The Correct Distance

Through many long years of his life, Alphonse Daudet lived with syphilis. For him the illness manifested as tabes dorsalis, in which the posterior columns and roots of his spinal cord slowly degenerated; resulting in ataxia, intractable pain and eventual paralysis. Daudet came under the care of Charcot and was subjected to a good deal of chloral, bromide, mud-baths, and the Seyre suspension: in which he was hung up by his jaw for several minutes in an effort to stretch the spine and loosen the joints. It did not work.

Daudet’s view of hardship was straightforward: “Suffering is nothing…it’s all a matter of preventing those you love from suffering.”
Instead of complaining aloud, he kept a notebook of his course and treatment. He asked if words are capable of describing what pain really feels like? He answered: “Words only come when everything is over, when things have calmed down.”

I returned from The Gambia, where I worked for the first half of 2019, and struggled to speak. This was in part because I was depressed. But it was also because I didn’t have words for what I had seen. Now a year has passed since I boarded a flight to Banjul and I can feel my tongue loosening again. I want to find words for that portion of my life - some words which are true. Or at least words less banal than challenging or eye-opening. 

*

At 2.30am one Saturday morning in late January I got up from a rack of cushions on the floor of my brother’s room, showered, snatched up my things, and beetled through the still bawdy streets of Edinburgh dragging a mountain bike bag and such essentials I imagined I would require to start a job as a volunteer doctor in West Africa. My main feeling was trepidation. What was I getting myself into?

I had returned to Scotland briefly from East Africa where I had studied tropical medicine for three months in Tanzania and Uganda with the London School of Hygiene & Tropical Medicine. It had been the fulfilment of a long-held dream and had been even more moving, joyous, stimulating and fulfilling than I had imagined. Now it was time to put some of my new learning into practice. 

I’d found a job with the Medical Research Council Unit in The Gambia - a small enclave in Sengal bordering the River Gambia. Since 1947, the MRC-Unit has been providing clinical care and conducting research and has contributed much to what is known about malaria control. Currently, the Unit prioritises research on vaccines and immunity, disease control and elimination, and nutrition. I had been lucky to land a position there - even as a lowly volunteer.

At the end of my first week, I was nudged into my first 24 hour on-call shift. Dr Sonko, one of the other Medical Officers, had a family bereavement so I was asked to take over her call a week earlier than planned. I didn’t really know anyone and didn’t have much of a clue how the hospital worked. Apparently there was a consultant I could ring for help but I was warned that some were research staff with little recent clinical experience, who didn’t always pick up the phone, and were not necessarily in the country. 

After about 12.30pm all the medical staff left (clinic finished early on Fridays) and I was left to fend for myself until the following morning. A mother rushed into the ward with her dead baby in her arms. The first cardiac arrest happened an hour later. Then a woman having a miscarriage. 

Then a patient was admitted from clinic who I only heard about an hour and a half later by chance when I bumped into one of the clinic nurses in the canteen: a 28 year-old woman with a few days of chest and abdominal pain, vomiting and bloody diarrhoea, who was now bleeding from her mouth and eyes. She was breathing fast and shallow, with tachycardia, low blood pressure and a fever.
Holy hell does she have a viral haemorrhagic fever?
Her bloods showed deranged clotting, her white blood cell count was low, she was anaemic with low platelets. She could have had any number of things but aplastic anaemia or acute leukaemia seemed likely. I gave her some broad-spectrum antibiotics and fluids and bundled her into an ambulance to the main hospital in Banjul.  

Then there were a load of kids who were unwell and I didn’t really know what to do about them but I called Lucy, a paediatric registrar from Newcastle who helped prevent me from doing anything harmful. 

Then the computer system went down so I couldn’t access any test results and was flying blind.

Then a taxi arrived containing a comatose elderly lady having a seizure. A paper result from Darboe the on-call lab technician came back with a sodium of 115 so I started her on treatment on the presumption that her low levels had given rise to the fit. We didn’t have any of the normal treatment so I cobbled together a hazy plan B involving phenobarbitone and some 0.9% saline over a phone call with the consultant. The phone made an infernally loud scratching sound throughout the call so I only caught part of what he said. 

