Call Mama Doctor

Chapter 17. In the Shadow of a Tree

By Louise Jilek-Aall, M.D.

Having lived for awhile in the fresh air of the Mahenge mountains, the hot, humid climate of the coast seemed unpleasant and exasperating to me, and I was reluctant to leave the mountain mission. But a priest at a small outpost south of Dar-es-Salaam sent a message to me that he had some very sick people and needed medical advice. I was to travel in one of the trucks commuting regularly between headquarters in town and the outpost mission. Happily, the driver turned out to be a Father I knew who planned to visit his friend the priest at the same small mission station near Kilwa.

It was during the rainy season and traveling on the unpaved coastal road would be tedious and even hazardous, so we decided to set out early in the morning, hoping to reach our destination before the hot afternoon sun made traveling an ordeal. During the night, however, it poured with rain and the next day we had to wait until the sun dried up the worst water puddles. Still the road was slippery and the heavily loaded truck skidded from one side of the road to the other. Going down steep hills I caught myself holding my breath and stiffening my muscles as if this would help to keep the truck on the road. On approaching the Rufiji River we found that it had overflowed its banks and flooded the fields. The water stood about one foot high on the road. The young boys who had been sitting on top of the loaded truck laughing and commenting on the Father's driving skills now slid down and waded in front of us to show him where to drive through the murky waters.

We reached the ferry landing without mishaps and looked for the ferry which was to take us across. There appeared to be some difficulties with a car on the other side, for we could see people standing on the riverbank gesticulating and running up and down. We had to swallow our impatience and prepare for a long wait, so we joined our good-humored boys in the shadow of a tree. As everywhere in the African bush, people turned up seemingly from nowhere and soon we were surrounded. They asked who we were and where we were going. As soon as they found out I was Mama Mganga some boys darted off towards a distant village, water splashing high as they ran. After a while a little procession came slowly marching towards us from the direction of the village. As they drew closer I could distinguish two men carrying a crudely made stretcher, presumably with a sick person. A burden descended upon my shoulders as I nervously watched them approach; who knew what problem they were bringing to me! The men put the stretcher down in front of me and the women and children who had come along stood around. The sick person was completely covered by a blanket in protection from the sun, and as I pulled it aside I was gripped with fear. Sleeping sickness! I knew it right away; the man held his arms and legs flexed in the typical posture of a patient in the terminal stage of the disease.

Sleeping sickness is caused by the parasite trypanosoma gambiense and is transmitted to humans from the blood of wild animals through the tse-tse fly, glossina morsitans. The painful bite of this fly is the nightmare of anybody traveling in trypanosoma infested regions. The parasite, once in the bloodstream, will infiltrate vital organs, producing toxic inflammation in the heart, the bone marrow and the spleen, causing excruciating pain and weakness. It has a special affinity to brain tissue and once having taken a hold there causes the typical stuporous sleep which gives the disease its name. The emaciated man before me was in this last phase of the dreaded illness. He was asleep and when I tried to awaken him he uttered a few confused words with a slurred voice but did not wake up completely. Clumsily he tried to ward off my touch with trembling hands. His swollen face had a stupefied expression. I knew it was too late; there was nothing I could do. Had he been brought to a hospital sooner he might have had a chance. The specific medication, a drug containing arsenic, can only be tolerated by patients in good general condition; it would kill this man now.

It is painful to have to admit to oneself that there is no hope for a patient and I knew from experience that these people would never accept such a verdict. They would believe that I did not want to treat the patient for some reason. Their friendliness would quickly turn into hostility and the news of my unwillingness to help one of them would travel fast and reach the mission station long before my arrival, making it nearly impossible for me to treat patients there. All this went through my mind as I stood there in the shadow of the tree, looking at the poor man. I knew he would go on sleeping until his death which was probably only a few days ahead. I quickly made up my mind to give this man an injection of a vitamin B preparation; it would do some good to his emaciated body. “This man is very ill;” I turned to the older men who had brought the patient. “I will have to give him a dawa ya sindano.” I could see approval on their faces. Sindano is the Swahili word for needle, and dawa ya sindano means medicine given by injection. To the people's understanding, only the most powerful medicines are given this way. Sick people would often ask me for a sindano without being the least concerned about what they were given.

