by Hans Rosling
That evening, I went home feeling a certain sense of accomplishment. The treatment had been an orthopedic procedure far beyond my technical qualifications.
When I arrived at the hospital the following morning the first person I saw was the old woman. She was standing in the doorway, waving to me. Upset, I rushed to speak to her.
“You must stay in bed,” I said in Portuguese.
But she only understood the local language Makua, so I tried to explain in sign language. A tearful nurse had been trying to persuade the patient to get back to bed. She translated what the patient was saying: her hens might get stolen so she had to get back home.
“Look, the cast is strong,” the old lady said, banging her foot on the floor for emphasis.
The entire hospital staff in front of the clinic—qualified medical staff in white and untrained staff in blue.
* * *
When I looked down at her foot, I discovered that something had gone very wrong: the immobilized foot was pointing sideways instead of forward, as it should. At the back of my mind, I heard the consultant surgeon’s warning from when I trained in orthopedics: “Check alignment before you put on a plaster cast. With a broken leg, get the relationship right between foot and knee. A patient in pain tends to twist the upper part of the leg inward. You have to pull the bits into their proper place before putting on the plaster.”
I had made a classic mistake and fixed the foot pointing outward. I felt terrible that I had done this.
Curious patients and their relatives stood in a ring around us, watching and giggling once they realized that the old lady’s foot was pointing the wrong way. I asked the nurse to translate my advice: I would have to remove the plaster, pull the leg into the correct position and put on a new cast. I twisted my right foot outward and lumbered about, surrounded by sniggering onlookers, as an animated illustration of how she would be limping for the rest of her life if she didn’t let me reset her foot.
But when I was done with my performance, the old lady smilingly put her hand on my arm. The nurse translated again.
“Doctor, what you’re showing is as much as I ever hoped to be able to do. I can feed my chickens and take care of my grandchildren. I am happy to have survived. To walk about like that is fine. Not to worry, you have other patients to cure today. I just came along to get some pills from the nurse and then wait for you so I could thank you before I go home.”
The people around us nodded and mumbled in agreement as she shook my hand. Then they stepped aside to let her cross the sandy yard in front of the hospital entrance. Almost fifty of us looked on as her footsteps in the sand formed a trail like the track of a large tractor tire.
I never saw her in the hospital again but learned later she had survived. The plaster had cracked and fallen off after a month and her foot was badly out of line. Still, her chickens were all right, so she could give her grandchildren eggs to eat now and then.
Patients, relatives, and the hospital staff taught me how to put up with the knowledge that I could not achieve everything I set out to do. Also—one of hardest things for me to accept—that, in the end, it was up to the patient. Slowly, I grasped that everyone, even the poorest, who were often the most superstitious, was fundamentally wise when faced with the toughest decisions of their lives.
My mentor, Ingegerd Rooth, who had been a mission doctor all her life, had told me: “When you work in a place of extreme poverty, don’t try to do things perfectly. All you will accomplish is wasting time and resources that could be put to better use.” In effect, this was the same lesson that the old lady with her broken leg had taught me.
That lesson generated a new way of working: the two-by-two table. The idea crystalized for me about a month later, on a Sunday night after another marvelous day on the beach. I had read the children a bedtime story and gone into the sitting room to work. It was a reasonably cool evening and there was no need for the fan to be on. I settled down at the cleared dinner table and started to look over the past week’s “de-stressing list.”
I had taken to carrying a small notebook in my pocket and grabbing whatever pen was at hand to write down a word or a brief phrase as a method for staying calm whenever I identified something that I felt must be changed in the provision of care or the structure of the organization. At first, my insistence on instantly correcting anything I thought out of order had made me unbearable to the people I was working with, and to myself as well. The solution I had arrived at was to confine myself to writing everything down.
That Sunday night, I planned to go through my notes and prioritize the things that needed to be changed. I began by writing a clean copy of the list of problems I had come across. Some problems were insoluble and I crossed these out at once. Next, I needed to resolve the rest of the problems. I drew a large square divided into four fields on a sheet of paper and wrote EASY and HARD over the two vertical columns. To the left of the two horizontal rows, I wrote IMPORTANT and NOT IMPORTANT. Now I could fit my notes into four groups. After pondering for some twenty minutes, the upper left field, EASY and IMPORTANT, contained four items. The first one was “separate the dressing of clean and infected wounds in outpatients’ minor injuries clinic.”
On Monday, I planned to have a word with Papa Enrique, the hospital’s oldest nursing assistant and a very kind man.
That Monday, I crossed the hospital yard after the morning ward round and entered Papa Enrique’s small premises, located in the middle of the long building that housed outpatient care. His was probably the only space in the entire hospital that did not smell bad. Everywhere else, the air was stale or worse. Some patients had suppurating wounds or rotting body parts. Others simply had no facilities for washing their clothes. Some of the bedridden patients did not get a bedpan in time. Relatives who came to help with feeding spilled food on the floor. Everyone, whether wearing shoes or not, brought in sand because the whole town was sandy underfoot. The need for cleaning was constant but our resources only sufficient for one daily round by the cleaners. We lacked effective ventilation and while some days could be suffocatingly hot, air humidity was too high for the towels to dry on the washing line during the rainy season. Despite all this, we fought to keep up appearances and had agreed there should be vases with freshly picked flowers in all the windows.