At 2am I left to go back to my room. I’d been on the go for eighteen hours. I didn’t yet have a Gambian phone so one of the nurses gave me his so I could be recalled when required. There were about twenty people with vital signs suggesting they were seriously unwell so I fully expected to be called back. Only the fact that the nurses were incredibly experienced and assured had kept the show even vaguely on the road.
I lay under my bed net and trembled quietly to myself. 
Oh my goodness. Oh my goodness.

For many weeks the hospital continued to provide a seat of great confusion for me. I realised that a lot of my ability to contribute usefully in previous jobs has come from knowing how to work within a system and for quite some time I couldn’t work out what or how things were done.  Even basic investigations seemed to take an eternity to come back from the laboratory, the necessary equipment for urgent procedures frequently wasn’t available, and there was an overwhelming lack of urgency at all times.

There were occasions when I felt I had made a seriously bad decision to come. The toll of 24-hour shifts weighed quickly and senior support remained thin on the ground. A number of terrible cases involving children further punctured my resilience. Over the course of one day a 3 year-old child admitted from clinic appearing jaundiced and non-specifically unwell with abdominal pain progressively deteriorated. I was with him for a much of the day and night by myself as he relentlessly declined, reduced in consciousness, developed seizures, and eventually died in the small dark hours of the morning with me performing futile CPR and his distraught parents watching on. I felt totally powerless. I had no idea what was going on and lacked the knowledge, skill, investigations or access to expertise to help with whatever was so aggressively ripping his life away. 

Most patients who arrived at the clinic and required admission to hospital were in pretty bad shape. A lot of the presentations in adults were with the non-communicable diseases we associate with Western lifestyles: strokes, heart failure, complications of diabetes, cancer. There is an epidemiological transition going on in many low-resource countries. Where previously the drivers of mortality were infectious, nutrition- and maternity-related, African health systems must now deal with all of these plus an increased burden of cardiovascular, cerebrovascular and oncological conditions as populations become more affluent and live longer. 

This dual burden of disease became increasingly clear as I began to spend more time in the outpatient department. The clinic saw around a hundred and fifty patients each day, with most consultations led by nurses. Consultations were free for all patients, as was all care for those admitted to the ward. People seen in the outpatient unit had to pay a nominal fee for drugs, blood tests and x-ray/ultrasound done on site - and would pay privately if we asked them to go elsewhere for CT or echocardiography in one of the private clinics.

The clinic saw the whole spectrum of Gambian society: from Grandmothers who had travelled hundreds of miles from the interior and required multiple rounds of interpretation (Fullah to Wollof, Wollof to English, then back again) to affluent Gambians living at the coast who spoke flawless English and went to Johns Hopkins and Harley Street to receive their healthcare. New patients often presented having received multiple diagnoses and courses of treatment at peripheral health centres and arrived brandishing ECG results, random bags of drugs and various inscrutable reports. It was common for multiple different patients and their families to wander in and out of the consultation room as I tried to see the person in front of me. I was usually paired with a student nurse, many of whom were excellent though not all were consummate professionals: taking selfies during clinics and lying with heads on the desk mid-consultation was fairly common. When things got particularly out of hand the senior nurse running the clinic burst into the waiting area and started shouting at the patients. This invariably made things worse and I would spend the rest of the clinic distracted by hollering matches on the other side of the door. There was great pressure to see people quickly, sometimes at the expense of providing good care and I felt bad about short-changing patients, especially when many had come from far up-country and had waited on the concrete floor overnight to be seen.

The range of pathology was varied and often severe. Heart failure in young people secondary to rheumatic heart disease was common, as were complications of diabetes, ischaemic heart disease, hypertension, malnutrition, obesity and thyroid conditions. Sickle cell disease and unspecified febrile illness in children was part of the daily fare. As was tuberculosis and new presentations of HIV.  Late presentation hepatocellular carcinoma secondary to hepatitis B infection was also routine. You could often make the diagnosis from the door of the clinic room: a young, emaciated man carried in by his brother or father - jaundiced, emaciated, hollowed-out temples, sometimes with an abdominal mass visible through a threadbare shirt. Their outcomes were poor.

Outpatient work was relatively new to me and my inexperience, language deficiency and poor grasp of the local healthcare infrastructure meant that my procession through my list was painfully slow. Often I would be assisted by one of the Gambian doctors who would skim a few patients from my list to allow the clinic to finish on schedule. I tried to make up for this by doing extra night shifts and offering to do swaps to allow colleagues to get to weddings and parties. But sometimes I felt like a burden to the team and seemed stuck. On one occasion, during a consultation with a newly diagnosed diabetic, the clinic room door handle fell off and we were all temporarily trapped inside the consultation room.

