulfed by the hot air and the smell of dried grass. I smile at the girl hanging brightly hued, traditional kitenges on the line, splashes of color amidst the dusty yard. I trail my preceptor up the crumbling cement steps to the rusty gate leading to the main street. Mothers and children are already awake, walking to the market with woven baskets and cracked plastic buckets balanced gracefully on their heads. Their soft chatter blends with the subtle buzz of the rising sun. Ahead I can see Mariko, the pediatric neurosurgeon, waiting on the road. She is European, an “expat” and a “mzungo,” which means white person or, so I’m told, a person who wanders in circles. I try to remember the neuroanatomy I frantically learned the night before, conjuring up a fuzzy image of the lateral ventricles and the flow of cerebral spinal fluid.
“Habari za asubuhi?” Mariko calls.
“Nzuri!” my preceptor replies.
“Njema,” I answer.
We walk briskly down the road towards Bugando Hospital, kitenge skirts rustling quietly in the hot white of the morning. At the gate, we show our ID badges to the guard, who waves us through the growing throng of people gathering outside the hospital. A small kitten scratches at the pile of garbage sprawled beside the gate, slowly leaking the sickly smell of rotten fruit into the air.
Inside the hospital, I follow Mariko through the maze of concrete stairs and hallways. We visit the ICU, checking on a post-operative patient with a brain tumor. Monitors blink and beep while patients rattle and groan. The nurses huddle around a central table, their pale-green cotton uniforms blending with the pallor of the room. Mariko examines the small child lying dwarfed in the bed before us; his large head perched amidst a halo of padding. My preceptor pulls the child’s CT scan from the large folder at the end of the bed and points out the mass in the right hemisphere.
“I don’t think he’s going to live,” Mariko sighs.
Mariko’s resignation may have seemed shocking in another setting, but in the given context of that day, it seemed only fitting. I doubt I will ever have another ICU experience quite like that again.
We move to a different ward; Mariko’s patient lies on the far side of the room. Beside her, another little girl moans quietly in her bed, her eyes closed, the monitor above disconnected. Mariko examines the shunt draining CSF into a bottle lying on the bed. She lifts the bottle up and observes the change in flow, explaining that this is a quick way to determine intracranial pressure. The child’s eyes flicker beneath her lids, but she remains unresponsive to Mariko’s voice; tiny beads of perspiration glint along her forehead. Just then the nurse arrives, reporting that the patient’s temperature was 40 degrees earlier that morning. Mariko orders paracetamol to control the fever, but the nurse gently reminds us that the family will have to buy the medicine from the pharmacy themselves. The hospitals here have very few resources, and the patient’s family is often expected to provide the necessary supplies, including tubing, needles and medications.
Mariko leads us down into the basement, to the operating room. We quickly change into scrubs and oversized gumboots and then push past the bustle of people and patients dressed in makeshift togas to the neurosurgery suite. The floor shines with soapy rust-colored water. A grubby screen divides the room in two, with adult neurosurgery on one side and pediatric on the other. We quickly discover that only one anesthesia nurse (a student in fact) has been booked for the day, to be shared between the adult and pediatric neurosurgeon. An anesthesiologist isn’t available.
Unfazed, Mariko begins to prepare the operating room for the first patient, an 8-month-old boy born with a myelomeningocele.
“Don’t touch anything until you are scrubbed in,” she advises me, knowing I have little surgical experience. “Also, don’t move too quickly. Nice and slow.”
The patient arrives a few minutes later and is quickly positioned prone on the operating table. A large cyst bulges from the spinal defect at his lumbar spine, containing the spinal cord and meninges. As Mariko covers the patient’s arms and legs with pieces of cotton for warmth, she explains to me that the patient has retained some movement in his lower limbs and that one of the main goals of the surgery is to correct the defect in the spine without worsening his motor function. She drapes the patient and then asks her surgical nurse, Albert, to help me scrub in.
“You can be scrub nurse,” she offers, “As it’s only me, Albert, and my intern, James.”
James and Albert help me to scrub in, and then James begins to review the surgical instruments lying on the tray beside the bed. He quickly explains how to hand the instruments to Mariko.
“Handle first, not blade,” he emphasizes, his voice muffled by the cloth surgical mask.
Mariko emerges from the scrub room, and we begin. She cautiously cuts into the cyst and exposes the tethered spinal cord. Meticulously she frees the nerves from the underlying tissue. Expanding the incision superiorly, she exposes more of the cord, revealing a diastematomyelia, or split cord. She explains that a split cord is rare and more often occurs in females than males. She then proceeds to rebuild the spinal cords, separating the meninges from the underlying connective tissue and sewing the severed dura matter together over the exposed cord. I stand across from her, riveted, and trying desperately to remember all the names of the different instruments. At several different points in the surgery, Mariko asks for instruments or sutures that are unavailable in the operating room. At each point she improvises, making use of the tools that are available. I am struck by her flexibility and resilience. It seems truly remarkable to practice such a complex specialty as neurosurgery in a resource-limited setting — without a proper scrub nurse, without the necessary instruments, without the correct sutures — and yet she presses on with her work.
I chose to describe this day in detail in order to reflect on my truly mixed feelings following my experience with Mariko in ICU and neurosurgery. On the one hand, the day was exhilarating: I have never been so closely involved in surgery before, nor have I encountered patients in such critical condition. I felt like my learning was amplified by the pressure and acuity of the situation. On the other hand, the day was unnerving: the attitudes towards critical patient care were not what I had expected, and the accommodations Mariko made during surgery provided me with a more nuanced, albeit uncomfortable, understanding of what it means to practice medicine in a resource-limited setting. In Tanzania, standing next to Mariko, Albert and James in the Bugando operating room, I realized that we were providing her patients with the highest level of care available. I was suddenly struck with more philosophical questions about why some people — like me — are born into such incredible privilege, while others — like this little boy — must make do with less. I suppose, really, the inequities of global health became more apparent and comprehensible to me in that moment.
Revisiting this experience also raises complex ethical questions about the role of medical students in these settings. I wonder at the precarious balance struck in medical training between the needs of the learner versus the patient. This balance is especially difficult to establish in international settings where communication and consent are made more challenging by language and cultural barriers, let alone in impoverished settings where patients are already acutely disadvantaged. While I would like to think that my learning experience did not infringe on the quality of patient care in the Bugando operating room, the reality remains that I would never be allowed such an experience in Canada — indeed this is often one of the reasons medical students seek out experiences in developing countries: the care teams are smaller and the need is greater. It is, however, always important to remember that while learning is important, patients are particularly vulnerable in these settings and ethical boundaries are easily breached.
I think, looking forward to how this experience might impact my future role as a physician, that it has ultimately furthered my interest in global health and opened my eyes, not only the possibilities of international medicine, but also to the immense complexities, both medical and ethical, encountered when practicing beyond the border.