Hope and Healing

The 20% Oath

noreply@blogger.com (Mark) — Fri, 05 Jun 2009 02:07:00 +0000

Last week, The New York Times published an article entitled "A Promise to Be Ethical in an Era of Immorality". It tells the story of a number of student-led initiatives in American business schools toward developing an oath for B-school graduates.

The oath—its content varies by school—pledges the students to, in the words of the article, "act responsibly, ethically and refrain from advancing their 'own narrow ambitions' at the expense of others."

For millennia, physicians have made similar vows:

I will prescribe regimens for the good of my patients according to my ability and my judgment and never do harm to anyone.... In every house where I come I will enter only for the good of my patients.

Many trades act similarly, and, to take the article at face value, business school seems to be catching up. But this is, by far, not the most interesting part of the piece.

No. It's glossed over in the article, but what boggles the mind is that only twenty percent of the graduating business school class at the institution profiled had actually agreed to the oath.

Eighty percent of business school graduates could not agree to acting responsibly and ethically!

Does this bother anyone else besides me? I warrant that probably somewhere on the order of eighty percent of physicians also do not abide by the Hippocratic Oath, but at least we all take it. At least we all promise to try to live up to its standards, and, I'd wager, most of us do so without our fingers surreptitiously crossed.

Are business school students simply more honest? Is it simply a case of, "I know I'm going to break this, so why take the oath in the first place?"

Or is there something more telling going on? Perhaps it's my naivete, but in light of the etiology of our current economic downturn, I'll admit that the other 80% bother me. Deeply.

The Right to Look Human

noreply@blogger.com (Mark) — Mon, 27 Apr 2009 01:40:00 +0000

If you happen to be in New York City in a couple of weeks and find yourself, on the night of Thursday, the 14th of May, with nothing to do and a hankering for premade cookies and a small talk on the practice of medicine in the developing world, consider clicking here.

Registration is free, but an RSVP is required.

Never the twain shall meet

noreply@blogger.com (Mark) — Sat, 28 Mar 2009 15:43:00 +0000

Blandine* is a beautiful, playful seven-year-old girl, who doesn't seem to notice the one thing about her that everyone else sees first: In the side of her head, in her infratemporal fossa, she has a large mass (What am I saying? Does anyone in this country have a small mass?). It extends to where her carotid artery follows its convoluted path into her brain. It impinges on five different nerves as they exit the skull on their way to her face, her tongue, the rest of her body. It, quite literally, goes for her jugular.

But to look at her, you'd never know. Her face is asymmetric, for sure, but that's about it. She's a happy seven-year-old.

So, explaining to her father that the surgery we were proposing might result in some very serious untoward events was difficult. But more than that—it destabilized the very core of the way I think about surgery. Not to put too delicate a point on it.

See, it made me question what it really meant to give informed consent.

Until Blandine, this was obvious. You go to the doctor, and she recommends a procedure. You expect that her next ten minutes are going to be spent explaining everything that could go wrong, scaring you to death with words like "cardiovascular compromise" or "cerebrovascular accidents." And then, in a perverted sort of altar call, she'll place a single sheet of paper in front of you, crammed with more words than the constitutions of some countries, and ask you to sign it. You will, probably without reading it, because that's what you're supposed to do, because in doing so you've declared that you've been informed of every possible risk, benefit, and alternative, and you still want to proceed with the surgery. Because it has become your decision.

The reasons for this are legion. There are the obvious, legal ones ones. There are the ones that place doctors firmly at fault: we want to protect ourselves, cover our rumps, in a completely self-serving way. We think that if the patient makes the decision, then we're absolved of all culpability if anything goes wrong (this is obviously erroneous).

But then there are the deeper, cultural ones, ones that I'd never thought to assume didn't exist everywhere. And it's on these that the entire concept is predicated. Very early in medical school, we learn words like autonomy and non-malfeasance and paternalism (and its more politically-correct cousin, parentalism; amazing how much stock we place on anagrams). We learn that, as doctors, we are supposed to tell you everything that could go wrong. We're supposed to give you as much information as we can. And you are the one who's supposed to make the final decision. We aren't to be paternal. You are to be autonomous. Obviously. This is so deeply ingrained in us as to be self-evident.

As it turns out, this self-evidence is, well, not self-evident. It's firmly based, instead, in the fierce individualism of our Western cultures.

After every sentence, with every enumerated risk, Blandine's father simply smiled at me and told me that she was in God's hands. No matter how strong I made my wording, no matter how bleak a picture I tried to paint, he was unwavering in this assurance. God was in control. God would bring his daughter back to him. God would make sure she was able to speak and swallow and move her face and stick out her tongue. God wouldn't let anything happen to her. This wasn't some blind, uninformed faith, either. God was really going to do this.

I found myself flummoxed. I wanted to take him by the shoulders and shake him, shake that assured smile off his face. Yes, I wanted to say, God is in control, but don't you see? Don't you understand? She might not...! He might not...! She might die! Do you hear me?

As missionaries, our objective cannot be to change the culture of a people. We do a tremendous disservice when we start believing that our way of viewing the world is the only correct way. But what happens when culture flies in the face of your own self-evidence? What if the very core on which you've built your day-to-day interactions with your patients—autonomy, self-determination—is whisked out from under you?

What if these concepts don't even enter the mind of the person you're talking to—and his overarching motifs (innate trust, for example, or determinism, or even fatalism) are themselves anathema to your Weltanschauung? Who is right? Whose worldview wins? Shall the twain ever meet?

I don't know.

I am happy to report, though, that Blandine's father's faith was borne out in the way he so inexplicably expected it to be. And in doing so, he challenged my reliance on autonomy—either as abdication or as deeply-held worldview—possibly irreparably.

And with that, I'm finishing my last post from Africa. I leave on Sunday. Thanks for following along.

Until next year.

Kicking at the darkness

noreply@blogger.com (Mark) — Tue, 17 Mar 2009 22:13:00 +0000

Two patients died earlier this week.

Now, I'll grant that in the day-to-day running of any hospital anywhere in the world, this may not seem such a significant event. People die every day. And this is doubly true in the world of head and neck surgical oncology, where the overall survival rate hovers around 50%.

Before you chastise me for being impersonal: this knowledge is just the opposite. Instead of depersonalizing, it frees the head and neck surgeon to negotiate the increasingly blurred line between physician and priest, to be fully present in someone's life at its most weighty.

But things are different on the ship. The hospital is smaller (it's a ship, after all), and most of the surgery we do is not for malignant disease. We work, instead, to restore to patients the right to look human, the right to re-enter society.

So death hits harder.

And it makes one ask: Why, then, continue? Specifically, what's the point of attempting, in our imperfect way, to heal, when all healed people eventually die? Why prolong the inevitable?