Going into Papa Enrique’s treatment room, the strong smell of cleaning fluid hit my nostrils the moment the door opened. On one side of the room, around a dozen patients were lined up on a low wooden bench, waiting to be seen. On the other side, a patient sat on a tall table covered by a stained, once-white plastic sheet. Papa Enrique leaned over him, bandaging his hand.
He straightened up at once and greeted me pleasantly. I told him that I had a small change in mind: to organize his patients so that he could attend to the clean wounds first and then move on to the infected ones. He looked troubled and said he wasn’t sure what I meant by clean wounds being different to infected ones. My attempts to explain got us nowhere, so I told him to finish the bandaging and then I’d show him the difference.
Two of the waiting patients had lower leg wounds, and I asked them to sit next to each other on the bench. One of them had a recent, substantial burn. His face looked pained as he told me how he had knocked over a large pan of boiling water that morning.
“This wound isn’t infected and it is very important you don’t cause an infection when you clean and bandage it,” I instructed Papa Enrique.
Then I turned to the second man with a lower leg wound. At the upper edge of the wound, pus flowed from a small hole. His was a tragic case of osteomyelitis. The pus was forming inside the infected bone and draining steadily through a fistula, a channel through the tissues.
I asked Papa Enrique if he could see the difference between the large but superficial blisters on the burned skin and the small hole where the pus was coming out.
He inspected the wounds carefully, looked up at me and said in a worried tone: “I can’t see any hole.”
&
nbsp; “What are you talking about?” I almost shouted. “Can’t you see the hole with the pus coming out?”
“No, doctor. I don’t see so well anymore,” he answered quietly.
I was quite taken aback. Then I remembered that my glasses had quite strong lenses because I had been farsighted since childhood. I put my glasses on Papa Enrique. He glanced at the legs of the two patients and gestured with both arms—now it was his turn to speak almost at shouting pitch:
“Now I see it! That one has just blisters but here there’s pus coming from a small hole.”
He took the glasses off, looked again and then held them up to me, exclaiming: “Without these, I can’t see the hole.”
I brought my spare glasses back after lunch and gave them to Papa Enrique, who thanked me very warmly. The gift was hugely important to him. I interrupted his flow of polite gratitude to show him something.
“Take a look at these two sets of notes. This is what I’m going to write for every patient before I send him or her along to you for wound dressing.”
The messages were straightforward: one said CLEAN WOUND, and the other said DIRTY WOUND. I handed both notes to Papa Enrique, who took them but looked troubled again.
“It’s really not at all difficult; don’t worry,” I said. The room was empty for a moment and I pointed at the bench, explaining that everyone with a clean wound would be seen first. Every morning, patients with dirty wounds had to wait until those with clean ones had been looked after. Between every batch, the bench should be cleaned with strong disinfectant.
By now, deep furrows had formed on Papa Enrique’s forehead. Embarrassed, he murmured his answer: “Doctor, I’ve something else to tell you. I can’t read.”
I had been working in the hospital for nearly three months but had failed to realize that almost all the assistants were illiterate. I had just taken a step on the long road toward understanding the complexities of social underdevelopment.
Later that afternoon I complained to Mama Rosa but she cut me short.
“I thought you understood what it was like in the colonial era. Most Mozambicans had no chance of going to school. Those who learned to read landed better jobs than assistant nurse. These days, many attend literacy classes in the evenings. Give us a few more years. Then all the staff will be able to read, even Papa Enrique, especially now that you have given him a pair of glasses. Because if you can’t afford glasses, you can’t learn to read either,” she added.
* * *
In the same month that Papa Enrique got his glasses, one of my days at work ended with me filling up our dark green Land Rover with patients. It was at this time the only vehicle we had to help us look after more than 300,000 people (at other times we had two) and tonight we were using it to take several acutely ill patients to the regional hospital in Nampula. It was a two-hundred-kilometer drive and the road, though partly paved, was studded with potholes. To make this particular journey worse, it was raining heavily.
Regardless, the car had to leave as soon as possible because it would be carrying patients afflicted by illnesses I could not deal with in Nacala. One of them was a man suffering from schizophrenia. He had arrived the day before in a florid, psychotic, hallucinating state. His family had grown very scared, tied him up and brought him to the hospital. He needed to be cared for in the psychiatric unit in Nampula. All I could do was give him massive doses of sedative until he was passive and drowsy. Later, he almost lost consciousness, but I had to keep him sedated while we waited for other very ill patients to join us. It took time but I could not send the car off with one patient at a time. The psychotic man would have to stay overnight.
