Growing Pruritis

Medical Development in Mali Moves Itchily Along

By Caitlin Cohen

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When I was a young child my mother plopped me on the "welcome" mat on the doorstep of our pox-encrusted neighbor and her equally spotty daughter. Her intentions were good enough: to spare me the adult hell of contracting a childhood disease later on. However, her informed consent process and methodology were a bit lacking. I resented her as I sat for weeks in cold bath tubs filled with Arm-and-Hammer baking soda and scratched the walls as if the act of scratching alone, regardless of the surface, might alleviate what my doctor cryptically called "pruritis": unbelievable itching. My mother had not told me ahead of time about the consequences of playing with my neighbor. She did not explain the mechanism by which she was sparing me a worse fate. And, several years down the line, I could have gotten a simple vaccine and avoided the disease entirely. Historically, colonial medicine has been equally shoddy with respect to informed consent, unfortunate biomedical outcomes, and especially effective peer education and patient participation.

Memories of my youthful chicken-pox resentment mingled with histamines in my skin this summer as I doused my mosquito-bitten legs with the calamine lotion I brought along to Mali, West Africa. I was there, in the swarming city of Bamako, on the pretext of conducting biocultural research about HIV and barriers to vaccine implementation. While we did conduct our project, I realized within days that research was secondary to impromptu lessons in biomedical ethics. The structural legacy of colonialism, combined with the ubiquitous Malian dietigia (hospitality/ welcomingness), has created an unquestioned trust in Western medicine. This has produced an expectation—almost a demand—that biomedicine (and both the black and white people that represent it) fix Mali's problems without popular participation.

Quarantine (Aka Exclusion)

The better of the two public hospitals in Bamako is on a hillside called Point G. Point G is also home to a small quartier, or neighborhood, which holds claim to one of the only street signs in the city, though this sign is on the outside of the outer wall of the quartier, isolated from any actual streets. Point G is a teaching hospital and a relic of French colonialism; it is home to some of the oldest buildings in the city, which are a source of mildewed frustration rather than historical pride. Point G was also my daytime home—very far away from home—while in Mali

I took a requin, or shark taxi, so named because of the potential for both tetanus and motor accidents, up the hill every morning to the infectious disease ward. The chosen location of this ward is an irritating relic of colonial biomedical theory: relegate supposedly contagious factions to the farthest part of town. Getting to the top of the hill costs roughly $2—a day's salary in Mali—while the diseases that require attention there are most prevalent among poorer populations. It doesn't help that the diseases treated at the ward require more long-term follow-up than other common care like surgery, emergency care, and reproductive/maternal health. As a result, people do not seek treatment until they are days from death, making the entire ward more of a hospice than anything else. As a pastime I would occasionally go through the "dossiers" or messy paper trails of the 22 hospitalized patients and record their weights. It was not uncommon that the heaviest in the ward weighed only a little over 30 kilos because of sustained illness and undernourishment, putting me at twice the weight of a six-foot-plus tall man.

My first day I foolishly neglected breakfast and promptly fainted for the first time in my life upon watching the insertion of an IV shunt into a convulsing tetanus-infected woman. I managed to eke out a brief and grammatically incorrect "I don't feel well" in French before falling to the floor, leaving smears of terra-cotta wall-paint on the shoulder of my borrowed white lab coat. I awoke to find about sixteen interns hovered over me shoving sugar under my tongue. Ironically, this was the most dramatic medical response I saw at Point G. Even the overnight emergency room doctors reacted with considerably less urgency when receiving patients with massive skull wounds or scrotal hernias.

Everywhere I went in Mali I could not but attract attention as the tubabu (white person), whether I was considered the feeble wilting flower or the endless source of cadeaux (gifts) and medical attention. Patients would request to be seen by me despite my having absolutely no medical experience because my skin color led them to two erroneous conclusions: that I was automatically endowed with medical knowledge, and (more importantly) that I would give them free meds. Because often the tubabu does just that.