Obviously, this question isn't an original one. In the introduction to his 1849 book, The Sickness Unto Death, Søren Kierkegaard asks this of a well-known story:

And what help would it have been to Lazarus to be awakened from the dead, if the thing must end after all with his dying?

Unfortunately, his answer, though unequivocally true, is too glib to be satisfying. Perhaps a better articulation (in both the negative and the positive) comes from the Anglican Bishop of Durham, a bald, bearded man named N. Thomas Wright:

If you turn faith into simply the hope for pie in the sky when you die, and an escapist spirituality in the present, you turn your back on the theme which makes sense of the whole story... [You] may feel some sympathy for the battered and bedraggled figure in the ditch, but [your] message to him will always be that, ultimately, it doesn’t matter because the main thing is to escape this wicked world altogether.

But that's not all there is. In the Christian aesthetic, he writes elsewhere,

the world is beautiful not just because it hauntingly reminds us of its creator, but also because it is pointing forward: it is designed to be filled, flooded, drenched...as a chalice is beautiful not least because of what we know it is designed to contain, or as a violin is beautiful not least because we know the music of which it is capable.

And that is why. We do this because, in an imperfect world, we see—and have fallen in love with—the perfection for which it was intended. We do this because we know that this darkness—of sickness, of tumors, of poverty, of war—isn't what was meant to be.

We do this because we know that there is a light behind it all, and that this very world, this very creation, will one day become light—but not just one day, not just in the sweet by and by. See, here's what's most important. We work because, in working, in the smallest and most imperfect way, we might just be a bit part in that redemption, right now, right here.

So that's the crux: despite the deaths, despite the setbacks, we know that the Barenaked Ladies, those most sage of Canadian philosophers, were right. We have to kick at the darkness till it bleeds daylight.

Sometimes, though, the darkness kicks back.

Rest in peace.

Seen and sucked dry

noreply@blogger.com (Mark) — Wed, 11 Mar 2009 21:45:00 +0000

I write this post with the unsettling knowledge that I'm firmly ensconced as part of the problem. And I have no real solution to offer.

That said, it is never pleasant to watch the insidious descent of a group of people into the indenture of tourism.

Last weekend, in an effort to see the sights of southern Benin, a group of us took an hour-long, eighteen kilometer boat ride to Ganvié. Situated in the middle of a shallow lagoon, Ganvié has been around since the 1600s (at least), a village of refuge, built on stilts. According to the story, the Dahomey warriors were forbidden, by their religion, from entering the water. And, because their prey, the Tofinu people, were intent on avoiding subjugation by the warriors, they capitalized on this fact, escaped to Lake Nokoué, and set up their town.

Ganvié has been minding its own business ever since.

However, a more nefarious sort of subjugation has begun—one which has no respect for the spirits of the lake. Supposedly (this is only hearsay; I have no corroborating evidence), Ganvié first became more widely known after it featured in a National Geographic special a couple of decades ago. Whether or not that is true, there has definitely been an inexorable incursion of tourism into the town. Hotels are being built (one proudly sports a banner on its front awning: Buses welcome!, it says, the absence of any paved roads evidently a just minor inconvenience). The traveller is seen as a purchaser of kitsch—the obligatory stop-at-my-cousin's-art-workshop was included—and, more importantly, as the provider of useless trinkets. So much so, in fact, that children mob you the minute you enter the town, performing handstands on the bows of their ramshackle canoes, asking you for chewing gum, pens, or money, and demanding (I kid you not) that you give them the sandwich you've half eaten. So much so that the outstretched palm is one of the first gestures learned here. So much so that children are taught the important phrases early: Monsieur Madame! Yovo!* Donne moi!

It's not a far reach from here to Kyrgyzstan.

This isn't a new phenomenon. In his Studies in Classic American Literature, DH Lawrence wrote

Behold then Septimus Dodge returning to Dodge-town victorious. Not crowned with laurel, it is true, but wreathed in lists of things he has seen and sucked dry. Seen and sucked dry, you know: Venus de Milo, the Rhine or the Coliseum: swallowed like so many clams, and left the shells.

Seen and sucked dry. It's the one unifying theme in so many disparate countries. The gestures are the same, the objectification unchanged (if understandable), the power differential ubiquitous. And to this ubiquity, I find no solution. Should we not visit? Should we not see? Should we not try to understand? Should we not be travellers?

I don't think so. As Byron, himself the quintessence of wanderlust, wrote in a letter to his mother:

I am so convinced of the advantages of looking at mankind instead of reading about them, and of the bitter effects of staying at home with all the narrow prejudices of an [Englishman], that I think there should be a law amongst us to set our young men abroad for a term among the few allies our wars have left us.

If this is the case—and I think it might be—how do we avoid leaving nothing behind but shells?

The rest of the pictures are here.

*Yovo is the Fon word for "white man"

Estragon's boot

noreply@blogger.com (Mark) — Wed, 04 Mar 2009 18:27:00 +0000

Just on the Togolese border, about a two-hour drive west of Cotonou (it's a narrow country), sits a resort. Grand Popo, despite its particularly fetching name (which I swear I didn't make up), is beautiful.

I'm told.

Last weekend, six of us made it our destination (as much as I'd like to pretend otherwise, it's not all work here). Unfortunately, exploring West African countries isn't always a salutary experience—at least, this time, there were no car accidents.

Ready for a relaxing day in the sun, we set off out of Cotonou, and onto a dirt road that runs west along the country's shoreline. Unpaved, and relatively untrafficked, this road offers both spectacular views and a chance for you to test the mettle of both of your esophageal sphincters. And the resolve of your tires.

About an hour and a half out of Cotonou, the first one blew. This wasn't going to be a problem, though. We're living in Africa, right? We know how to change a tire! And besides, any self-respecting, NGO-owned, white four-wheel-drive has a spare bolted to its roof. Ours was quite the self-respecting vehicle.

What ours didn't, unfortunately, have was a jack that worked. We tried everything (pens, sticks, knives), but without a pin around which the lever could ratchet, the jack was nothing more than a bright red, human-sized metal rod.

Because a faulty jack isn't enough, our wrench was also one size too big for the lug nuts. No amount of hoping (and we did our fair share) was going to change that.

In this hopefulness, we were helped by a cadre of Beninois (their luck was no better than ours), and a few, kind, passing French families (ditto), including the French ambassador to Benin (at least, according to his wife). After an hour of jumping on wrenches, we did what anyone else would do. We called the ship for help, sat down on the side of the dirt road, and ate cheese sandwiches. The Beninois disappeared. And we got to enjoy being stranded in some of the most beautiful surroundings you could imagine.

Three hours later, the ship called back. Our erstwhile savior had gotten lost and come back home. But, another group was at a pool 12 miles away, and were on their way.

