Encounters with different types of deprivation, and a needlestick injury, helped BMA News writing competition winner Jo Cannon understand why sometimes it makes sense to hide from the truth
My hands are red to the wrist. Blind and clumsy in outsized rubber gloves, my fingers probe the uterus to find the incision I made a few seconds previously.
The nurse scoops blood from the opened abdomen into a metal bowl. She pours it through a sieve and back into the patient via a hanging drip bag and tube. Fast as she bales, the level rises.
I locate the cut and, through it, a small hard head. My fingers inch along slippery curves of back and buttock, hook miniature armpits, slide the baby through the opening and into the nurse’s hands. She wraps the child deftly and continues ladling.
Trembling with tension, I detach the placenta from its gritty bed, and drop it into a bucket. The barely anaesthetised teenage mother murmurs. With looping stitches, I secure the gaping uterus. The nurse still ladles, but the lake begins to subside.
The patient is stirring as I close the abdominal wall: no bikini-line incision, just straight up and down — the safest way for an inexperienced surgeon to get the baby out. As I push the needle through wasted muscle, I misjudge the pressure. It snags, slips, and pierces my thumb.
I volunteered with VSO in 1988, directly after completing my vocational training scheme in general practice, and was posted to Malawi. After two weeks language training, and three months learning the rudiments of surgery, I was appointed district health officer in Mchinji, a small town on the border with Zambia. At the absurd age of 28, I was the only doctor in a district of 100,000 people.
On my first day, matron presented me with a list of women and their HIV statuses, all positive. ‘Our social workers,’ she said.
These, I learnt, were the impoverished prostitutes who serviced the truckers that passed through town on their way to Zambia. If I walked past the market at night, I’d see them dance in the flickering light of oil lamps, outside the wooden shacks that served as bars.
Music poured from tinny speakers, and the young women, most with babies strapped in colourful cloths to their backs, partied to the sounds of South Africa and New York. They sold sex for less than the price of a beer or even a condom. In a country where most people subsist on less than 60 pence a day, they had neither choice nor future. The girls laughed and danced vivaciously, in denial of the wretched truth: they were terminally ill.
My needlestick patient was HIV-positive. I considered this, as I washed my injured hand under the guttering tap. I thought of it a few months later during a week of feverish illness, and again when I found a strange bruise on my thigh — until I realised this was caused by my bike saddle.
In those days, HIV-AIDS was untreatable, and the public, misinformed by the press, still believed it to be highly contagious. I remember one lecture at medical school about a new, mysterious immunodeficiency suffered by homosexuals, Haitians and another two groups beginning with H that I have long forgotten.
By the time I arrived in Mchinji, one in 10 Malawians was HIV-positive (today, the statistic is one in seven).
On the wards, nearly everyone had AIDS. Nothing had prepared me for the desperate, Dantean suffering of which the world, and even the Malawian government, seemed unaware.
For years afterwards, whenever passing traffic lit up my bedroom wall, I would jerk awake in a cold sweat, imagining myself back in Mchinji. In the absence of bleeps and phones, the ambulance would come to fetch me at night. I’d hear revving outside, and then headlights would blaze at my window.
On the short, bumpy ride to the hospital, I used to dread whatever emergency lay ahead. There was no time to brood on my health. My colleagues — nurses and medical assistants — often suffered bouts of pneumonia or diarrhoea, and their skin was pitted and blotchy. I doubt any are living now.
Years passed before I knew my HIV status. Getting a confidential test seemed difficult, and it was easier not to think about it. In the early 1990s the Daily Mail, with feigned shock and sanctimony, liked to ‘out’ health workers suffering from HIV-AIDS.
I mentioned my concerns to my GP in passing, with one hand on the doorknob, as if in a consultation skills teaching scenario. He suggested I attended a GU clinic, or speak to the Sick Doctors Trust.
As a new GP in a small town, I was embarrassed by the prospect of my patients spotting me in the queue for an STD check; and I wasn’t ‘sick’ — the euphemism for alcohol and drug-addicted doctors. I knew I didn’t endanger patients. I had lost my appetite for the bloody and heroic side of medicine, and couldn’t bear even to remove ingrown toenails.
Now I work in the inner city. Everyone eats enough, and though my patients moan when I run late, they get excellent free healthcare. Many lead lives of miserable deprivation, but of the emotional or existential kind. Crushed by depression, loneliness or addictions, some have never been loved by anyone, nor succeeded in any meaningful activity. People suffer, but differently.
Recently, as I tentatively broached DNAR with an elderly man with metastatic cancer, I was horrified to watch his morale suddenly collapse.
In a moment I had undermined the powerful, yet underrated coping strategy that supported him: denial. It took a few weeks to rebuild, but once more, we cheerfully agree that he is ‘getting there’.
I salute him. We are all running headlong into a wall. Why think about it? My negative HIV test was a reprieve, but only of sorts. Let’s dance with our friends to tinny music, in flickering lamplight, as if there were no tomorrow.
Details have been changed to protect patient anonymity.
- Jo Cannon won the annual writing competition organised by BMA News, the weekly medico-political newspaper for BMA members. This year's theme was A little knowledge.