Local Justice?

The death report at the morning meeting is often a slightly harrowing event. Hearing about the demise of patients is never pleasant news, particularly when they are children and especially so when I think that their outcome might have been different had they been in the UK healthcare system. Today however, it was harrowing for a different reason. We heard about a 25 year old man who had been brought to the hospital by police. He had been caught thieving in a rural village and had been beaten so badly by the locals, that he died within a few hours of arrival with us. I had heard about such things occurring here in Tanzania, but this was the first time I have actually had ‘personal’ experience of it. There is apparently a profound intolerance of crime, with particularly severe retribution for perpetrators in more rural parts. A sobering reality perhaps, but I suspect this is part of the reason why it is otherwise such a safe place to be. When ‘petty’ crime is so strongly punished, it perhaps dampens the escalation to more severe misdemeanours.

Before and After
(Suitable permissions granted)

Outpatients was again a gruelling affair, particularly so today because it is hot still and the ceiling fan has died. ‘Just’ twenty patients seen today though in that hot stuffy room. However, the regular boost from follow up patients doing very well kept us going in good spirits. I was particularly delighted to see the 4 ½ year old boy whom I had excised the large lateral abdominal wall lipoma. The scar is small, the wound healed well and even after just two weeks you can barely tell that he had such an extensive lesion removed. His grandmother (another motherless child) had determinedly kept the compression bandage on as per my instructions, and whilst it was grubby to say the least, there was not even a hint of seroma or haematoma formation (when you remove a big lesion, the potential space left behind can fill with fluid or blood and be quite a nuisance).

Of course, it never is all ‘good news’ (which is the same as any such clinic anywhere in the world). The older man with probable lymphoma and the young man in his mid-twenties with a fixed epigastric mass were particularly difficult to see. With access to what would be considered routine investigations in the UK (CT and special blood tests) only available in distant referral centres, it makes satisfactory management of these patients basically impossible. You can recommend these tests, write the referral letter and encourage them to go, but they probably won’t (logistically or financially prohibitive for them). And they are even less likely to come back. It feels like guess work. I suspect the young man has some kind of bizarre cancer (possibly liver, possibly stomach), but without investigations we could not be sure it isn’t something else (like a huge liver abscess). In the UK, even if he did present with an unusual and advanced cancer, there would always be some kind of treatment option (such as palliative chemotherapy), here the only realistic pathway is to try and achieve good basic palliative care. He had that harrowing look of pending death about him. He seemed to know. He seemed resigned to what his body was instinctively telling him. So sad. Oh how I wish I might be wrong (but I am a certain as I can be that I am not). So young. Such a harsh roll of the dice.