Week 7: “The Last Signatures: Fieldnotes from a Week of Endings”

Fieldnotes on farewells

This final week at Tosamaganga was a slow unraveling—of cases, relationships, and the rhythms we’d come to know. It was a week of goodbyes, of quiet grief, and of trying to hold together the fragments of a place where medicine is practiced in the open, and care is always a negotiation.

We began with Bibi in the private ward, her metastatic breast cancer managed with morphine stored in a recycled water bottle. The image was both resourceful and heartbreaking—pain relief improvised, dignity preserved in fragments. She was being referred to Dodoma for chemotherapy, a reminder that even in private wards, care is often deferred elsewhere.

In female, Jane’s long journey through local hospitals culminated in the start of hemodialysis. Another bibi, still undiagnosed due to financial constraints, prompted Edson to ask if I could contribute money. It was the first time in seven weeks that he had asked me, and it felt uncomfortable—not because of the need, but because of the timing, coinciding with the arrival of another American group. The shift in perception, the subtle recalibration of roles, was palpable.

Edward, still ill, had finally been transferred to surgery, but his chart hadn’t been updated in days. The copy-paste documentation felt emblematic of a system stretched thin—where even recordkeeping becomes a ritual of survival rather than precision.

Rachel’s absence was quietly devastating. We never got to say goodbye, and her leave meant Edson and Ema were now alternating overnight call every other night. The weight of responsibility, shared and reshuffled, was visible in Edson’s fatigue and Ema’s quiet persistence.

In ICU, the centenarian babu called out for help, his voice cutting through the clinical quiet. His death from aspiration the next day was labeled with a kind of bureaucratic mercy—aspiration being the “easy out” on a death certificate, unlikely to be questioned. It reminded me of Rachel’s story, of the patient whose family tried to end his suffering by force, only to demand resuscitation after the fact. The contradictions of care, of love, of exhaustion, were laid bare.

Throughout the week, we saw patients whose diagnoses were shaped as much by financial feasibility as by clinical need. CT or X-ray? Which test is cheaper? Which diagnosis can be delayed? The postpartum mama with suspected pulmonary embolism was improving, but her monitor beeped wildly, inaccurate and eventually turned off. The Italian doctors suggested ECHO and EEG, but the path to clarity was burdened with referrals and cost.

Steve (from Week 2)  reappeared—no longer in ICU, but in the general male ward. His case stretched back to our earliest days, a thread of continuity in a place where patients often vanish without closure. He looked stiff, his creatinine stable, but his story felt unresolved.

On Thursday, our last day, we scrambled to collect signatures, questionnaires, and fragments of data that might later become insight. The postpartum mama continued to desaturate, and we moved through the ICU with a sense of urgency and quiet farewell. Saying goodbye to Ema and Edson was harder than expected. Their presence had anchored us, taught us, and reminded us that care is not just clinical—it’s relational, improvisational, and deeply human.

This week reminded me that endings are rarely clean. They’re layered with fatigue, gratitude, and the ache of unfinished stories. Observation here was never passive—it was a form of care, of witnessing, of holding space for what couldn’t be fixed.

And maybe that’s the real work: showing up, listening, and leaving with more questions than answers. With that, we left Tosamaganga, bumping home on our final bajaji ride, grateful for our weeks spent there, but aching for what humans always want: more time.