Somatic Cessation (Aka Death)

Public health development in Mali is oxymoronic. Doctors do not develop sustainable health models; they dispense medicine. It is hard not to give things away when you see children with unbelievably painful skin irritations and can picture yourself vainly dabbing at your bug bites with pink calamine lotion. Foreigners come with loads of expired meds that are not even on the World Health Organization's 'necessary medications' lists, creating the illusion of the existence of a seemingly endless supply of specialized meds in the developed world, which we purposefully deny to those in need as though they individually offend us and don't deserve quality care. Perhaps this impression is not too far off. But these gifts are not necessarily effective and perpetuate the view of tubabu as provider, as selective giver of human rights.

Similarly, most doctors in Mali (mostly Malian, though some are Nigerian, Cameroonian and Senegalese) give out medical expertise as though spouting the gospel from the pulpit. They are never questioned. You can order a spinal tap as a twenty-two-year old fourth year Malian medical student; no one will think twice about the wisdom of putting a needle into the spine of an individual who may or may not have meningitis. (Inevitably, this procedure will occur without anesthetic, for there is no palliative care.) All that is valued in U.S. medical professionals (approachability, clarity, thoroughness) are not part of the socially constructed image of the profession in Mali. If a Malian doctor speaks in language that a patient understands, it means that he is not more knowledgeable than the patient. If he examines anything but the afflicted part, it means he believes the patient to be unhealthy or at high risk for diseases. If he does not give out pills at every visit, it means he thinks the patient is a lost cause.

And so often the patients are indeed lost causes. Roughly ninety percent of the people hospitalized in the infectious disease ward at Point G have HIV. Many come in for the first time with CD-4 cell counts of less than ten. (CD-4 cells are immune cells that are infected by HIV and mark the progression of the disease. A normal count is about 1200 cells per microliter.) Mono kills these patients. Hangnails kill them. At a certain point it becomes moot even to figure out the cause of their infection. As Dandio, the sister of one patient, pointed out to me, it is no accident that the morgue is situated next to the infectious disease ward. For seven weeks, she sat on a mat in the concrete corridor outside a shared hospital room, waiting for her sister to join the ranks of the draped dead bodies that bounce down the lone paved road on little carts every morning.

Cardiomegaly(Aka Slowly Breaking Liberal Bleeding Heart)

So what, then, of healthcare in Africa? The cold economist in me says that it is cost-inefficient to provide last-ditch-postponement-of-death care when preventative services are underfunded. The solution, therefore, would be to get people to the clinic earlier, preferably before they contract a disease. Unfortunately, the majority of foreign-sponsored preventative care is culturally inappropriate and ineffective. (I am thinking of an HIV pamphlet in French which features an "if they say, you say" column. The call is "Condoms are not natural" and the response is "Like a knife and fork. Why eat with your hands?")

Prevention can't wait for science or a shipment of meds. Prevention is self-produced and can be instigated by a small number of people, provided they are not just familiar with the culture but are from the culture. Unfortunately, as a foreigner in Africa you cannot fill this role; you can only provide the initial sense of imperative behind prevention without directly telling people to prevent. (The act of instruction just breeds theories about Westerners trying to curb African population growth). The foreigner in Mali sees everything—sewers, food, sugar content, heinous traffic, clothes laundered in the Niger—as a potential public health hazard. The Malian sees it as life.

The merger of these two views, the sense of urgency and the grasp of the logistical reality, is absolutely necessary for change. The solution is to take the time to respond to the children in your neighborhood so that they stop shouting "tubabu, donne-moi cadeaux!" and start shouting "tubabu, come see our AIDS play!" Two things struck me about the lack of a healthcare system in Mali: One, that there is so much to be done. Two, that (provided you solicit some help) it is really easy to do it.

Caitlin Cohen B'07 likes to roll around in piles of (unused) condoms and laugh like a robber-baron.

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