Week 02: Between Knowing & Doing

Navigating Care in Constraint

This week immersed me in the layered complexities of clinical care in a low-resource setting—where medicine intersects not only with biology, but with economics, social stigma, language, and improvisation. Practicing medicine here is rarely linear—it's an adaptive, daily negotiation between what is known, what is possible, and what simply has to be accepted.

What stood out most was the tension between knowing and doing. Diagnoses unfolded with thoughtful clinical reasoning—stroke, DKA, renal failure, Kaposi sarcoma—but action was often stalled by resource gaps: unavailable tests, unaffordable imaging, and chronic shortages of blood or medication. Time and again, I witnessed the heartbreaking truth that confirmation does not guarantee intervention.

One woman suspected of having a stroke couldn’t receive any further treatment because she couldn’t pay. The chief doctor paused after her case was presented and simply said, “Let’s keep this patient in our prayers.” That moment struck me—it was sincere, not dismissive—but also sharply emblematic of what medicine looks like when hands are tied by cost. I heard this statement several times, each time emphasizing the limits of physicians in this country. 

Blood availability became symbolic of these limitations. One leukemia patient was languishing after receiving just one unit of blood due to shortages—transfusion options were not a matter of clinical choice but dependent on whether a cooler of blood could be secured from another hospital hours away. I learned that here, relatives are expected to donate blood, which is then sent to Dodoma for PCR screening for HIV, hepatitis, and other infections before it is sent back. The process makes perfect sense from a safety standpoint—but in emergency situations, it creates delays that carry real consequences. If blood isn’t available through the blood bank, there is always the calculated risk of receiving blood from a family member with a match, the blood screened for HIV and Hepatitis and the patient could sign a form saying they understood they were receiving “unsafe” blood. Another patient, with liver disease and profound anemia, had a relative warming a donated unit of blood beneath a kitenge as they waited to transfuse. That image—striking in its intimacy and improvisation—is a perfect example of the necessity of both biomedicine and family members when in the hospital. 

I was struck by the fluidity of diagnosis, often shifting day to day due to new findings, communication gaps, or lack of consensus. Misdiagnosis looms when imaging is delayed or clinical information is lost in translation. Confusion was common, not due to incompetence but due to the fragmentation of information and limited use of electronic records. When tests can't be ordered quickly—or information conveyed confidently—diagnosis becomes slippery. 

There were many cases that left me emotionally conflicted. A 17-year-old boy suffering from malnutrition because his mama was a chronic alcohol user and would prioritize her drinking before her children’s hunger. Another with a large infected mass growing from his foot—possibly Kaposi sarcoma in the setting of HIV—and increasing respiratory difficulty that could signal metastasis to his lungs. The solution, if confirmed early, might have been amputation and chemotherapy, but by the time it was identified, options had narrowed. In cases like this, time itself becomes a treatment—or a missed opportunity.

Mental health cases added yet another layer of difficulty. A woman with HIV/AIDS was diagnosed with psychosis, but some doctors suspected neurocognitive decline or undetected meningitis. The inability to afford a CT scan meant the team debated whether to treat empirically with meningitis protocols “just in case,” but how sustainable is that reasoning when resources are already scarce? Another patient had lost consciousness multiple times with suspected GI bleeding, anemia, and previous transfusions from a different hospital. His care plan shifted between urgent and palliative as his story was slowly decoded.

Even more telling were the cultural and social dynamics that informed treatment adherence and stigma. Sister Asunta, a former nun, had stopped taking her hypertension medications, and now her condition had worsened. Her status meant certain exams weren’t performed, out of respect for her religious identity. Another friend of one of the doctors had TB but avoided taking medication in public because of stigma—taking it at 4:00 AM in secret. Teen girls, embarrassed to be seen taking ART meds at school, would miss doses or try to hide it. The stigma around disease invisibly shapes outcomes, delays treatment, and silences care.

Still, amid all this, care persists in deeply human ways. Dr. George taught at every bedside, asking students probing questions, pushing back against weak diagnostic reasoning, and offering clinical pearls grounded in pragmatism. He discussed the stages of renal failure, the logic of escalating blood tests, and the biomechanics of inhaler use (even referencing House M.D. with a wry smile). When Dr. Rachel made a clinical comment suggesting amputation might be needed, he gently challenged her, “If Dr. Rachel was your doctor, your limb would already be gone.” Blunt, but never cruel—always in service of sharpening understanding.

And yet, humor, mentorship, and kindness thread through every ward. As my tattoo peeked out from under my scrub top, he gently grabbed my arm, whispering he had one too. When I asked what, he replied “E for Edson, E for Eagle,” pointing to his back and flashing a grin. Later, we watched Rachel buy fruit during visiting hours, seated on the edge of a patient’s bed transforming the space from a high-pressure clinical space to a casual hangout. 

Even the unfinished ICU, decorated with ribbons for a blessing by the Bishop, was a reminder: sometimes appearances must precede readiness, because optics matter. But readiness, in the true sense—staffed, supplied, equipped—is still to come.

By the end of the week, I was physically tired and mentally full. The hospital rounds start early and end late, and the emotional labor is real: observing illness that might be treatable elsewhere, feeling the limits of advocacy, sitting with stories that don't conclude neatly.

So what does it mean to practice medicine where the textbook answer is out of reach? It means making decisions in the dark, hoping your clinical instincts are enough and adapting if they aren’t. It means stretching every resource, every conversation, and every drop of blood. It means remembering that medicine is not just a science of treatment but an art of response—of presence, persistence, and humility.

This week showed me that it means doing your best within limits, questioning what those limits are, and caring fiercely anyway.