Their jack worked. Their wrench fit our lug nuts. And, with a fair amount of shouting back and forth between the us and the Beninese men that had mysteriously reappeared, we got ready to leave.

Tut tut.

"You must," I was told, "satisfy these men." Yes. Satisfy. I'm not making that up either.

We tried giving the group some money; this served only to inflame things. Volley after volley, satisfaction being more loudly demanded with every increasing incursion into personal space. Exasperatedly, I finally asked, "How am I supposed to satisfy you?" To which my interlocutor answered, "I can't tell you. It's up to you."

This was Samuel Beckett on crack. Estragon's boot wasn't ever coming off.

Instead, we piled into the car, gave them the money, and decided that their satisfaction was up to them.

We drove through Ouidah, the birthplace of voodoo (or vodoun), past the Door of No Return, commemorating the point on the coast of Abomey from which Portuguese slave ships departed with their cargo of humanity and self-righteousness, and to Casa del Papa, a mere shadow of Grand Popo. With a worse name, but, importantly, with a pool.

The Door of No Return, Ouidah, Benin

Everything was fine on the way back home. We stopped at an Indian restaurant for dinner, and were about 20 minutes away from the ship when, yes, the second tire blew. No working jack, no working wrench, and this time no spare, we were stuck. Another of our cars was still at the restaurant. We borrowed it, took their spare, tested their wrench, and went to jack our car up.

This time, the useless, human-sized piece of metal was bright blue. But the helpful taxi drivers that finally jacked our car up demanded no satisfaction.

The remaining pictures are here.

The numbers and the pictures

noreply@blogger.com (Mark) — Mon, 02 Mar 2009 21:28:00 +0000

The official numbers—and, more importantly, the official pictures—are finally available.

2773 patients seen at our screening days
513 surgeries scheduled, and
300 patients booked for follow-up appointments prior to surgical scheduling

This doesn't include patients undergoing eye surgery—we do about 25 of these a day, nor the 30 that show up on the dock daily. Word is getting around.

The rest of the pictures are here.

The video

noreply@blogger.com (Mark) — Mon, 23 Feb 2009 14:49:00 +0000

Apologies to those of you who receive this blog by e-mail and weren't able to view the video. It's also available here.

1939

noreply@blogger.com (Mark) — Sun, 22 Feb 2009 11:32:00 +0000

Seventy years ago, when Benin was still Abomey, a Q-tip-shaped parcel of land wedged within French West Africa; when the memory of Portuguese slave ships was fresh and the mention of Dahomey warriors still struck fear; when Mohandas Gandhi was fasting, Adolf Hitler was attacking, Judy Garland was following yellow bricks, and John Steinbeck was writing about angry grapes—seventy years ago, when the world was declaring war on itself for the first time, Gbayi* got sick.

It may have been measles—it often is. The thing is, unlike others who got what he got, he survived, but the victory was unfortunately Pyrrhic: not long after, his lips fell off.

No, seriously. I've written about noma before, but it never ceases to amaze me. See, we all carry around in our mouths somewhere on the order of 800 species of bacteria, but, besides feeding on the detritus you leave behind when you don't brush your teeth (and lining the pockets of Procter & Gamble executives), these bugs do very little of dramatic import.

Except in noma.

In noma, an immune system weakened by a recently-fought-off infection becomes unable to contain the bacteria, and they're left alone, free to devour more than food.

Why they attack some patients and remain docile in others, I don't know. But seventy years ago, when the French were still guillotining people and Clark Gable was going with the wind, they ate Gbayi's upper lip. And part of his nose.

Gbayi is now 77 years old. Age has rendered him unable to walk—he was carried to the stadium on his son's back—and, seven decades later, his hands perpetually hover around his mouth, as if by doing so they can prevent the shame that has shadowed him since Einstein was researching atomic bombs.

And Gbayi was only one of over 2000 stories we saw in two days at the Hall des Arts, Loisir, et Sports this week (loisir, for sure: half the chairs in the stadium were brown—sometimes garish red—leather armchairs, incongruously defying the remaining wood-and-metal seats; they, I assume, are where the important people sit). Over the course of two days, patients who had begun lining up in the middle of the week wended their way through the sports stadium toward the surgical schedulers, who would give them a date for their surgery. Not everyone made it there, but we said yes far more often than we said no.

Massive tumors and goiters the size of watermelons, clubbed feet and contracted arms, burned faces and bowed legs, hernias, hydroceles, and fistulas—each accompanied by a story like Gbayi's.

Physical deformity, a lawyer once wrote, calls forth our charity. The need, as always, is greater than any group of humans can help. But that is perpetually a good reminder.

The first patients arrive on Monday. Pictures will be forthcoming, but, in the meantime, here's a six-minute video from the day (Gbayi shows up near the end):

*Not his real name

They do things a little differently here.

noreply@blogger.com (Mark) — Tue, 17 Feb 2009 08:50:00 +0000

All it took was a nun.

The flight from New York City to Paris and on to Benin was about as uneventful as flights go; maybe half an hour of turbulence and two complimentary glasses of cognac rocked the entire sixteen hours of travel. Until I landed in Benin, the only thing eventful that had happened to me was that, despite my best efforts, I thoroughly and completely lost an armrest war to my left-hand neighbor, who seemed to consider that his window-seat ticket also bought him a controlling share in the adjacent aisle seat.

Given that he was approximately double my size (you will see...this promises to be a recurring theme), I'm surprised I lasted as long as I did—which, to be fair, was only about 27 minutes. I had little choice but to become intimately familiar with the contralateral armrest, and each passing, just-wide-enough-to-make-you-rue-elbows, duty-free-stocked beverage cart propelled by plastic smiles.

All this changed, though, on arrival at Cotonou's Cadjehoun airport. Miles more developed than Monrovia's airport, Cadjehoun has regimented lines with regimented passport agents sitting at actual, regimented desks behind actual, regimented plastic, with actual stamps, making actual, official, stamp-like sounds.

It's a thin veneer.

Evidently passport confiscations are de rigeur here; my kindly, smiling, official-sounding passport agent conveniently "couldn't find" my passport after she sent me aside to fill out an arrivals form (the first attempt being deemed subpar). She was sure she'd given it back to me. I must have just misplaced it.

My refusal to believe her led to a swift surrounding by three other very kindly and official-sounding passport agents, reminding me that—don't you know?—they were police officers and would be sure to deal with me as police officers do, merci beaucoup. Thankfully, the bluster didn't last long, and some well-placed obstreporousness aided the magical reappearance of my passport.

A little shaken, I got my hands on one of a number of freely-roaming luggage carts and settled into the throng of people waiting for suitcases. Apparently, I chose poorly, because, of all the passengers, with all their luggage carts, I was singled out.

"That's my cart," someone behind me said.

