The challenge of acceptance

For some reason (perhaps the planets have aligned in a unique way – more likely not), I have found myself challenging the same issue a number of times today. I am not sure that today is particularly special in fact, rather perhaps that my exposure to this recurrent issue has finally reached a critical mass and (rightly or wrongly) I have felt compelled to make some efforts to redress it. Or perhaps I have reached a place of confidence in my presence here and feel able to. Or perhaps I am just exasperated. Regardless, it is endemic to this part of the world.

It is the matter of acceptance.

It is not, I believe, that people here are indifferent to the huge problems that they face. Far from it in fact. Rather, I believe that things like death, inadequate resources, interrupted supply chains and poverty have become so familiar that they are ingrained into the culture as ‘just the way it is’. People are extremely grateful for what they have, and, accept what they do not. In many ways this is a hugely admirable perspective to possess. Many a book that I have read about mindfulness extol the importance of such an approach to life. To reach this place of universal acceptance is to find a sense of supreme satisfaction that enables you to live a life of genuine happiness. Whatever ‘deal of the cards’, ‘role of the dice’ or ‘twist of fate’ you find yourself with, you are content. Somewhere within this paradigm probably lies the secret to why Tanzania is such a beautiful place to be, and why, perhaps, people here are so happy. It is also possibly something that we, in the West, could do with a healthy dose of reminding about.

However, acceptance can easily roll into indifference (it is a very fine line I think) and it is certainly very easy for this to also drift into a closed, fixed mindset (simply, this limits significantly what can be achieved). Whilst I could give you countless examples of a closed, fixed mindset back home in the UK, here I believe it is particularly problematic. Furthermore, I believe perhaps somewhere within this complicated matter, lies one of the greatest challenges that faces a country like Tanzania.

(I have probably very inadequately addressed what I am trying to write here and completely accept that ‘musings’ this time might in fact be ‘ramblings’. However, to continue…)

Now that I know what I am looking at, I see it all around me. There have been clues everywhere.  This morning there was another child death. A three year old diagnosed with severe malaria. They attended the hospital and were treated for severe malaria. They died from severe malaria within 12 hours of arrival. Except that they might well not have had “severe malaria”. They essentially presented with a clinical picture of severe sepsis (I think most will understand such terms). This is bad and in the UK the patient’s care would be rapidly escalated. The child would almost certainly receive a dose of strong IV antibiotics within the first 20, possibly even 10 minutes of arrival. Here they did not get any. Blinkered by the finger prick malaria test (which I am told is positive in up to 80% of the population – it indicates exposure, not necessarily active infection) the course of management was decided. Perhaps sealing the child’s fate. I may be being unfair, the child may have had severe malaria and despite the best possible care, died because of a late presentation. But they might not.

I have listened to several such stories (and you might recall the dilemmas I faced in the older child I ultimately performed a laparotomy on towards the beginning of my time here). Perhaps they did all indeed have severe malaria, with parasites overwhelming their immune systems and ability to survive, but I am suspicious that several of these cases did not. Today, as we were moving on to the next death, I questioned the diagnosis. I asked what the parasite count was (which we can do here and would provide definitive diagnosis) and also when the child received the first dose of antibiotics. There was silence. Then some discussion. Cats and pigeons come to mind. I think there was some useful discussion. Certainly, there was very positive support for what I was suggesting from the senior medical staff. Perhaps it is a small step towards broadening clinical thinking.

Exploring this matter of acceptance further, I have come to recognise that there is a reluctance here to question what is suggested or presented as fact (for example by a positive MRDT result (malarial finger prick test). It is very apparent when talking to medical students. You can also easily uncover this in any clinical situation if you adopt an educational role and try to encourage clinicians to broaden their differential diagnosis. It is particularly problematic if a patient has already been assessed by another clinician of the same level.

As an individual who has never been shy to ask questions (many a raised eyebrow and nodding head reading these words perhaps), I find this particularly interesting.

The next death was no less harrowing. A maternal death following emergency caesarean section with heavy blood loss. There were warning signs post op. Why didn’t they take the patient back to theatre?

Rounds were brief and we had managed to salvage a few cases for theatre today (the blood crisis persists).  However, we were bounced. Our access to theatre was denied. Once, twice, thrice and then a fourth time by emergency caesarean sections. I did ask whether we could run parallel theatres, but when I discovered that one of the cases had progressed to an emergency hysterectomy for a ruptured uterus. I found myself just accepting. The baby had died. Sometimes, it is definitely better to just go with the flow. I occupied myself admirably whilst waiting – home for a cup of tea and paperwork, I even squeezed in a bit of DIY (fitting a wall fan that we had been waiting to be replaced for over a month – when it didn’t work, I quickly uncovered that the previous ‘faulty’ fan had been wired live to earth. Hmmm. Well at least it is all sorted now).

On my way back to the hospital I crossed paths with the pharmacist. Disappointingly, all the time I had spent trying to understand the logistics and supply chains seems to have been in vain. We were apparently no closer to being able to stock the drugs for BPH or new sutures that I had requested over a month ago. Why not? Great question? Quite a long discussion ensued. The long and the short of it was that I have encouraged some lateral thinking, perhaps asking other departments how they manage to get such things. Again, perhaps we have made some progress.

We eventually got into theatre, overlapping with the final C-section. Unfortunately, the air-conditioning unit in theatre two was broken. To say I sweated my way through a difficult inguino-scrotal hernia repair is an understatement. I think I would have been drier if I had lain down in a bath. Sweat dripping down my back as I operate is definitely something I have had to get used to here. But today, with the air-conditioning out, it was a particularly special experience. Although I did have to smile as the very considerate theatre team started to fan me with papers in a very ‘emperorial’ way. Unprompted, they then then proceeded to mop my brow and neck. Ha! They should see me after my morning run!