Week 01: Standing in the Silence

Listening, Learning, and Asking in the Margins of Care

After being in the hospital last year, we had to remind ourselves that it was important to become acquainted with our surroundings and ease into our work. We would not start our interviews for a few weeks, but begin asking questions and establishing trust with our new coworkers. The questions were not about the medical nature of an issue, but about why it happened, taking a true ethnographic approach. 

Wednesday: 

We arrived late and a bit on edge due to our unexpected tardiness, but ready to start anew. We stood at the front, immediately being examined and observed by the packed room of doctors, students, and nurses. First, I was a bit confused as to whether this meeting was a meeting for just internal doctors or everyone. Lots of doctors were on their phones during the presentation and were silent when Dr Tom asked them questions about the case being presented. Additionally, with being so soft spoken, it was hard to hear questions, if there were any. The morning meeting lasted just about an hour, so that’s an hour of standing and listening intently, deciphering the soft-spoken broken English mixed with Swahili words. 

We then met with Father Benjamin, the head orthopedic surgeon, and he questioned why we were repeating research Dr. Strong had conducted last year. We did our best to explain the difference and how we would be under her guidance, but conducting our own projects. We then spent the rest of the day in the medical outpatient department clinic (MOPD), where we saw case after case of hypertension, diabetes, heart failure, and chronic illness. Although there was diversity in some cases, there was almost always a limiting factor to care: cost. Dr. Magdelena alternated between her own login and one of her chief's, an internal specialist, to enter prescriptions so they would be covered by the national health insurance if they weren’t paying cash. Her commitment to providing care despite the financial issue of each patient stuck with me. How can compassion fit into medical care here and across other cultures? 

Thursday: 

Arriving earlier today, Lucy and I secured a seat for the morning meeting, avoiding having to stand in the front and be inspected by curious eyes. We listened to the morning meeting case of an 82 y/o woman with hypertension, edema, and difficulty breathing. The cause of her issues was chronic alcohol consumption, causing heart failure (HF). They mentioned using morphine for her chest pain, my attention piqued since we rarely saw morphine used last year at this hospital. As we rounded, we visited this patient and I inquired if she would get morphine, as diagnoses, prescriptions, and perceptions change by the minute and between doctors. They confirmed she would get it and followed up with the nurses to ensure her needs were met. 

Later in the clinic with Dr. Mag, we saw more cases of chronic illnesses and some more interesting ones. One patient was 29 y/o and had progressive heart failure. This was odd to me as he had HF, chronic kidney disease (CKD), and edema, yet had one of the lowest BP of 102/81 of all of the HF and similar patients. Obviously, there was something wrong since he was so young and had no previous symptoms of heart issues throughout childhood until 3 mos ago when diagnosed with cardiomyopathy. I asked Dr Mag what his prognosis/life expectancy is, and she said he will be on HF meds for the rest of his life and should have 10-15 years left. Without knowing the cause of the HF or the ability to easily find out, it is harder to know what lies ahead. Learning about the high rates of non-compliance with medications, I wonder if he will comply and keep his health, or risk shortening his life for fear of stigmatization. 

Friday: 

After taking instruction from Dr. Mag, we skipped morning meetings and joined major ward rounds in the ICU to listen to a cross-cultural tug-of-war about the treatment of a young diabetic patient, arguing over whether her glucose levels or an infection was the cause of her illness. No conclusion was made as we moved to the male ward, seeing a known AIDS patient convulse in front of us, hands and legs stiff. Prescribing an expensive CT scan and some anti-seizure medicine, we continued the rounds in the female ward. We followed up with the patient who was previously administered morphine, and I enquired again, wondering if she would get more today. Dr. Mag responded no, “it wasn’t bad enough” for morphine. Frustrated, I wondered how Dr. Mag knew what she was feeling and why she wouldn’t receive treatment for her pain after it was specified yesterday. We did a quick visit at the clinic, where we saw an 80 y/o patient who wouldn’t answer questions and seemed very out of it. I question how Dr. Mag knows if patients are in pain if they cannot speak up or advocate for themselves.

Final thoughts: 

During our first week here, our ability to speak Swahili was overestimated, and we were often left in the dark on details regarding care. This motivates me to ask more questions next week and be a nosy ethnographer who asks annoying questions. Still, we continue to show up, listen to the best of our ability, and forge friendships that will grant us access to future interviews.