How well do we prize life, how important is it to be alive and stay alive?
In the developed world, life is sanctioned, its sacred, when death occurs, even if it is expected, it is still shocking and somehow unexpected. In a society that we come from where we are almost immortal, death is a distant and intangible concept.
What if you live somewhere that death is a frequent occurrence in all, be it young, be it old be it in-between. What if you never lived long enough to think about pensions, life insurance or inherited cancers you would develop....?
Life seems so less prized here and death is so common fold it is not even thought twice about. The death of children I have often ranted about in my previous blogs, but it is unacceptable and alien to me to have children die in front of my eyes, but here I fear it is normal. The usual culprit of the herbal doctor poisoning continues, with no justice. Post mortems are so rare, there is a very strong cultural resistance to them and the cultural preference supersedes the actual legal requirement, so patients die and we never find out what happened. If we don't know what happens then we can make anyone culpable. Such is the way.
Child abuse is another area that when suspected we investigate medically and socially but the end result seems to be the return of the child to the home. With large numbers of people living together and little elsewhere to go, there is a very little to do. We have social workers who do home visits etc but there is no safe haven and placements are so rare and queues very long. Again collecting evidence, processing it and having valid specialists to process forensic evidence is such a distant reality.
A recent mortality ward audit meeting revealed the actual incidence of young adults dying very abruptly. I have wondered to myself how with a ward with a mortality rate of 20%, I have been relatively impervious to the potential emotional impact whilst the paediatric ward deaths had a profound affect on my mental health.
It boils down to common themes, the language and the culture are miles away from mine, so being to empathise with problems is incredibly hard. Not speaking the language and having a translator immediately takes away a lot of the finite parts of the doctor-patient relationship. You never quite get a right answer to your question and in a reciprocated way the patient never reveals very much as you are as alien to them and I guess they know you wouldn't understand their beliefs, I suppose this is not too untrue. The lack of a true rapport in a way acts as a protective factor against ever getting to 'know' your patients, to having their story of their rubbish social circumstances and daily struggle to get enough food.
Almost everyone is on the brink of starvation, not being able to afford food for themselves or their families, the transport problems - living miles away and having no money buses, having to travel ages to do or get anything, being at the mercy of any driver who will give them a lift.....every now and again you do get tied to one persons story of struggle and feel your arm is being twisted to pay for someone's bus fare or signing someone off for a disability grant.
To retract a bit and home in on the disparity of cultural beliefs, I need to explain via example, stroke is a very good example, here it is not a reason to see the doctor. I have seen numerous patients who are brought in by relatives and are plonked on a stretcher and then come to see the doctor for something completely different, like toe pain, I have come to realise since then that strokes are not seen as medical problems. To the locals it is a form of bewitchment, so when it happens, it is the iSangoma one sees. So for that reason we see few strokes or late stage strokes when they have become difficult to manage at home or developed aspiration pneumonias. Other examples include the psychotic patients (commonly to other cultures too) who are sometimes promoted to iSangoma level for their psychosis.
iSangomas I know I like to hold responsible for societies profanities but having found out recently that they were suggesting to young men with HIV in the area that if they had intercourse with a virgin or young girl they would be cured of the virus!! Which may be one explanation for such high rape rates particularly on the young orphan girls.
Basic explanations of medical conditions can be a real struggle, because some people have never had even basic anatomy lessons or simple medical exposure like you layman off the street does in the UK. People do not often what a heart is let alone where it is, they don't understand after a miscarriage you cannot reinsert the aborted foetus. We take simple layman knowledge for granted, but realise its true worth when trying to make people take responsibility for their health. Patients stopping diabetic medication and hypertensive medication because their BPs were ok and sugars were ok, even after rigorous explanation that the diseases are chronic and not treatable but managed. But i suppose the management of chronic disease is pretty much a worldwide problem!
The human psychology can be strong in many ways to the extent it is cold. I think of the number of death certificates i have signed, it has become pretty much another chore. Those being familiar with defence mechanisms terminology; denial, intellectualisation, projection, run rife here, you see it especially in those who are here long term, and it is perfectly understandable.
Death is a very normal phenomenon, its the end of the cycle of life, on this Earth anyway.
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