THE VALLEYS BETWEEN US | Sophia Gauthier
“No, no,” Wycliffe gently shakes his head. “Ana-kohoa, not una-kohoa.”
He taps the side of his coffee mug with his pen and little ripples appear on the surface. Wycliffe and I are sitting at a wooden table outside under a white plastic tent. The morning is bright and brisk and I burrow into my fleece, frowning at my cheat sheet. My half-eaten plate of scrambled eggs is pushed off to the side and his coffee has long stopped steaming.
“Tena,” he says, which means, again, in Swahili.
Five years ago, I might have been intimidated by this experience – I was intimidated by a lot of experiences, specifically those that might end in failure. But today, over eight-thousand miles from home and almost seven-thousand feet above sea level, I’m taking Swahili lessons in the mornings before rounding on the pediatric ward of Moi University’s children’s hospital in Eldoret, Kenya. It’s my first time in Africa.
Wycliffe is a fantastic teacher. He is very silly and when he laughs, he bounces up and down in his chair. He laughs easily.
Today, we have named his coffee mug, “Wycliffe Junior.” Wycliffe Junior is five-years-old and has a chest cold. I am supposed to be taking Wycliffe Junior’s medical history but I keep asking, “Are you coughing?” instead of looking at Wycliffe and asking, “Is he coughing?”
Wycliffe believes I am having difficulty with conjugation. To be fair, I usually am having difficulty with conjugation, but I don’t know how to explain to him that in the U.S. we often ask children directly about their symptoms. “How are you feeling?” or “Does your throat hurt today?” The culture shift is subtle, but it’s one of the first things I notice about practicing medicine in Kenya. The hierarchy is stricter here. At a speaker presentation a few nights ago, a Kenyan man held his hand horizontally in front of his forehead. He said, “Here is God.” He lowered his hand a half an inch and said, “Here are doctors.”
Wycliffe nods towards my eggs.
“Please, eat!” and he relaxes in his chair indicating we don’t need to rush the lesson. He can tell I am unaccustomed to the leisurely pace and smiles wistfully.
***
Rachel tugs gently at the elbow of my white coat. She is quiet and nervous; she speaks like she is humming and I cannot hear her. I tilt my head.
She swallows and tries again, unconsciously pressing her fingers to the hearing aid in her right ear, like it will help me hear her better too.
“Can you tell me why Kamau’s left arm is so… puffy?” I tilt my head in confusion. I haven’t examined Kamau. I haven’t examined most of our patients today. I spent the majority of rounds scrolling through UpToDate, trying to remember the primary metastatic spread of a Wilm’s Tumor. I color at my mental absence.
Rachel is a fourth-year Kenyan medical student and I am an American pediatric fellow. We are rounding on the same pediatric hospital medicine team. As a foreign visitor, I’m still figuring out how to be an asset here.
We make our way together across the ward. It is a small room, but the journey takes time. We weave clumsily through a sea of family members, some cradling purple plastic dishes of ugali and beans, some carting young babies wrapped to their backs in kitenge slings, some driving small children to their beds, a firm palm on the back of their heads. My white coat catches on a bed frame, I bump into a nurse.
Most of the beds cradle two patients, their sleepy parents, their neatly stacked possessions. They watch us on rounds, us and our unwieldy white coats, us fiddling with notecards, us exchanging portable pulse oximeters, us flipping through pink patient folders, us fumbling with the shoestrings that secure our medical notes.
Us shaking our heads.
Many families only speak the local dialects of their ancestors. Our Big, Important Medical Discussions are in capital “E” English, and they nod and smile when we use words like “leukemia” and “encephalopathy” to describe their children.
Rachel and I finally land in the corner of the room. Kamau is sitting up, his eyes are big and curious and yellow like an owl, his front teeth gently gnawing on his bottom lip. I kneel in front of Kamau and his mother.
I introduce myself in rudimentary Swahili and they nod politely. I unzip Kamau’s sweatshirt. It is dirty, speckled with old blood after a failed IV. Kamau is six years old but cannot weigh more than fifteen kilos. He has a stippled mass the size of a grapefruit fixed to the left side of his neck. The otolaryngologists have been hesitant to biopsy it because he has not been able to maintain a hemoglobin level above seven. Blood is scarce.
Rachel points to his arms and I take his wrists and extend them into the light. His skin stretches taut over his bones, like a sheepskin drying in the sun. I am gentle as I rotate his wrist, because I feel like there can’t possibly be enough muscle to hold his joints in place.
Kamau’s left forearm is disproportionately plump. I press my thumb into the belly of his wrist, and when I remove it, there is a soft impression. I ask Rachel to run her hands over the mark.
“Pitting edema,” she says. She looks back at me, a question poised on her lips. I wonder if Kamau’s neck mass is starting to compress his subclavian vein.