I saw no reason to believe him, and, admittedly, told him so.

"You use my cart, you pay me," he protested.

This went on for a few parries, just long enough to settle the matter peaceably, without the exchange of either money or fisticuffs. But, unfortunately, also long enough to infuriate a thrice-as-large-as-me passenger from my flight (who, incidentally, happened to be friends with my armrest mate). He turned around, sheer anger on his face, took my two bags and proceeded to hurl them to the floor with as much force as he could muster (which was a lot).

As if this wasn't dramatic enough, he then began screaming at me, his words mostly drowned out in the shower of spittle I found myself under. When he started pushing—hard—a small British nun in a grey habit stepped between us. For this, I'll one day get to thank her.

After my erstwhile attacker had returned to his conversation with my erstwhile armrest antagonist, she turned to me, said, "They do things a little differently here," and quickly disappeared into the throng.

Evidently.

—o—

Meanwhile: It is spectacular to be back on the ship, back among friends. Our screening day is tomorrow, and surgeries start on the 24th. Updates will be forthcoming.

Know any OR nurses?

noreply@blogger.com (Mark) — Fri, 16 Jan 2009 13:59:00 +0000

Because, evidently, the ship is short, especially for the start of the outreach. So if you are an OR nurse (and I know there are some of you out there), or if you know one, let me know!

Going back

noreply@blogger.com (Mark) — Fri, 09 Jan 2009 23:52:00 +0000

They say that when you come back from Africa, you enter a bizarrely perpetual dissociative state: your time in Africa was real—as real as the red earth that inexorably worked its way beneath your fingernails—but somehow, in North America, it's relegated to that portion of your psyche usually reserved for recurring dreams. The part of your psyche that engenders nostalgia, that remembers only snippets. The part of your psyche that makes you relate what you've seen with such jarringly juxtaposed sentences as, "So I was standing. On a dock. Jutting out into the Atlantic. Somewhere in West Africa. And half my friends thought I was in Costa Rica. And he was having a seizure, but his wife thought he was demon-possessed." It's the part of your psyche that remembers Amachin and Alimou and Michael (who, thanks to the quiet tenacity of a woman named Michele, has just returned from Ghana, disease-free), but silently downplays the weevils and the seasickness, the two-minute showers and the quickly-rotting bananas swimming in their liquefied remains.

That part of your psyche, though, beckons you, and, despite your greatest Odyssean efforts, no amount of rope can strap you tight enough to the mast of your passing vessel for you to withstand it.

So, I'm going back. Which means that, after seven months of pure silence, you—unless you hastily unsubscribe now—get to be regaled with stories cobbled together from not altogether related experiences, overly-stretched metaphors (Look! One already! A certain dead Greek poet is viscerally angry right now...), excessively long and parenthetical sentences, and ruminations on the often competing roles of medicine, volunteerism, NGOs, bottom lines, faith, and culture.

This is all because, for the six weeks between 15 February and 30 March, I've been given the spectacular chance to go back on board the Africa Mercy for another round, this time in Benin (the map is on the right of the blog's homepage). I land just after the ship docks in Cotonou, and get to be there for the opening of the hospital, for screening day, and for the first five weeks of surgery.

Wish me luck!

Humility

noreply@blogger.com (Mark) — Thu, 24 Jul 2008 23:58:00 +0000

I didn't think I'd post much after getting home, but I thought I needed to share this audio file. Last Sunday, Dr. Gary Parker, the chief medical officer on the Africa Mercy, was interviewed by the BBC's All Things Considered, talking about life on the ship, health-care in the least developed world, and the role of his faith in his work.

Click here or here (it will be available until July 30).

If you've got 27 minutes and 57 seconds, it's worth a listen.

Home

noreply@blogger.com (Mark) — Fri, 27 Jun 2008 18:14:00 +0000

I suppose it's time.

I've been avoiding writing this one last post out of denial—if I write it, it means it's true. It means the year is over, Africa is over, and the "real" world is real again.

But, these last two weeks have forced itself upon my psyche, with a stubbornness surpassing that of Macarthur's promise to the Philippines. The real world has returned. And it bears a striking resemblance to what it was when I left.

It is strange to think that, just twelve days ago, I was sitting on a ramshackle dock in an impoverished country in West Africa, debating whether the rainy season had actually started or whether it was just being coy. People warned that returning to the west would make you feel like what had happened to you in Africa was just a dream.

And it's true. It's amazing how easy it is to slip back into western culture, to slip back into home. But it's home, redefined, and it's western culture seen through a pair of changed lenses.

Here's hoping those lenses remain changed.

How did they find us?

noreply@blogger.com (Mark) — Thu, 26 Jun 2008 15:00:00 +0000

The Hindustan Times?

Really?

Reformed curmudgeons

noreply@blogger.com (Mark) — Sun, 08 Jun 2008 19:43:00 +0000

We're officially into our last week in Liberia, the last week in a year away from what used to be reality. Sunday, we'll be on our way back home, retracing the steps we took nearly five months ago when we came here. Monrovia. Abidjan. Brussels. New York.

There will, I predict, be plenty of things that we'll have to get used to. Grocery stores (though you could make an argument against that in New York City). Restaurants. Traffic. Sushi. The lack of ready beaches. The ability to take showers that last more than two minutes. Cold weather. And cheese.

But, most of all, I think it will be exiting communal life that will be the hardest.

This surprises me. Acculturated to the fierce individualism of my generation, I figured that being stuck on a boat with 400 other people would frighten me. It had all the makings of immense claustrophobia. I've never been one for small-town living. The blessed, communal anonymity that NYC offers—of running into a thousand people just leaving your apartment for shrivelled hot dog and faux papaya juice, each of whom would avoid your gaze with a studied detachment—that was the sort of community I was all about.

So, my impressions of communal living were uninformed and—I hate to admit it—stereotypical. Unwashed. Militantly utopian. Dandelions and dirty fingernails. Greasy-gray ponytails and socks the color of day-old guacamole. It's hard even to write these descriptors now. Because, see, now I know it's different.

Practicing medicine in Africa has been spectacular. I'm going to miss it. This country itself is gorgeous. I'm going to miss it, too. But missing those pales in comparison with missing community. Community isn't about Esperanto or people who think that the word ganja is anti-establishment verlan.

No. Community is about sitting on a dock, watching the sun take its final spectacular breaths for the day, cheering loudly, with ten people whom you met only a few months ago but who have become your family, as the quickly descending globe scatters its golds and reds and baby blues and ominous greens across the sky with the abandon of a reformed, Dickensian curmudgeon. Community is about watching massive jellyfish over the side of the ship, embroiled in a two-hour-long conversation about the merits of marmite, millenialism, or post-racial presidential candidates. Community is a Scottish dance on a West African pier. It's learning how rubber is made from a man with one eye. It's four Koreans and a Norwegian performing English songs. It's a Canadian, a Swiss guy, an American, and two West Africans dancing to the victory of a British football club. Community is having spontaneous gatherings of music, with people whose voices blend like only the voices of strangers can.

