The Normalcy of Dying

You wonder what the effect of watching loved ones die one after another could be. You think of the psychological trauma caused by a country losing so many of its young men and women. You consider the effects on morale when hopelessness seems to reign for so many years. When the president in Botswana in 2001 gave an impassioned speech at the UN (https://www.un.org/ga/aids/statements/docs/botswanaE.html), telling the world his people were threatened with the extinction from HIV/AIDS, the world responded. It really was a beautiful call for revolution, for re-thinking the notion that we should accept people dying in such impressive numbers. Investments from PEPFAR to Bill and Melinda Gates to multiple universities (like Penn) and NGOs followed, and in many ways it was inspirational that the world resolved not to let things continue as is. Twelve years later, after many successes and indeed some failures, it's interesting to see the effects of the epidemic on the ground as a medical student.

I just finished my first week at Princess Marina Hospital, and to say the least, it has been a rollercoaster of emotions. The hospital is a fascinating place. Each morning starts with morning report, where cases from night before are presented and administrative issues are discussed. Medical students line the back row, attendings sit toward the front - from diverse places like Italy and China and Cuba - and house staff fill the rest of the room. After report, young medical officers, interns and residents fly through the halls with their masks on as patients wait to be rounded on, some in fear, some grasping for air, some casually texting on their cell phones. One thing the patients have in common is that they are very ill, many on the precipice of life and death, coming in with serious opportunistic infections. As a medical student I am learning so much everyday - I'm doing procedures (did my first lumbar puncture!!) and I am engrossed in our discussions of topics like HIV and TB co-infection or cryptococcal meningitis. I love the process of thinking about the diagnosis and the challenge of management decisions in the context of a resource poor setting. For example, one of our HIV+ patients has profound anemia and thrombocytopenia, however they had no family member to donate blood for days and there was no blood available. There was also only one unit of platelets. As the patient continued to have epistaxis, the hem-onc team was hesitant to do a bone marrow biopsy. So we thought hard about how to proceed with such limited options, we thought critically about which labs we needed to send off and which procedures would be helpful - in the US, we'd send a full battery of tests without even a thought to the cost, and of course blood would be available. I'm hoping it will make me a better doctor one day gaining this perspective...

While the medicine part is great, the more personal side has been frustrating and maddening at times. The week started with the death of the Stevens Johnson patient from last week. I couldn't stop thinking about him, how much he likely suffered before he died. How is this fair or just? And how often must this have happened that some of the staff in the hospital were not moved emotionally by the possibility of losing him? Do we become numbed to such suffering? In my mind, I figured that in one week I've seen multiple end-stage AIDS patients, in terrible condition, wasting away from malnutrition. Many are not far from death. Theoretically, if I continued to see this for years into the future, what would it do to my sensibilities? How would it affect my thoughts on death? Would I even think twice about this boy?

I'm sure all healthcare providers feel helpless at many points in their career. There's only so much that can be done, and in many cases should be done to try to save someone's life. But when it's these 20 or 30 something year old people losing their lives instead of the 80 something year old, multiple co-morbidities type of patient, it boggles my mind. And from my experience as an American medical student, there's nothing normal about it. From the Botswana perspective though, this has become a new normal. And I'm not sure what can be done to reverse it...

However, what makes me hopeful is the diligence and kindness of the University of Botswana medical students I have worked with and the residents who work so hard everyday. It is because of them hope is not lost in this situation, and I think they will be the key to addressing this new normal that has arrived in the wake of HIV/AIDS. This country has come a long way from that speech in 2001, and we'll see what direction these young leaders will take. I'm excited to be a participant and a witness to this process.