A woman arrived the following day, pregnant and nearly full-term. She was bleeding and I suspected that a low-placed placenta was blocking the passage for the baby’s head. Unless the baby was taken out by caesarean section, she would bleed to death once her contractions started. I made her wait, too, because the Land Rover could hold three patients, and another acutely ill patient might well turn up in the next few hours.
Later that afternoon, a middle-aged man came in with a bad complication to a hernia. The patient had been ignoring the bulge in his left groin for ten years. Now, his intestines had begun to twist themselves around each other, a condition that would likely kill him within twelve to twenty-four hours. He urgently needed an operation. Time for the Land Rover to go.
The driver had it all worked out. The drowsy man would sit in the front passenger seat. The man with the hernia would be on a stretcher in the back, across the seat. The pregnant woman and her relative would sit on the two remaining seats at the back. The relative promised to help the hernia patient when he threw up.
Why would we agree to take the pregnant woman’s relative, an elderly woman, rather than a nurse? The simple reason was that the patient refused to go to a large hospital in a town she had never visited unless the other woman came with her. Mama Rosa decided that the relative should be allowed to go along.
Once the patients’ few belongings had been packed, the vehicle was full. I checked that the driver had a full tank and that the nurse had given the psychotic patient a top-up dose of sedative. As the sun set, our only health-service vehicle was rolling down the main street to begin its three-hour journey to Nampula. Once I had checked that there were no other acute cases to deal with in the hospital, I went home for a calming family supper, hoping the bigger hospital would save my patients. I needed a good night’s sleep. It was still raining and I fell asleep to the sound of drumming raindrops.
Knock knock knock, I heard in my dream. Then I realized that someone was actually hammering on our front door. I pulled on a dressing gown, switched the light on, undid the safety chain and peered outside. A man was standing in the rain. His eyes lit up when he saw me.
“Good evening, doctor,” he said.
I took in the surprising fact that Manuel, our driver, had returned. “Are you back from Nampula already?” I said.
“No, senhor, I’m bringing this tire back. It had a puncture. I need you to help me fix the puncture tonight because I don’t think those people can wait until the morning,” he said, indicating the car tire held under his arm.
Utterly baffled, I asked where the car was. He had left it on the far side of the dam, he said, only fifteen kilometers outside Nacala but still in the middle of the countryside.
“Where are the patients?” I almost screamed.
“Oh, they’re all there, inside.”
“Inside what?”
“The car. The old mama said I had to hurry because her daughter had started bleeding again. That’s why I thought it better to wake you up, doctor.”
Manuel explained that it had taken a long time to get the tire off because he didn’t have a screwdriver.
“Why not put on the spare tire?” I asked.
“This is the spare. I drove on it. Don’t you remember me saying last month we needed a new inner tire? It hasn’t arrived yet.”
By now, the situation was clear in all its horror. My three critically ill patients were stranded inside a car in the middle of nowhere during a stormy night.
I dressed, packed a screwdriver and the damaged tire into our private car and drove to the port, which was open round the clock. I chased up the harbormaster and, after taking the time to brief me on his family’s health issues, he agreed to get a mechanic from the port’s machine workshop to repair the tire. He left me to supervise the work while he went off to find help with transport. He got hold of a truck just about to leave for Nampula despite the pouring rain. An hour later, Manuel and the repaired tire had joined the truck driver in his cabin. I drove home to snatch some sleep.
The next afternoon Manuel returned. I was very relieved to learn that all my patients had arrived at the regional hospital alive.
It was consistently difficult to foresee the different ways that having very limited resources would impact us. Insufficient transport for fuel and medicine, and a lack of skilled staff and decent
equipment, didn’t just hamper our ability to achieve what we set out to do; it made it almost impossible to even predict what might be achievable.
* * *
On the evening of the day I almost died, I squeezed into the Suzuki jeep, perched on a board between the driver and the front passenger. We had been to a very useful Friday meeting with the regional health service bosses and the heads of each of the eighteen districts in Nampula. A few other medics and I had nagged the organizers to be allowed to go home that night. My only other medically trained colleague in Nacala, Ana Edite, was also with us. We had bought sacks of flour and avocados in the market and packed them away in the car.
The road, which came from Malawi, crossed northern Mozambique and ran all the way to Nacala. It was in relatively good condition but rainwater that had gathered in the massive potholes was spilling over and washing the road’s shoulders away. All along the road, there were scattered villages surrounded by cassava fields without boundary ditches. It was like driving through a forest of low willow shrub.
Cassava, a fast-growing bush, has edible roots, which are a basic foodstuff in many tropical countries, including Mozambique. The roots have a high starch content but can be toxic unless a lengthy preparation process is carried out properly.
The horizon was ringed by beautiful hills shaped like sugar cones and just a few hundred meters high. I felt these hills had been there since the beginning of time.
The driver was an electrician without a driver’s license who was half asleep at the wheel and drove at 110 kilometers an hour. About halfway to Nacala, we were held up because a bridge had collapsed. About fifty meters before the gorge, traffic had been redirected by means of the usual local device—a large pile of twigs and branches. It had to do the job of more conventional road signs because tin signage was always instantly stolen.
