“At its best, medicine is a service much more than a science.”
- Paul Farmer, MD
Long lines form when the global health team show up. In El Salvador, people arrive in the backs of trucks and then wait hours for one of our provider groups to assess their stomach pains, headaches, or dental problems. The men, all in long pants despite the heat, talk while women in bright dresses tend the children. In rural Kenya, women in cotton print Kanga wraps and men in tattered clothes come from all directions by foot, bicycle, or “boda boda” (the ubiquitous motorcycle taxis), waiting on long benches in the equatorial sun. At the medical center in Eldoret, Kenya, the hallways adjacent to the ENT Clinic are packed with people wearing US-donated t-shirts bearing the names of sports teams, universities, and companies – shirts re-sold to them by roadside vendors.
There is no way we could ever operate on everyone who shows up. What could we possibly offer to so many people?
“This is crazy!” I say to one of our hosts. “We’ll never get through them all.” During a typical workday at home, I see several patients, prepare Epic notes, check diagnoses and billing codes, click all of the boxes, and close the charts. If I am lucky, I can get through twenty people.
“We told them that the Americans would be here this week, so they showed up.” He shrugs. “No problem.”
The ENT Clinic in Eldoret, Kenya is an exercise in controlled bedlam. The handwritten records fall apart as I flip through them. The quality of the scans and ultrasounds remind me of those I saw in my training forty years ago. We jam two or three patients in the same exam room so the Kenyan and US doctors, nurses, and medical students can peer over one another’s shoulders; there is no HIPAA or pretense of privacy. Patients for whom we have something to offer nod and move to the nurse’s desk to schedule surgery. Patients for whom we have nothing nod and head home.
At the end of the day, I look down the hallway. There are still several people who have been waiting since early in the morning. “They’ll be back tomorrow,” says my Kenyan colleague. And they are.
I wonder how it feels to wait hours for an opportunity – maybe the only opportunity – to see a specialist and then be told to return the next day or, maybe, never at all.
My very first humanitarian trip was to El Salvador where we saw dozens of unfailingly gracious patients. At the very end of the final day, there were still many people outside the clinic. My wife, Kathi, who had dusted off her nursing skills for the trip, accompanied an interpreter to talk to those in line. “Lo siento (I’m sorry),” the interpreter said. “We can see no more patients. The doctors and nurses must return to San Salvador before dark and they will not be back until next year.”
“That’s all right,” one of the women responded as she shook Kathi’s hand. “Thank you for coming to help us. We will return next year, as well.”
The next day, as we waited in Houston for our connecting flight, Kathi told our traveling companions about her encounter with the grateful woman. While she was speaking, the gate agent announced that our flight to Milwaukee would be delayed several hours because of a major storm disrupting air traffic all along the eastern seaboard.
“This is outrageous!” A sunburned man near us angrily strode to the counter and berated the agent. “My family and I are heading back from vacation in Mexico and I must be at work for very important meetings tomorrow morning. I demand that you re-route us now! We will not wait!”
The gate agent, in a remarkable display of self-control, apologized and said there were no options; every airline had been affected by the storm. The man paced the waiting area, yelling into his cell phone and circling back to the counter at intervals to loudly register his displeasure. Finally, he announced that he and his family were heading to a hotel and that the airline had better cover his expenses. “You’ll be hearing from me!” Off he stormed, family in tow.
“What a contrast!” Kathi noted. “Imagine if the Salvadorans who waited had reacted that way.” We were not blind to the grinding poverty in El Salvador and had heard stories about the people’s lack of opportunity, safety, services, and health care (a process Paul Farmer terms “structural violence”), but every one of us noted how grateful and gracious the Salvadorans had been during our one-on-one interactions.
Later that evening, a plane arrived. It was a long day, but we did sleep in our own beds that night.
As Paul Farmer notes in his book, Pathologies of Power: Health, Human Rights, and the New War on the Poor,
“The voices, the faces, the suffering of the sick and the poor are all around us. Can we see and hear them? Well-defended against troubling incursions of doubt, we the privileged are precisely the people most at risk of remaining oblivious, since this kind of suffering is not central to our own experience.”
Each global health opportunity has allowed me to view life through a brighter, sharper lens. The lines are always long and colorful. My memory is filled with people, each one hoping that they will hear a word of hope and healing when their time of waiting is finally done.
This essay also appears in the Kern Transformational Times newsletter on 12/4/2020 in conjunction with MCW's annual Global Health Week. Thanks to the MCW Moving Pens and to my wife, Kathi, for valuable advice. A previous version of this essay first appeared in my blog, Reflections in a Head Mirror, in 2017.