And I'm going to miss it. I'll confess. Maybe there's room for one more reformed, Dickensian curmudgeon in this world.

Bookworm

noreply@blogger.com (Peggy) — Mon, 02 Jun 2008 20:22:00 +0000

My sister Ingrid is a year older than I am. While growing up, the most significant privilege of her seniority to me was her access to books that I could not read. Throughout elementary school, I would beg and borrow her required textbooks for English class so I could race through the stories. My jealousy intensified when Ingrid made it to middle school and I was still in elementary school. Suddenly she had access to the middle school library, which was combined with the high school library and had roughly ten times the number of books. I began to resort to desperate measures when Ingrid started getting annoyed at my constant pestering. When we went to bed at night, I would sneak into her bag and pilfer her books. I would scuttle back to my bed where I would fling the covers over my head and read by flashlight. Even though we shared a room, my parents had the foresight to put us in bunkbeds. Ingrid luckily preferred the top bunk, leaving me free to my nighttime scavenging. I remember finding out one day that Charlie, the weird kid in my first grade, frequently read in the bathroom while his parents were sleeping. I felt a sudden kinship with him knowing that someone else was sitting on a plastic toilet seat in the middle of the night flipping through the adventures of Nancy Drew (or, I suppose, the Hardy Boys).

This is why I found it unbelievably tragic today when 24-year-old Bendu came to be admitted. On March 14th, she curled up in bed with a book, as was her habit, and probably fell asleep. Her kerosene lamp got knocked over, and set the mattress on fire. Bendu was overcome by the carbon monoxide fumes, and when her mother rushed into the room, Bendu's face and right arm were already burned beyond recognition. Although Bendu spent the next two months convalescing at St. Joseph's Catholic Hospital, the burns on her face started to form contractures such that she could no longer close her eyes. When she came to Mercy Ships today she was starting to have blurred vision. Her cornea had begun to ulcerate from exposure. Bendu's mother sat across from her, lips compressed, arms crossed, as I tried to explain that all we were able to do was to put a skin graft on her face such that she could close her eyes and preserve her vision. There was no hope of restoring her face back to a semblance of normal, not here, not even on Mercy Ships, where the goal of burn contracture surgery is to restore function, not form. I was at a complete loss for words.

Faith

noreply@blogger.com (Peggy) — Sun, 01 Jun 2008 10:35:00 +0000

Augustus was dressed in black when he walked into the admissions tent. Odd, since we were not in New York City, but then who am I to comment on Monrovian fashion? I had made a remark to a patient several weeks ago about his slick black outfit, only to be reprimanded that it was actually navy blue and his metrosexual digs were appropriate to his profession as a tailor. So I let the observation slide.

Augustus's story was fairly typical of the patients we see. In 2003, he was a passenger in a motor vehicle accident. After the accident, he went to JFK, Monrovia's biggest hospital, and was given only tylenol for a right humerus that had snapped in half. He did not get an x-ray nor was he casted, and fortunately for him it was a closed fracture, meaning that the broken bone had not pierced the skin. His arm healed, although the bone had healed unfused, in what we term "non-union of the humerus." He was lucky in that he was neither a farmer nor a mason but rather an economist, which meant that despite having a permanently broken arm he could still write and therefore he could work.

As we chatted about his medical problems and such, I began to ask him if there was any history of illnesses in his family. "My son died yesterday, and I am in mourning," he said. Augustus Jr. was in the 10th grade, a miracle by any measure in Liberia, where I have only met a handful of people who have progressed beyond the 6th grade. On Friday, Augustus Jr. stepped on a nail on the way to school. He was brought to the local hospital and given some antibiotics and had his wound cleaned out. On Sunday, August Jr. was dead. "Tetanus," Augustus told me. Because of the war, vaccination programs had ground to a halt and many children had fallen through the cracks.

As Augustus spoke to me, tears welling in his eyes, I was struck by something. He was neither bitter, though he had every right to be, nor was he emotionally detached. He firmly believed in a benevolent God, who was watching out for him and who knew what was best. It occurred to me that perhaps faith is just as important as clean water or a bed to sleep on, because faith makes the intolerable tolerable. Western donors are never going to have pockets deep enough to fix the problems caused by civil war or natural disasters. Furthermore, even though foreign aid workers like to throw around terms like "sustainability" and "cost-effectiveness," very few projects ultimately are. If, however, we can offer the sort of faith that Augustus had, faith that on the one hand costs nil in terms of resources yet is also impossible to purchase with any earthly currency, then perhaps we have made a lasting difference.

I read recently a quote from Martin Luther:
"Faith is a living, well-founded confidence in the faith of God, so perfectly certain that it would die a thousand times rather than surrender its conviction. Such confidence and personal knowledge of divine grace makes its possessor joyful, bold, and full of warm affection toward God and all created things—all of which the Holy Spirit works in faith. Hence, such a man becomes without constraint, willing and eager to do good to everyone, to serve everyone, to suffer all manner of ills, in order to please and glorify God, who has shown toward him such grace."

Augustus had this sort of faith that Luther describes, and I thought rather wistfully that I would like to have it too.

God's explosion

noreply@blogger.com (Mark) — Sun, 25 May 2008 12:23:00 +0000

Liberians are enamored of acronyms, it seems. Every sign, every store name, every window must be bedecked with an abbreviation, to give it—I can only surmise—a sense of import.

Some of these acronyms are eminently obvious: The International Church of Monrovia, for example, is always referred to by its assistant pastor as "The International Church of Monrovia, or ICM for short" (The fact that the offending appendage does nothing to shorten the sentence seems lost. But what do I know?)

Some, on the other hand, are perfectly superfluous. The John T. Fahme Provision Store has JTF, in parentheses, on its awning. Because, naturally, referring to "JTF" must obviously mean a reference for John T. Fahme. Lucky guy. Similarly, should you ever want to refer to God's Executive Praise, you are reminded that you may do so as GEP.

Some are more cumbersome than the names they abbreviate: Why you'd ever be tempted to refer to the War-Affected Women Employment and Empowerment Programme as WAWEEP is beyond me.

And then there are those the simply ironic. Does, for example, the Hope of Glory Conquerer's Chapel recognize the porcine nature of its acronym? Or is the Amputee Rescue Mission trying to be mean? (I think they might be).

Ah, but then there's my favorite. Because of the disturbing mental image it conjures:

Consider yourself warned.