The family looked on in deep silence as I performed the usual “ritual” of preparation. They stood motionless as I spread out a clean cloth on the ground, unwrapped the box with medicines, took the syringe from its alcohol filled container, mounted a needle, filed off the point of the vial and then drew up the liquid medicine. Eager and gentle hands turned the patient on his side. As I cleaned the skin with alcohol and slowly injected the liquid into the muscles, I looked at the men helping me. I thought I could read in their sad eyes that they knew the sick man was going to die. Surely they must have felt that I knew it too. It was as if we had a gentleman's agreement to say nothing but to give the dying man the sindano for the sake of his family. At least the distressed relatives would have the soothing feeling that everything possible had been done for him.

While the others prepared for the return to the village I spoke to the two older men. I warned them to look out for early symptoms of sleeping sickness in other villagers. I told them to pay attention to people complaining of headaches, fever, general weakness and pain in the heart and in the bones. If a person with such symptoms developed fast heartbeat and swollen glands, he should be suspected of having contracted sleeping sickness and should be taken to a hospital. I assured the anxious men that medical treatment could be quite successful if the disease was treated in its early stage. The men listened attentively and before leaving grasped my hand with both of theirs, thanking me profoundly with tears in their eyes. I could see the little group of people wading homewards through the flooded fields as we were slowly ferried across the river.

The Father told me that the forest and savannah around here were full of big game. They made up a vast reservoir for the protozoa causing sleeping sickness. The government health services had urged people to clear the bush for an area a mile wide around the villages to keep the tse-tse flies away from the huts, but the men who went out hunting could not avoid being bitten. In areas where the game was massively infested about one third of the flies would carry the deadly trypanosoma. Still, only some people bitten by such carriers still actually develop the fatal type of sleeping sickness we had just seen. Others may only suffer from a slight malaise. Their lymph glands will successfully conquer the invader before it has a chance to spread to other organs.

Badly shaken by what we had witnessed, the Father was speeding up to get through this inhospitable region. Being less cautious, he overlooked a shallow spot on the road where the sun had not yet dried the surface. The truck skidded helplessly and before the driver could prevent it, one of the front wheels sank deep into the slough and we were stuck. We all had to get off. I stood in the scorching sun and watched the sweating boys unload the truck and pile the goods at the roadside. Not before the truck was completely empty did they succeed in jacking it up and lifting the wheels out of the mud. They had to chop off branches and place them in front of the wheels to prevent the truck from sliding into the mud again as the Father carefully maneuvered it onto safe ground. While we waited myriads of mosquitos feasted on our arms and legs. I did not mind them too much though. I knew that I was immune to their stings as I never missed taking the antimalaria medicine. It was the tse-tse fly which made me nervous. Anxiously I watched for the brownish insects. They had the habit of sitting in wait on smooth, sunwarmed surfaces from which point they suddenly dive for their victim, aiming at the nape of the neck or some other place difficult to reach. Their bites cause intense pain and a shiver of fear down the spine. The driver of a car is especially vulnerable as he cannot watch out for the insects or take his hands off the steering wheel quickly enough to chase the vigilant flies away. In spite of our watchfulness we had all received a few agonizing bites when we finally were ready to drive on. Our fear made us keep the truck windows tightly shut as we drove through the tse-tse infested bush, even though we were nearly cooking in the overheated cabin.

It was already afternoon and the sun was shining mercilessly at us through the front window. My head was burning and I felt nauseated; my skin became flushed and oversensitive from heat, moisture and the many mosquito stings. The ghastly sight of the man dying from sleeping sickness would not leave me and made me sick at heart. I could not help wondering if by now one of us might be harboring those deadly parasites. Of course the chances were small, but the Father must have had the same thoughts because he asked me what would be the yearliest signs of an infection. To boost our spirits I told him about the newly developed medicine pentamidine which, if given early, cures the type of sleeping sickness we had seen. At any rate the incubation period was twenty-one days, I explained, and we would by then be back in town and could have a blood test if we noticed a swelling around the site of the fly bite or a slight rash on the skin, symptoms indicating that the fly had been carrying trypanosoma.

