Iganga introduced me to nurses and porters left and right; everyone was busy but friendly, and I struggled to memorise the barrage of names. The wards were all crowded, with patients spilling into the corridors, a few in beds but most on mattresses or blankets. The building itself was dilapidated, and some of the equipment must have been thirty years old, but there was nothing squalid about the conditions; all the linen was clean, and the floor looked and smelt like you could do surgery on it.
In the Yeyuka ward, Iganga showed me the six patients I’d be operating on the next day. The hospital did have a CAT scanner, but it had been broken for the past six months, waiting for money for replacement parts, so flat X-rays with cheap contrast agents like barium were the most I could hope for. For some tumours, the only guide to location and extent was plain old palpation. Iganga guided my hands, and kept me from applying too much pressure; she’d had a great deal more experience at this than I had, and an overzealous beginner could do a lot of damage. The world of three-dimensional images spinning on my workstation while the software advised on the choice of incision had receded into fantasy. Stubbornly, though, I did the job myself; gently mapping the tumours by touch, picturing them in my head, marking the X-rays or making sketches.
I explained to each patient where I’d be cutting, what I’d remove, and what the likely effects would be. Where necessary, Iganga translated for me — either into Swahili, or what she described as her “broken Luganda.” The news was always only half good, but most people seemed to take it with a kind of weary optimism. Surgery was rarely a cure for Yeyuka, usually just offering a few years’ respite, but it was currently the only option. Radiation and chemotherapy were useless, and the hospital’s sole HealthGuard machine couldn’t generate custom-made molecular cures for even a lucky few; seven years into the epidemic, Yeyuka wasn’t yet well enough understood for anyone to have written the necessary software.
By the time I was finished it was dark outside. Iganga asked, “Do you want to look in on Ann’s last operation?” Ann Collins was the Irish volunteer I was replacing.
“Definitely.” I’d watched a few operations performed here, on video back in Sydney, but no VR scenarios had been available for proper “hands on” rehearsals, and Collins would only be around to supervise me for a few more days. It was a painful irony: foreign surgeons were always going to be inexperienced, but no one else had so much time on their hands. Ugandan medical students had to pay a small fortune in fees — the World Bank had put an end to the new government’s brief flirtation with state-subsidised training—and it looked like there’d be a shortage of qualified specialists for at least another decade.
We donned masks and gowns. The operating theatre was like everything else, clean but outdated. Iganga introduced me to Collins, the anaesthetist Eriya Okwera, and the trainee surgeon Balaki Masika.
The patient, a middle-aged man, was covered in orange Betadine-soaked surgical drapes, arranged around a long abdominal incision. I stood beside Collins and watched, entranced. Growing within the muscular wall of the small intestine was a grey mass the size of my fist, distending the peritoneum, the organ’s translucent “skin,” almost to bursting point. It would certainly have been blocking the passage of food; the patient must have been on liquids for months.
The tumour was very loose, almost like a giant discoloured blood clot; the hardest thing would be to avoid dislodging any cancerous cells in the process of removing it, sending them back into circulation to seed another tumour. Before making a single cut in the intestinal wall, Collins used a laser to cauterise all the blood vessels around the growth, and she didn’t lay a finger on the tumour itself at any time. Once it was free, she lifted it away with clamps attached to the surrounding tissue, as fastidiously as if she was removing a leaky bag full of some fatal poison. Maybe other tumours were already growing unseen in other parts of the body, but doing the best possible job, here and now, might still add three or four years to this man’s life.
Masika began stitching the severed ends of the intestine together. Collins led me aside and showed me the patient’s X-rays on a light-box. “This is the site of origin.” There was a cavity clearly visible in the right lung, about half the size of the tumour she’d just removed. Ordinary cancers grew in a single location first, and then a few mutant cells in the primary tumour escaped to seed growths in the rest of the body. With Yeyuka, there were no “primary tumours”; the virus itself uprooted the cells it infected, breaking down the normal molecular adhesives that kept them in place, until the infected organ seemed to be melting away. That was the origin of the name: yeyuka, to melt. Once set loose into the bloodstream, many of the cells died of natural causes, but a few ended up lodged in small capillaries — physically trapped, despite their lack of stickiness — where they could remain undisturbed long enough to grow into sizable tumours.
After the operation, I was invited out to a welcoming dinner in a restaurant down in the city. The place specialised in Italian food, which was apparently hugely popular, at least in Kampala. Iganga, Collins and Okwera, old colleagues by now, unwound noisily; Okwera, a solid man in his forties, grew mildly but volubly intoxicated and told medical horror stories from his time in the army. Masika, the trainee surgeon, was very softly spoken and reserved. I was something of a zombie from jet lag myself, and didn’t contribute much to the conversation, but the warm reception put me at ease.
I still felt like an impostor, here only because I hadn’t had the courage to back out, but no one was going to interrogate me about my motives. No one cared. It wouldn’t make the slightest difference whether I’d volunteered out of genuine compassion, or just a kind of moral insecurity brought on by fears of obsolescence. Either way, I’d brought a pair of hands and enough general surgical experience to be useful. If you’d ever had to be a saint to heal someone, medicine would have been doomed from the start.