The congregation of the sideshow

noreply@blogger.com (Mark) — Sun, 25 May 2008 11:27:00 +0000

I have mentioned ward church in a few posts in the past, but I've never really written about it. After today, I must.

At half-past ten every Sunday morning, all the patients that want to and that aren't, for medical reasons, confined to their beds, are gathered on one of our wards for church. Now, for those of us who come from the west, this isn't church like we're used to. This isn't the sort of church you visit to hear convicting, intellectual, well-thought-out and well-referenced, culturally relevant sermons delivered by quite possibly one of the smartest men you've ever listened to (whom I still miss). This isn't the sort of church you go to for messages about always being happy, never giving up, pressing on, having only positive expectations, and claiming the pecuniary blessings of a divine being whose sole purpose in life is to make sure your SUV has enough gas. This isn't the sort of church you go to simply to have a thing to do on a Sunday morning, or to get your rock-music fix, or to pretend that a single hour covers a multitude.

Ward church is different. It's held in a hospital ward without any windows, and it spills out into hallways without any windows. It's filled with a congregation of the transient—a group of short-term volunteers from thirty-five nations, and short-term patients from the surrounding four or five.

And today, they were dancing (what am I saying? Every day, they're dancing). It struck me, from my comfortable perch in the back of the room: the guy on congas? He was a man who, just two months ago, had a massive, fungating, smelly squamous cell carcinoma growing off his left shoulder. The guy next to him? He almost died in February from a dental infection that had spread to his chest. (The two of them have become fast friends; they come every week, despite no longer being patients). And the men and the women dancing, spurring us occidental types on to louder singing? Their faces were fantastically deformed by Brobdingnagian tumors, scarred expressionless by burns, and bandaged beyond recognition. They jumped, shuffled, and shook, with their trachs, their crutches, their legs casted into immobility. They danced, amputated. They sang, voiceless. They smiled, scarred.

In the middle of all of us westerners who sheepishly ringed the edges, this was the church of the outcast, the shunned, the spurned, the grotesque. This was the congregation of the sideshow.

And it was beautiful.

The etiquette of calendars

noreply@blogger.com (Mark) — Sun, 18 May 2008 11:47:00 +0000

I had no plans of visiting Guinea. The trip to Robertsport was enough off-road adventure for one outreach. I thought.

But, the ship maintains a departures and arrivals list, available publicly (to the crew, at least). I was perusing the this list one day, bemoaning the constant exodus of outright amazing people, when I ran across my name. Evidently, I was leaving the ship on May 6.

I had no idea.

Turns out, it had been decided that I was joining a group of four others and heading up-country—and out of country—to Guinea, in search of more patients. See, despite a wildly successful screening day in February, the entire surgical schedule wasn't filled (this, likely, is due to the fact that the ship has been in Liberia a few times before—it's actually made a dent in the need here). So, every few weeks, teams have been sent out to other parts of Liberia, further afield from Monrovia, looking for patients who might have been missed. We're flinging out a broader net.

The net, on May 6, was to extend to the eastern portion of Guinea, to the section of the country, just across the Liberian border, called Guinée Forrestière. Of the four topographic sections of Guinea—from west to east, they are Basse-Côte, a thin band of coastal land encompassing Conakry, The Fouta Djalon plateau, Haute Guinée, and finally Guinée Forrestière—the latter is the furthest away from the capital, which is where the Africa Mercy will dock the next time it visits the country. As a result, Guinée Forrestière is better served from Liberia than from its own port, 24 hours away.

It was, therefore, to the virgin African rainforests of Guinea that we set out, across roads that started out pretty well (and ended up making us thankful for four-wheel-drive control), toward N'Zérékoré, an NGO hub, and the biggest city in the region. Just outside of N'Zérékoré is a small village called N'Zao, and a mission hospital at which we were based.

Let me tell you: land borders are the same, the world over. And they are infinitely more fun than any airport immigration, because, for the most part, they are shacks, staffed by bored men and their muscid companions, and adorned with tattered calendars of yesteryear. The land border between Liberia and Guinea is no different. Except that the calendar of yesteryear was juxtaposed with a ghastly photodocumentary of Saddam Hussein's execution.

The land border is to your left as you drive, just before the leper colony (no, I'm not making that up). There are five checkpoints, each a little more thinly-veiled attempt at extracting your money than the other. There is only one such checkpoint on the Liberian side; the rest are across the bridge. That's right: four checkpoints before Guinea lets you into its embrace. It's a long, protracted no-man's land, filled with plenty of men. And women. And children. And livestock.

Which, incidentally, you don't notice are missing from Liberia until you leave the country. Guinea has livestock everywhere. You wonder where Liberia's all went; unfortuantely, the gruesome truth is that they were all eaten during the war. But not so in Guinea. The road is littered with fowl (guinea- and otherwise), pigs, goats, sheep, dogs, and cats.

Once you enter no-man's land, the demigod that sits enthroned in each checkpoint expects a little gift from you. On our way into Guinea, we were guided by a man who's lived there for nearly two decades and were therefore shielded from these dealings. On our way back, we weren't. And, I didn't realize that this was the culture until I walked out of our first checkpoint with all five passports, having thanked the guard, shaken his hand, and sprinkled blessings on his family. As I was leaving, he called to me, "Et quoi? Tu n'as rien pour moi?"

Thankfully, our hosts in Guinea had anticipated this turn of events. They had given us enough calendars (yes; calendars) for each checkpoint. This small offering seemed to appease the little demigod, and we were let through. It worked on all the others, too. Who would have thought? I may try the calendar gambit on my way into Canada.

I'm just starting to get comfortable with this African way of dealing with things. Case in point: on our second day in Guinea, we were taken up the Nimba mountain range. It forms part of the border and is eminently climbable from the Liberian side; it's a common trip for crew from the ship. The Guinean side, though, has been taken over by a mining company and is closed to foreigners. Except that one of our hosts knew someone in the local government, who knew someone else, who took the day off to show us around. And to show off his political muscles at the mining company's gate.

Because of this man's clout (I never got his name. He was simply known as The General), we were welcomed at the mine by its director. Whose smirking first words to us, followed closely by a conspiratorial guffaw from his underlings, were, "I'm glad your primary concern is healthcare and not the environment." We were shown around the compound, given lunch, and sent away on a tour of the region.

When all was over, The General also graciously took us to his home, to meet the mayor, and to dine (again) on rice, well water, and boiled kidney and liver. I'm not making that up, either.

The screening was a success, by the way. Twenty-two patients will come down to the ship in the next few months for their operations. One of these has already done so.

For this man, a twenty-two-year-old economics student, the boiled kidney was worth it. Despite a six-and-a-half-pound tumor growing on his face, he was one of the kindest men I've met. For a third of his life, he'd had this tumor on his jaw, subjecting him, likely, to insane amounts of ridicule. But when the cameras came out, he dove into each one's field. His smile was infectious. His attempts at befriending a child with a cleft lip and palate were heartfelt (if immediately rebuffed; she's in the picture too). And as I write, he's asleep on the wards. Six and a half pounds lighter.

