good medicine in the far far away

i’m working from senegal this month. my friend joe and i are doing a one-month rotation for med school at the clinique borom darra-J in tivaouane, a small town about 95 kilometers north of dakar. the town is a road lined with corrugated tin shacks and stacks of tires and sonatel mobile credit vendors and women in bright red/orange/black wild print dresses with matching headscarves that leap out at you from the dust. there is no beer. no internet cafe. no hot water. but many small children who run up to slap your hand and say bonjour and then run away screaming. and many white goats ambling in the streets. and every morning the minarets shout what sounds like the entire koran at 6am when i am for some reason always in my deepest sleep under my bugnet. ive gotten used to showering a fraction of the amount i do in new york, which is probably good for me.

the clinic where we are working is the project of an investment group, aventura invest, started by a friend of joe’s. mostly they are working on developing agricultural projects but their mission also includes developing a chain of rural health clinics to support those projects, modeled on a franchise that has been successful in southern nigeria. they have plans to get this flagship clinic to use standardized forms, so they can follow patients over time instead of just managing the traditional stream of walk-ins. they eventually want the clinic to achieve enough efficiency be profitable, and then serve as a model to others.

after working there for a week, the phrase that comes to mind is, the best intentions, the gravest consequences. this is not because of anything aventura invest is doing wrong - although getting anyone we have worked with so far to stick with a complicated standard form for more than a week in the absence of someone hovering who is invested informs seems completely dicey - but more the reality i’m personally finding as i throw my fancy US medical education at the maladies of the people in this town and watch what happens.

everyone here speaks wolof, the local language, and the better educated also speak french, like the clinic’s midwives and nurses. i speak pretty good regular french, sort of terrible medical french, and joe speaks only english. so each patient visit is this assembly line of translation, including me physically demonstrating things i can’t think of the word for in french. that part is ok. my head kind of hurts by the end of the day, but it works.

the harder part is that up until now joe and i have spent 99% of our medical education at the bottom of a very tall totem pole of doctors, in a place where decisions are based on an average of three body scans like MRIs and X-rays and CTs, and about 100 variable blood tests. almost every patient we’ve seen is super sick, admitted to a hospital stocked with the highest level of medical technology, and has about 6 very complicated things wrong with them and is on at least 10 medicines at once. on top of that we have worked almost exclusively with adults, and the kids we have seen had things wrong with them ranging from the genetically catastrophic to the run-of-the-mill for washington heights, like RSV brionchiolitis, a viral respiratory infection that lands some little kids on ventilators but is always treatable. to top it off we’ve always been in a place we we can do next to zero besides the obsequious fetching of coffee and rubber operating room gloves, without someone else giving the ok.

here at clinique borom darra j, we have no supervision, no blood tests, no body scans, no ventilators, and very few medicines. we also don’t have the internet to fall back on as our tutor, when even the sort of expected like malaria and malnutrition walk through the door.

and then the director of the clinic, who has no medical training, refuses to triage patients, and spends most of her time nursing her way too old to be breastfeeding son, sends us patient after patient with “douleur au tout le corps” (pain all over the body) for mysterious reasons that the one MD who stopped by called the “disease of Africa,” and we turn to our very kind midwife/translator and after 35 minutes of questions that would take 5 minutes at home, and a physical exam yielding only pterygiums of the eyes, ask her to prescribe advil and maalox and tell the patient to come back next week when the “real doctor,” who is coming from nigeria to assess the clinic, will be in town. it would be comical if we weren’t earnestly trying to be of help and if at least i weren’t feeling like 4 years at columbia med has, in this particular setting, left me with many well-informed questions with few legit answers.

one success though. a very sweet 80 year old man from the neighboring town of thies. he complains he has lost his vision. we pull out our cards and do a vision test and our lights to see the clouds adrift in his pupils and determine he has cataracts, complete on the left, partial on the right. he says he has no money for the operation. the midwife says it costs about 50,000 CFA, or $100. we tell him to come back next week to see the nigerian doctor, to confirm, because we still don’t completely trust ourselves after this great week of medical-ego deflation… but if all this is what it seems to be, joe and i will split it and buy the operation. our education might not help this guy as much as our dollars. which is fine.

this same man also complained of pain in his legs. so i taught him a little yoga, like a forward fold and some side stretches to relieve what we determined was not sciatica but tight hamstrings. afterward he said we had lit up a light in his heart. i hope this will change when i have a bit more training in residency, but for now i am definitely a way better yoga instructor than doctor.