I was nervous as I cut into my first Yeyuka patient, but by the end of the operation, with a growth the size of an orange successfully removed from the right lung, I felt much more confident. Later the same day, I was introduced to some of the hospital’s permanent surgical staff—a reminder that even when Collins left, I’d hardly be working in isolation. I fell asleep on the second night exhausted, but reassured. I could do this, it wasn’t beyond me. I hadn’t set myself an impossible task.
I drank too much at the farewell dinner for Collins, but the HealthGuard magicked the effects away. My first day solo was anticlimactic; everything went smoothly, and Okwera, with no high-tech hangover cure, was unusually subdued, while Masika was as quietly attentive as ever.
Six days a week, the world shrank to my room, the campus, the ward, the operating theatre. I ate in the guest house, and usually fell asleep an hour or two after the evening meal; with the sun diving straight below the horizon, by eight o’clock it felt like midnight. I tried to call Lisa every night, though I often finished in the theatre too late to catch her before she left for work, and I hated leaving messages, or talking to her while she was driving.
Okwera and his wife invited me to lunch the first Sunday, Masika and his girlfriend the next. Both couples were genuinely hospitable, but I felt like I was intruding on their one day together. The third Sunday, I met up with Iganga in a restaurant, then we wandered through the city on an impromptu tour.
There were some beautiful buildings in Kampala, many of them clearly war-scarred but lovingly repaired. I tried to relax and take in the sights, but I kept thinking of the routine — six operations, six days a week—stretching out ahead of me until the end of my stay. When I mentioned this to Iganga, she laughed. “All right. You want something more than assembly-line work? I’ll line up a trip to Mubende for you. They have patients there who are too sick to be moved. Multiple tumours, all nearly terminal.”
“Okay.” Me and my big mouth; I knew I hadn’t been seeing the worst cases, but I hadn’t given much thought to where they all were.
We were standing outside the Sikh temple,
beside a plaque describing Idi Amin’s expulsion of Uganda’s Asian community in 1972. Kampala was dotted with memorials to atrocities — and though Amin’s reign had ended more than forty years ago, it had been a long path back to normality. It seemed unjust beyond belief that even now, in an era of relative political stability, so many lives were being ruined by Yeyuka. No more refugees marching across the countryside, no more forced expulsions—but cells cast adrift could bring just as much suffering.
I asked Iganga, “So why did you go into medicine?”
“Family expectations. It was either that or the law. Medicine seemed less arbitrary; nothing in the body can be overturned by an appeal to the High Court. What about you?”
I said, “I wanted to be in on the revolution. The one that was going to banish all disease.”
“Ah, that one.”
“I picked the wrong job, of course. I should have been a molecular biologist.”
“Or a software engineer.”
“Yeah. If I’d seen the HealthGuard coming fifteen years ago, I might have been right at the heart of the changes. And I’d have never looked back. Let alone sideways.”
Iganga nodded sympathetically, quite unfazed by the notion that molecular technology might capture the attention so thoroughly that little things like Yeyuka epidemics would vanish from sight altogether. “I can imagine. Seven years ago, I was all set to make my fortune in one of the private clinics in Dar es Salaam. Rich businessmen with prostate cancer, that kind of thing. I was lucky in a way; before that market vanished completely, the Yeyuka fanatics were nagging me, bullying me, making little deals.” She laughed. “I’ve lost count of the number of times I was promised I’d be co-author of a ground-breaking paper in Nature Oncology if I just helped out at some field clinic in the middle of nowhere. I was dragged into this, kicking and screaming, just when all my old dreams were going up in smoke.”
“But now Yeyuka feels like your true vocation?”
She rolled her eyes. “Spare me. My ambition now is to retire to a highly paid consulting position in Nairobi or Geneva.”
“I’m not sure I believe you.”
“You should.” She shrugged. “Sure, what I’m doing now is a hundred times more useful than any desk job, but that doesn’t make it any easier. You know as well as I do that the warm inner glow doesn’t last for a thousand patients; if you fought for everyone of them as if they were your own family or friends, you’d go insane…so they become a series of clinical problems, which just happen to be wrapped in human flesh. And it’s a struggle to keep working on the same problems, over and over, even if you’re convinced that it’s the most worthwhile job in the world.”
“So why are you in Kampala right now, instead of Nairobi or Geneva?”
Iganga smiled. “Don’t worry, I’m working on it. I don’t have a date on my ticket out of here, like you do, but when the chance comes, believe me, I’ll grab it just as fast as I can.”
It wasn’t until my sixth week, and my two-hundred-and-fourth operation, that I finally screwed up.
The patient was a teenaged girl with multiple infestations of colon cells in her liver. A substantial portion of the organ’s left lobe would have to be removed, but her prognosis seemed relatively good; the right lobe appeared to be completely clean, and it was not beyond hope that the liver, directly downstream from the colon, had filtered all the infected cells from the blood before they could reach any other part of the body.
Trying to clamp the left branch of the portal vein, I slipped, and the clamp closed tightly on a swollen cyst at the base of the liver, full of grey-white colon cells. It didn’t burst open, but it might have been better if it had; I couldn’t literally see where the contents was squirted, but I could imagine the route very clearly: back as far as the Y-junction of the vein, where the blood flow would carry cancerous cells into the previously unaffected right lobe.