The Father fell silent and I did not know whether he felt as miserable as I did, but when we passed through a village and I asked him to stop for a moment to breathe some fresh air, he willingly complied. He pulled the truck to a halt under a big tree in the middle of the village square. As we staggered out more dead than alive, the air in the shadow was heavenly cool in contrast to the heat of the cabin. Again people swarmed around us. Children stared at me with curious big eyes but recoiled when I tried to touch them jokingly. A man in police uniform came up to us and spoke to the Father. He then turned to me. Could I please see a woman at the police station? She had tried to commit suicide and the police officer did not know what to do with her. I resigned myself to the fate of never getting a rest anywhere and followed him. The crowd of women and children swelled as we went across the square. They had to be pushed aside so I could enter the police station. In the darkness of the stuffy room I saw a sinister looking young woman with an unwilling, dull expression sitting in front of me. Through the noise of the curious people outside, I looked into her withdrawn face and asked, “Why did you chose to take your own life?” The woman looked at me with dark, expressionless eyes but did not answer. “Did your husband beat you?” She gave a slight nod. “Can't you return to your father's place?” She looked at me again, this time with some surprise. Perhaps my knowledge of local customs brought us a little closer. “My husband will not let me go and I can't stand living with him, so what can I do? I have nothing to live for.” Her voice was low and monotonous. “Don't you have any children?” She blew the air through her nose in contempt, “With that man!” She did not elaborate. “Does your husband not have other wives?” Again that surprised look. “No other woman would ever live with him,” she said scornfully. “Could you not ask for a baraza, a village court hearing?” She shrugged her shoulders. “I would lose, of course. I have no rights, I am only a woman.” Obviously she had given up. “What are you going to do then, when you get out of here?” I asked hesitantly. “Kill myself,” she answered with a tired voice. She got up and turned away without looking at me and went into the cell with stooped shoulders and drooping head.

In the sweltering heat of the little office I tried to think out a solution to the problem. When I finally came out, some village elders had joined the crowd. “Unless you return this unhappy woman to her father and prevent her husband from taking her back, she is going to die.” I spoke out loudly so everybody could hear what I said. I refused any discussion of the matter and returned to the shadow of the tree. By stating that the woman would die unless certain actions were taken and by avoiding mentioning her intention to kill herself, I had placed the responsibility for her life in the hands of the people. Up to now the neighbors of the desperate woman must have been rather indifferent to her suffering, but if she died now through suicide or otherwise, her death would be blamed on them for not having acted according to my suggestion.

There was no way I could take a rest in the shadow of the tree. People were jostling around me demanding my services. The Father was already seated, waiting for me in the truck. Only with great difficulty could I climb into the cabin. People looked at me with scorn when they realized I was getting away and angrily banged their fists against the sides of the truck as we slowly made our way through the crowd and drove on. The strain of all that had taken place on this day had exhausted me. I felt faint and utterly worn out. As I sat there dazed by the heat and fatigue, my thoughts could not find peace, even though I nearly dozed off. The arbitrary way in which things happen plagued my mind. Within such a short time span, I had played a part in two human tragedies. Regardless of my own feelings, they had presented themselves to me, naked and merciless as life itself, and I had been forced to act. First the sick man; he wanted to live and I was not able to help, yet his friends had thanked me with tearful eyes and warm handshakes. Then the depressed woman who wanted to die; I was able to help her, yet the people had not thanked me but had shown scornful eyes and clenched fists.

My weary mind went on working at such puzzles. When circumstances forced me to stay in the shadow of a tree without wanting to, I was not given a chance of saving a life, but when I was prevented from staying in the shadow of a tree although I wanted to, I was given the chance of saving a life.

It did not seem to make any sense.

Copyright © 1979 Louise Jilek-Aall
Reprinted with permission

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