While I am talking to Rachel, I forget I am still holding Kamau’s left wrist. I feel a soft tug at the back of my neck and notice Kamau has reached out with his free hand and is examining the bell of my stethoscope. I involuntarily laugh. He is so weak and so small, but in that moment, he fills my entire space. I can no longer hear the moans from bed seventeen, or the screams from the procedure room.
Rachel and I need to rejoin rounds. I close my fingers around his tiny hand and squeeze. It is warm and still full of life.
“Good-bye, Kamau,” and I let go.
***
The death book is a black and white marble composition notebook. This one is well used: it has masking tape on the binding and its pages are thick and crinkled with ink. It sits under the admission book and a stack of lab requisition forms against the wall in the corner of the nurses’ station.
It took me a while to find the death book. I didn’t know how to ask for it. Imagine me and my thick American accent flippantly asking around for a “death book” because it’s obvious I trained in a part of the world where we don’t have a need for one. I don’t know if the local staff even call it the death book. But other visiting trainees do, and they whisper about it like the world’s worst kept secret, so I went looking.
I leaf through the pages, there are hundreds of entries from this year alone. Each page is dedicated to a single patient, like a headstone. The first paragraph is a summary of their hospital stay. It reads professionally: “four-year-old male with lymphoma” or “nine-year-old female with difficulty breathing…” The second paragraph is a summary of the events leading up to their death. Kamau’s entry reads, “At 12:32am, child found with pupils fixed and dilated.”
I’ve only been at the hospital for two weeks, but I know three of the patients listed.
Here in Eldoret, death on the pediatric wards is routine. I’ve been told that one in eight children who walk through the hospital doors leave by way of the mortuary. To be clear, the patient population here is sicker and the access to intensive monitoring is limited. These are children who come from all over, from tribes in Kenya’s interior, even Tanzania, Uganda, Sudan. They make the expensive journey because they can no longer afford to delay care.
In a few short weeks, I have become accustomed to death; I have forgotten we are allowed to grieve. When a young mother is screaming and pounding her fists into the concrete floor, crying out for her child as staff wrap him in a shroud and cart him away, we have to turn our backs and move on to the next patient.
However, the death book tells a different story. Every entry ends with “RIP.” It feels powerfully sentimental for the sterility of a medical record, a testament that the staff here are mourning too, ensuring the memories of their patients are stamped in permanent ink.
***
The Maasai Mara is a nationally protected game reserve in western Kenya, contiguous with the Serengeti in neighboring Tanzania.
It’s noontime, the equatorial sun blazing overhead, and an impala struggles to give birth. She is naked and vulnerable in the savannah, nothing but wispy grasses to offer cover for miles. Finally, her calf spills unceremoniously onto the earth. It is uncoordinated and covered in blood and stringy amniotic fluid. It writhes in the dirt below the shade of its mother’s loose belly. The two are exhausted.
Within an hour after the birth, two male lions are panting under the same unrelenting sun. One is sitting on the ground, guarding the mother impala, dead and bloody at his side. The other is trotting away, the broken neck of the calf clenched in his jaws, its scrawny legs swinging, hooves scaping the soil.
A violent birth transitions into a violent death and all I can think about are the inevitabilities of place. Back in an American children’s hospital, we like to call our patients resilient. They are resilient. But it strikes me that they are also lucky.
In contrast, here in sub-Saharan Africa, at a facility where family members line up to donate blood because there isn’t enough in stock, in a hospital where patients with cancer share beds with patients with tuberculosis because there simply is no space, in a country where about one third of the population lives on less than two dollars a day, I see Kamau in my dreams, I beg for forgiveness, I grieve for his mourning mother, and I think about the rotten luck of his loss.
***
On my last day in Kenya, we hike a steep dirt path through the Kerio Valley to the base of Torok Falls. It is an impressive 150-meter column of cold water. It cascades from the top of a towering escarpment 2400 meters above sea level, home to some of the greatest running champions the world has ever seen.
I am winded and poorly acclimated to the altitude but this is the daily school path for many of the local children who live on the surrounding farmland. They call out to us and giggle when we wave back. At one point, we pass a young boy hauling a wooden table down the mountain to sell at market. It’s hoisted over his left shoulder and he deftly descends past our hiking boots in a pair of leather sandals.
Our tour guide beams with pride when he tells me that his 16-year-old daughter finished second in the regional cross-country meet. He’s been hiking this route for twenty years and barely breaks a sweat. He’s met tourists from all over the world, faraway places I’ve never heard of, but he himself has never set foot outside of Kenya.
When we reach the base of the waterfall, we are drenched by icy waves of spray and I scream into the valley because I feel so wonderfully alive. My voice dissipates into the rift. To our guide, the Kerio Valley is not some novel tourist attraction, it is home. He knows how cold the water gets, so he keeps dry at a careful distance, leaning gracefully along a wind-carved tree.
Sophia Gauthier, MD is an Assistant Professor of Pediatrics at Duke University School of Medicine. She is a pediatric hospitalist in her real life and a storyteller in her imaginary one, with special interests in narrative medicine and global health. Her short story "Myrtle Beach" was published in Pulse.