“It seems to me I am trying to tell you a dream–making a vain attempt, because no relation of a dream can convey the dream-sensation, that commingling of absurdity, surprise, and bewilderment in a tremor of struggling revolt, that notion of being captured by the incredible which is of the very essence of dreams…No, it is impossible; it is impossible to convey the life-sensation of any given epoch of one’s existence–that which makes its truth, its meaning–its subtle and penetrating essence. It is impossible. We live, as we dream-alone…”
On arriving at my dorm within the compound of Pariyenyatwa Hospital (Pari) here in Harare, Zimbabwe, I was offered a Zambezi beer by my new (and unexpected) roommates and advised to read Joseph Conrad’s Heart of Darkness. Much derided as a source of perpetuated racism, Conrad’s novella nonetheless contains a number of passages that are striking, some of which I find myself relating to as I begin my rotation here at Pari. The epigraph above relates the depth of the struggle I find myself experiencing in attempting to communicate our experiences here. I may recount the events along with bits and pieces of what I have learned, but I know that I will fall short of capturing the penetrating essence of this place.
Week one necessitates a paradigm shift. Though this is my first formal experience as a medical student learning on the wards, I know from an intellectual standpoint that the medical system I am seeing here is miles and miles apart from what I will see back home. Appreciating these differences has been central to my coming to grips with the raw nature of this experience. First and foremost has been understanding how medicine works in a severely resource limited setting. First line treatments that we take for granted in the US are not available. However, the consequences of this reality lead to practices that we forego in the states. One of the most common reasons for a patient not receiving treatment here is the family’s inability or unwillingness to put forward the money. An MRI costs approximately $1,000 USD, a truly crippling sum for most here in Zimbabwe. The result is that physicians are keenly aware of the cost of each procedure, scan, or treatment involved in their treatment plan for each patient. They advocate for their patient and the cost of their care at every turn. Indeed, Dr. Maturase, one of our attending physicians, explained to us his seminal research on how he has been able to demonstrate marked reductions in overall mortality in stroke patients without the use of imaging, based more on clinical presentation and the WHO stroke criteria. Therefore, while it is challenging to see patients dying here when their outcomes would have likely been much better in the states, it is impressive to see how this resource limitation has led to innovations that dramatically improve patient care.
The cultural component plays an important role in how I have come to process the daily shock we experience rounding in Pari. On returning to check on one of the patients we had seen in the morning, my resident informed me that the patient was exhibiting agonal breathing and would likely not live more than an hour or two longer. When asked if the patient’s family should be called, the nursing staff said that they would likely not come. Over the course of the next twenty four hours we lost several other patients, including one of whom was dead when we rounded on him (yes, we rounded on a dead patient—we even made a plan involving calling neurosurgery). Death began to become eerily familiar—you start to eye each newly empty bed in the hospital with a certain degree of suspicion. Part of this familiarity is undoubtedly due to resource limitations, but another significant contributing element is that the cultural paradigm here is that you bring your loved ones to the hospital to die.
The frequency with which it seems that patients pass on here at Pari can further be attributed to another cultural idiosyncrasy of Zimbabwe: due to the prevalence of traditional and spiritual healers, particularly in rural areas, people often treat western biomedicine as a last resort. The predictable result is that when patients present to Pari, they are often critically ill. Many patients who would undoubtedly be treated in the ICU in the states are routinely covered on the wards due to the overflowing abundance of severe disease. Walking through the wards, it is not uncommon to see patients in status epilepticus, patients with HIV encephalitis, and patients with miliary TB. Though I have seen firsthand the efficacy of traditional healing practices, the result of relying solely on traditional practices, particularly in a country where the prevalence of HIV is estimated at around 16%, can be devastating—and in our case, difficult to stomach. Too often we encounter patients with CD4 counts in the single digits. When asked why they defaulted on their Highly Active Anti-Retroviral Therapy (HAART), many of these patients will tell you that their traditional or spiritual healer told them that they were negative. While, according to the local medical students, this problem is improving and patients are recognizing the need for a combined approach to their ailments, it can be heart wrenching to hear these stories.
Despite these challenges, one overwhelmingly positive part of our experience as medical students here at Pari has been the quality of the teaching. In one of the rounds designed for resident doctors, one of the hospital’s senior physicians described—at length—a recent humbling experience where his diagnosis of a myxoma had been proven wrong, all to demonstrate both that dogma has no place in medicine and that we all still have room for growth as physicians. This teaching point seemed particularly in keeping with the strong humanistic focus that is such an overriding principle of medical education in the US.
The dream-sensation that Conrad describes in Heart of Darkness factors heavily in our day-to-day life here in Harare. The past week and a half feels like an eternity and I feel utterly lacking in my ability to relay the essence of this place, much less the overriding sense of shock I feel on a daily basis. However, contrary to Conrad’s morose refrain, I do not dream alone. Fortunately, Richard Mendez, Dr. Ruth Musselman, and Dr. Pat Wetherill, my global health team here in Zimbabwe, are all right here beside me. I am thankful for the support, the very personal education afforded me by my program, and the opportunity to share and reflect on this dream like reality.