More pictures from the trip are here.

Pita for 450

noreply@blogger.com (Mark) — Wed, 14 May 2008 20:21:00 +0000

What does it take to cook for 450 people?

I knew it was massive. We get fed three meals a day here. Each one of the four hundred fifty of us get more food than we could want, three times a day, seven days a week. Just what does it take to provide that for us?

Well, let me tell you. For one meal, it takes:

90 cups of flour
210 grams of yeast
6 gallons of water
1 gallon of olive oil

72 liters of yoghurt
100 onions
40 legs of lamb
20 heads of garlic
1 can of dried mint

4 gallons of rice
1 pound of butter
1 gallon of pasta
750 ml of salt

2 liters of lemon juice
10 gallons of garbanzo beans
2 cups of paprika

12 hours of work
5 other galley staff

and two very dedicated friends.

It was a glimpse into a part of the ship that we don't see often—a part of the ship that works hard, no doubt, and that does so with parsimonious amounts of positive feedback. So, here it is, publicly: Thank you, Peter, Tyrone, Ernest, Patrick, and Michal. Thank you, and Nigel and Margarita, for helping with the meal, and thank you (and Tim and Vandi and Eddie and Freddie and Carlos on Saturdays) for the food. Daily.

Oh, and by the way. In a totally unrelated attempt at shameless reciprocal plugging, we've just been included in a compendium of the 100 best travel blogs. We're about midway down, in the road-less-travelled section. Some of the blogs we read regularly are there too. Check them out, if you've got a lazy, rainy weekend.

Will the real Mamie Kankor please stand up?

noreply@blogger.com (Peggy) — Wed, 14 May 2008 20:17:00 +0000

Yesterday morning we were expecting a 34 year old woman named Mamie Kankor to arrive for surgery. Mamie had extensive burns to both her legs, the scar wrapping all the way around her thighs and impairing her ability to walk. She had been seen at our screening early on in Febuary and later by Dr. Tertius, our South African plastic surgeon, who agreed that she would need skin grafts to her burns so that she could move about freely again. So when we called out her name and she came in, we went through the usual procedure of getting her demographic information, checking her blood pressure, heart rate, temperature, and weight, and of course explaining to her the planned surgical procedure and getting her consent for them. She readily agreed and signed all the neccesary paperwork. After being processed by the admissions nurses she moved to my desk so that I could do a history and physical and deem her fit for surgery. It was just another routine patient in another regular day.

Except that it wasn't. "Show me your problem," I asked her. She gestured in the direction of her head and neck. "No, I mean the problem you came here for," I said, as I pointed towards her thighs. "You mean do I have pain in my knees?" she asked as she lifted up her skirt to reveal smooth unscarred skin. I stared at my admissions packet, which had the words, "circumferential burns to bilateral thighs" printed in the diagnosis section. I looked at her again, now truly confused. She pointed to her neck, and I saw a navel orange sized lump at her Adam's apple. She had a goiter.

It's a long story.

Mama Korkor is a 40 year old woman who went to an ear, nose, and throat specialist at JFK Hospital, Monrovia's largest public hospital. There, the doctor diagnosed her with a large thyroid gland. He also noticed that her eyes were more protuberant than usual and after questioning her, found that she had been losing weight and frequently felt her heart racing. These are all signs of an overactive thyroid gland, and since he did not have the ability to perform thyroid function tests at his hospital (a very commonplace test in the United States but not here-people need to travel to Ghana to get this test), he sent Mama to us.

Mama arrived early in the morning to the dock. There, her referral letter was collected along with those of the other patients waiting to be screened and brought in for our patient care coordinator, Ans, to see. Ans went out and called, "Mama Korkor." She was brought in along with Comfort, one of our translators and apparently a friend of the patient. Ans, and later our ENT surgeon, Mark, noted that although the patient did have a lump in her neck it was not an enlarged thyroid gland, but rather something called a thyroglossal duct cyst, a congenital abnormality. She was given an appointment card to return in July to have the cyst removed.

However, Mama had never seen Ans. Someone else did. Mama was sitting on the dock, waiting patiently, until our hapless admissions nurse had called out, "Mamie Kankor." Perhaps unable to understand our English, perhaps afraid to miss her opportunity to be seen, she leapt up and identified herself as Mamie Kankor. Thus chaos ensued.

We often kid ourselves into thinking that we are perfectly clear when we are not. Mama had signed a consent form saying she would accept all the risks associated with putting her under general anesthesia and placing skin grafts on her two perfectly good legs. Thankfully the error was caught early on but this just goes to show how great the power differential is between us and the patients who come to us for help. The vast majority of the patients suspend judgment the moment they receive these precious green appointment cards for surgery, and place themselves under the care of Mercy Ships with complete childlike trust. I now think back on all my prior patient interactions here and wonder if a careless word I said could have crushed someone's self esteem or buoyed someone's hopes up. May we have the wisdom and discernment to do the right thing for those who come to us for help.

Can we pull a Moses?

noreply@blogger.com (Peggy) — Fri, 09 May 2008 19:03:00 +0000

The rains are getting worse.

I ventured out to downtown Water Street with fellow crewmember Megan today. Although overcast, the weather was great. A slight breeze ruffled our hair as we clomped down the gangway in our flip flops and made our way to the main gate. Before I left my cabin, I briefly debated bringing my umbrella. However, a misadventure last weekend had left a small explosion of SPF 50 sunscreen all over it, and so I decided to leave it behind.

It started out as a relatively lucky transportation day. As we walked out of the main gate we started making a lateral chopping motion with our hands (the only proper way to hail a Liberian taxi). After about 5 minutes we were in a run-down yellow cab crammed with 6 other people, on our way into downtown Monrovia. At Broad Street, our driver turned to us and told us we had to switch cabs, to another one going to Sinkor. And so we hopped out and started to search. Buses and taxis passed us by, all too full or too busy going somewhere else. Finally, a guy driving a Cellcom service van stopped and we hopped in, on our way to Sinkor.

We had a quick lunch in Sinkor, and then tried to find another taxi. Again, an unfruitful expedition. Finally, we were picked up by a well-meaning Lebanese contractor, who gave us a ride back to downtown Monrovia.

Hitchhiking has never been my thing. However, in Monrovia, with NGO and UN workers totaling over 10,000, it is often a better bet to get a ride in one of their vehicles than to take your chances with a yellow cab. Yellow cabs here are often crammed 7 people to a car (2 in the front passenger seat and 4 in the back, plus a driver), have cracked windshields, and lack door or window handles. These Nissans and Sunnys are the most prevalent vehicles on the road, and are often plastered with slogans like "City Boy" or "God's Choice." Or worse.