I swore for ten seconds, enraged by my own helplessness. I had none of the emergency tools I was used to: there was no drug I could inject to kill off the spilt cells while they were still more vulnerable than an established tumour, no vaccine on hand to stimulate the immune system into attacking them.
Okwera said, “Tell the parents you found evidence of leakage, so she’ll need to have regular follow-up examinations.”
I glanced at Masika, but he was silent.
“I can’t do that.”
“You don’t want to cause trouble.”
“It was an accident!”
“Don’t tell her, and don’t tell her family.” Okwera regarded me sternly, as if I was contemplating something both dangerous and self-indulgent. “It won’t help anyone if you dive into the shit for this. Not her, not you. Not the hospital. Not the volunteer program.”
The girl’s mother spoke English. I told her there were signs that the cancer might have spread. She wept, and thanked me for my good work.
Masika didn’t say a word about the incident, but by the end of the day I could hardly bear to look at him. When Okwera departed, leaving the two of us alone in the locker room, I said, “In three or four years there’ll be a vaccine. Or even HealthGuard software. It won’t be like this forever.”
He shrugged, embarrassed. “Sure.”
“I’ll raise funds for the research when I get home. Champagne dinners with slides of photogenic patients, if that’s what it takes.” I knew I was making a fool of myself, but I couldn’t shut up. “This isn’t the nineteenth century. We’re not helpless anymore. Anything can be cured, once you understand it.”
Masika eyed me dubiously, as if he was trying to decide whether or not to tell me to save my platitudes for the champagne dinners. Then he said, “We do understand Yeyuka. We have HealthGuard software written for it, ready and waiting to go. But we can’t run it on the machine here. So we don’t need funds for research. What we need is another machine.”
I was speechless for several seconds, trying to make sense of this extraordinary claim. “The hospital’s machine is broken —?”
Masika shook his head. “The software is unlicensed. If we used it on the hospital’s machine, our agreement with HealthGuard would be void. We’d lose the use of the machine entirely.”
I could hardly believe that the necessary research had been completed without a single publication, but I couldn’t believe Masika would lie about it either. “How long can it take HealthGuard to approve the software? When was it submitted to them?”
Masika was beginning to look like he wished he’d kept his mouth shut, but there was no going back now. He admitted warily, “It hasn’t been submitted to them. It can’t be — that’s the whole problem. We need a bootleg machine, a decommissioned model with the satellite link disabled, so we can run the Yeyuka software without their knowledge.”
“Why? Why can’t they find out about it?”
He hesitated. “I don’t know if I can tell you that.”
“Is it illegal? Stolen?” But if it was stolen, why hadn’t the rightful owners licensed the damned thing, so people could use it?
Masika replied icily, “Stolen back. The only part you could call ‘stolen’ was stolen back.” He looked away for a moment, actually struggling for control. Then he said, “Are you sure you want to know the whole story?”
“Yes.”
“Then I’ll have to make a phone call.”
—
Masika took me to what looked like a boarding house, student accommodation in one of the suburbs close to the campus. He walked briskly, giving me no time to ask questions, or even orient myself in the darkness. I had a feeling he would have liked to have blindfolded me, but it would hardly have made a difference; by the time we arrived I couldn’t have said where we were to the nearest kilometre.
A young woman, maybe nineteen or twenty, opened the door. Masika didn’t introduce us, but I assumed she was the person he’d phoned from the hospital, since she was clearly expecting us. She led us to a ground floor room; someone was playing music upstairs, but there was
no one else in sight.
In the room, there was a desk with an old-style keyboard and computer monitor, and an extraordinary device standing on the floor beside it: a rack of electronics the size of a chest of drawers, full of exposed circuit boards, all cooled by a fan half a metre wide.
“What is that?”
The woman grinned. “We modestly call it the Makerere supercomputer. Five hundred and twelve processors, working in parallel. Total cost, fifty thousand shillings.”
That was about fifty dollars. “How—?”
“Recycling. Twenty or thirty years ago, the computer industry ran an elaborate scam: software companies wrote deliberately inefficient programs, to make people buy newer, faster computers all the time — then they made sure that the faster computers needed brand new software to work at all. People threw out perfectly good machines every three or four years, and though some ended up as landfill, millions were saved. There’s been a worldwide market in discarded processors for years, and the slowest now cost about as much as buttons. But all it takes to get some real power out of them is a little ingenuity.”
I stared at the wonderful contraption. “And you wrote the Yeyuka software on this?”
“Absolutely.” She smiled proudly. “First, the software characterises any damaged surface adhesion molecules it finds — there are always a few floating freely in the bloodstream, and their exact shape depends on the strain of Yeyuka, and the particular cells that have been infected. Then drugs are tailor-made to lock on to those damaged adhesion molecules, and kill the infected cells by rupturing their membranes.” As she spoke, she typed on the keyboard, summoning up animations to illustrate each stage of the process. “If we can get this onto a real machine…we’ll be able to cure three people a day.”
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