In my 4th year of medical school, I trained at a rural hospital in Malawi, Africa. One day, I returned from lunch to find the senior nurse leaning over an unresponsive 7-year-old patient. The patient had been admitted that morning for 24hours of cough with fevers and one time seizure, diagnosed with severe malaria and possible pneumonia. As I approached, I noticed the child was breathing slow, deep, labored breaths and was drooling. I found a rapid but strong femoral pulse, an oxygen saturation of only 78% and fluid-filled lung sounds. I retrieved a bulb suction and bag valve mask, as that was the extent of our resuscitation capabilities. The nurse and I cleared the airway and assisted the child’s breaths as his mother sat next to us. I began searching for reversible causes. The nurse had already given dextrose (the glucometer was broken) and no sedatives had been given for the prior seizure. He had no meningeal signs at presentation and his Blantyre Coma Scale had been normal until just hours ago. We had started antibiotics and antimalarials on arrival anyways. Nothing else we could reverse seemed to be the cause of his acute mental change.
After giving another breath, I flashed a light over the child’s eyes-- pupils were fixed and dilated. I took a slow, labored breath myself, as I knew the prognosis of this was not good. I had seen a similar case a few days earlier. His brain had likely herniated from cerebral edema secondary to cerebral malaria. His breathing slowed more and more, and we breathed for him as his heart also slowed, until it stopped. I closed his eyes, and the mother stood up and walked into the nurse’s station where the father and two other family members awaited. I followed her in.
This was the first time I was the one to tell the parents their child had just died. My nurse kindly translated, and I asked him to adjust my words as he felt appropriate. I explained they did the right thing to seek care early, and we aggressively treated the malaria but the malaria became serious rapidly, as it can do. It progressed beyond our control, and now their son has died. Though the mother had been with me during the event, she seemed to need to hear me confirm the death for it to become real and definitive. She began wailing. I knew that wail, everyone in the ward knew the wail of a mother mourning her child’s death. I said I was very sorry for their loss and asked if there was anything I could do for them. The mother’s cries softened, and the father responded that he needed the accounts department to settle the bill and call for a ride. I was surprised by this pragmatic response to such a profound loss. He didn’t cry or scream. He didn’t blame me or anyone else. Life went on. The staff and the family seemed to understand loss is part of life. Having seen the response of the staff and other families before, I noticed my own demeanor had become less shocked, less staggered, and more graceful than it had been on previous malaria deaths I had witnessed. The villagers helped me start to understand and accept death as they did.
When the family left for the accounts department, the staff informed me that the hospital bill of 6000 kwacha (about $8) needed to be paid for the family to leave and without a ride, which costs 4000 kwacha (about $6), the father would walk 12km home, carrying the dead child in his arms. Knowing the minimal financial resources, I went to fetch my money, but when I returned, they had already started walking.
In the evening, still troubled by the event, I went for a run. Many people walked along the dirt road next to me, and I let the beautiful African sunset and gentle breeze lift the weight from the day’s heavy events. Then, I recognized a man’s grey suit coat from the back. All the weight suddenly plunged back into my heart, pulling it down to my feet and stopping me instantly. I could not run past the father carrying home his dead child. My broken pace was noticed by the man who turned toward me. My stomach twisted and tears welled up in my eyes. But, it was not the father!
What a relief. I picked up stride again. As I ran down the dirt road, many villagers waved from the fields or greeted me on the road in their native Tumbuka language. Children ran beside me. Young adolescents danced and sang with me as I passed. Their cheer drowned out my pain and lifted the weight again. I felt connected, welcomed and elevated. I learned pain and loss are more manageable when community support rejuvenates and uplifts you. The kind Malawian villagers probably didn’t know the healing gift they gave me on the dirt road that evening. And, had the hospital villagers not helped me begin to accept death earlier, I probably would not have been primed to embrace their engaging liveliness and joy here. I can only imagine the experience of the father on his trip along that same dirt road. I have seen the community extent love to those outwardly suffering, sometimes joyous as with me and other times in a soft smile, a warm recognition or a quieter sign of respect. I fully believe in their uplifting influence and hope he felt the healing gift as well.
Seeing and feeling this great healing gift, I hope to bring both the grace of acceptance and kind expressions home to my medical practice. Simple smiles and greetings to patients, family members or staff can help support people through their challenges, often more than we know. Supportive communities, acceptance of the circle of life and compassionate human connections can transcend dirt roads and tile hallways, bringing healing and hope to those in need.