Water Street is known for its fabric shops. The larger, more prosperous shops are Lebanese-owned, with proprietors who travel as far as Dubai where there is a large fabric exchange. Cloth vendors converge from all over the world to hawk their wares, and these fabric shops sell anything from cotton prints and tie-dyes to fine Japanese lace and velvet leopard print. Smaller shops usually line back alleys, and are more wooden shacks with plastic tarp than anything else. Finally individual women and boys carry lappas (one lappa is 2 yards) bundled together in plastic tubs and perched on their heads. These vendors usually sell only African prints, which are always a swirl of color, and on closer examination reveal a repeating motif—chickens, crustaceans, giant tubes of lipstick, or tree stumps.

We were happily browsing on Water Street when the skies opened up. The erstwhile roads and sidewalks quickly became a mess of trash, mud, sewage, and water. With no drains and a fierce tropical storm, we were quickly left knee deep in filth. As we debated how to reach higher ground, the local Liberians, huddled underneath awnings, started to shout things like "Roll up your pants!" and "This is Africa!." That's when Megan turned to me and asked, "Can we pull a Moses?"

Sparks

noreply@blogger.com (Mark) — Sun, 04 May 2008 20:39:00 +0000

Forgive me bloggers, for I have sinned. It has been 11 days since my last post.

And I can’t promise that this one will be altogether all that uplifting. I had to say no to two patients on Friday; saying no is the hardest part of this job.

Ballah
Ballah* is a sixty-five-year-old woman who, for the past six weeks, has noticed a swelling of her jaw. It’s a painful swelling, interfering with her eating, and causing her to lose weight (or, as our interaction went, I’ can peeyⁿ me. I caⁿ ee’ freely. Ohhh, I be reducing. Because of the worry... I’m going to miss Liberian English). She had been prescribed antibiotics for the jaw swelling, and had been sent to our dental clinic for further work-up.

God bless our dental clinic. They are the front-lines. Firmly ensconced at Redemption Hospital, a former MSF hospital turned over last year to the Liberian government, our dentists, dental assistants, dental coordinators, dental sterilizers, and a vanguard of translators occupy the former pediatric ICU (which sounds significantly better stocked than it actually is. It's a room. With fans. And numbers on the wall).

They see everyone. Jaw swellings. Ma-too’-be-hurtin’s. My-breasts-be-too-bigs. And Vicki, the indomitable whirlwind of a woman who runs the clinic, brings them in or sends them away with a gentleness and a care that rivals many.

Ballah, she sent to the ship. Unfortunately, Ballah’s jaw swelling was inoperable. See, it wasn’t a simple swelling that was paining her. It wasn’t worry that was causing her to reduce. Ballah had a carcinoma of her gums, a volcanic eruption of uncontrolled tissue growth that had eroded through the bone of her jaw and out her skin, completely replacing normal tissue across about 75% of her mouth. Back home, Ballah would have required a pretty massive operation, and, after an entire day on the operating table, would still have had a significantly greater chance of succumbing to her tumor than of surviving. We would have thrown the proverbial sink at her—surgery, radiation, chemotherapy—to give her that chance.

But, here, there is a bizarre economy. In a situation in which radiation and chemotherapy are not available, in a world in which heroic measures fail more often than not, in a culture in which surgery for palliation is not understood, what is the right way to deal with Ballah? And with the other patients who would, by necessity, not be able to get surgery if Ballah did?

It’s an economy I still struggle with.

Joseph
Joseph’s* story is not much different. Fifty-five years old, retired, with a six-year history of an eye tumor, pushing his left eye forward and causing pain. It was a small thing, externally. Not one of those tumors you look at and immediately start calculating how many nerves you’re going to have to sacrifice getting it out.

Its appearance belied its actual size. A CT scan revealed a large tumor in his frontal sinus, with extension directly into his brain. And the economy reasserted itself. We have no neurosurgeons on-board. What we have is the ability to do a few, basic neurosurgical things, should they be necessary. But nothing more.

Joseph, too, succumbed to the economy. And, having experienced the Liberian health-care system first-hand, I know what we were sending him away to. It makes saying no exceedingly difficult.

But, let me tell you the story of Precious:

Precious
Precious* is Liberia. Her problems are the problems of the health care system of a developing nation. See, on February 5, Precious tripped on her way home from school. She scraped her knee and her elbow. She probably cried. She probably ran home to her mother. She probably got a hug. At home, she could have featured in any number of brightly-lit, quotidian Tylenol commercials. But not in Liberia. Here, there are no manicured front lawns with sun-dappled trees and a stay-at-home mother smilingly washing dishes over a white formica countertop. No soft-focus filters here.

Precious’s mother—a woman who commands amazing respect for the amount she has given up to care for her daughter—brought the girl to the big white hospital ship that had just, that day, arrived in Monrovia. Patients weren’t being seen for another two weeks, and, regardless, Precious wasn’t the sort of patient we could have given anything to. But mom tried. And she was sent off to one of the local hospitals to treat the cellulitis that had set into her daughter's knee.

There, Precious received appropriate antibiotics. Except that she was allergic to them, unbeknownst to anyone. Her face swelled up. Her knee and elbow got no better. And then, slowly, the facial swelling turned into outright death. The tissues on her face succumbed to a condition—unique to the malnourished developing world—called noma. Or, in its more grotesque nomenclature, cancrum oris. Noma is an opportunistic infection that attacks a slightly depressed immune system (usually after measles; sometimes after other infections), almost exclusively in the undernourished child. The bacteria that live in all of our mouths decide it’s time to feast. And feast they do.

Precious was—relatively—lucky. She lost her lips. They turned black and fell off. I’m not making that up.

But she could have lost more—others have lost lips, noses, and eyes. Her mother did not give up. Precious had been befriended by one of the receptionists on the ship, who visited her at the hospital daily. Three months later, during which time her mother had not once been home, not once left her daughter’s side, the infection had been successfully controlled and the noma had run its course.

Precious was brought on-board for reconstruction of her lips. It’s a long, four- or five-month ordeal, with six or seven stages (for those of you facile with lip reconstruction, this is like nothing you’ve ever seen before). She has finished stage I. And, for the first time in three months, mom has been home to sleep in her own bed.

What happened to Precious would never have happened at home. At home, kids eat too much. At home, they get vaccinated against measles. At home, when they scrape their knees, mom drops her dishes, runs out under those sun-dappled leaves, concern dancing in her eyes, antibiotic ointment in hand. At home, we make feel-good commercials about the very thing that has permanently scarred a little girl like Precious.

Man is born into trouble, wrote the ancients, as surely as the sparks fly upward.