Something I found distressing about the job was the feeling of not having a friend to go through it with. I have lived in remote spots before - a six month stint in Orkney had passed swiftly and with joy in part because in Jack Cunningham I had a great colleague and friend. 

In The Gambia I was a peripheral figure on the fringe of a group of hepatitis researchers who graciously let me join for regular dinners and weekends away. I lived with Gabriel and Amelia, a couple I had met in East Africa. They could tell I was struggling as I was a much more subdued and dejected version of myself than the person they had got to know in Moshi and Kampala. I couldn’t have been much fun to be around most evenings as I silently dragged my body back from the hospital and slumped onto the couch.

I was far from the doctor I wanted to be - compassionate, precise, lucid, warm. I wanted to be like Marc Mendelson and Sean Wasserman in the Infectious Diseases department in Cape Town had seemed to be - imperturbable and ataraxic. I wanted to work in places where there were not enough doctors. To push back against some of the unmet need for care in places where that need was dire. I wanted to labour where few can abide. 

I had held this inspiration since my second year in St Andrews where I’d picked up Mountains Beyond Mountains in Barnardo's bookshop. Tracey Kidder’s biography of Paul Farmer, the Harvard and Haiti-based humanitarian had inspired me to keep going though medical school at a time when I wasn’t sure it was for me and Farmer’s life had been, as for many of my peers, an inspiration.    

Yet here I was, eight years after that morning in Barnardo’s, and I was struggling. I thought I had prepared: I’d taken student placements in Malawi and South Africa, worked in acute medical departments in Edinburgh and Inverness, staffed a hospital alone at night in Kirkwall, and studied how to practice medicine in low-income settings on the London School of Hygiene & Tropical Medicine diploma. 

But here I was at the MRC-Unit, working a job many of my colleagues would love to have taken, and I hated myself. By mid-March I was unravelling. I wrote in an email around that time which summed up my state of mind:  

“I feel numb toward the patients I'm supposed to be looking after. I seem to be incapable of more than the most basic speech and am consumed with negative thoughts. I don't think I'm doing myself or anyone else any good by being here but the prospect of quitting and going home with no plan and no hope is also unappealing and would feel shameful…At the moment I feel like a doctor in name only and in clinic or on the ward I can't seem to make even the simplest decision, or even formulate sensible questions that I can ask the consultants…I don't feel self-pity about this - in fact there is is a kind of fairness in being crushed when I have so completely failed to do a good enough job with the opportunities I have had access to.”

Looking back on this now it’s clear that I was depressed. But I wonder now if something else may have been at play. 

It was noted by Brett Litz and colleagues that some combat veterans exhibit long term psychological consequences of their deployments that are not well captured by concepts of adjustment disorder and PTSD.

Moral injury was first described in American war veterans and is commonly defined as occurring when one perpetrates, fails to prevent or bears witness to acts that transgress deeply held moral beliefs and expectations. For Jonathan Shay, moral injury is present whenever there is a betrayal of what is right by oneself or by “a person in legitimate authority in a high stakes situation.” Exposure to such injury, Shay notes, impairs our capacity for trust and can result in despair, violence and suicide.

Moral injury is most commonly discussed in military and policing circles, but it is increasingly cited among healthcare staff. Humanitarian workers are particularly vulnerable to these episodes which provoke a disruption of what a person believes about themselves and the world. 

In some respects it would be abnormal not to be phased by the experience of seeing avoidable, treatable suffering and loss on a daily basis. You go into medicine with the knowledge that you will be exposed to this. But for those who have experienced the discrepancy between what should happen and what does happen in hospitals, who find themselves unable to help where they should - and when that experience persists over time - the rot accumulates in your heart.

I can recall on more occasions that I would like looking out at the ward at people in pain, young people in the last days of their lives, mothers holding on to babies who would not last the night. I can recall rushing to the Medical Director with a critical patient and what I thought was a cunning plan to be met with a shrug:
“This is The Gambia, what do you expect?”

Seumas Miller, a professor of ethics at Oxford, discussed moral injury in combat and police personnel:

“When it comes to the honour that is so important to police and military personnel […] The self-worth that those individuals feel and the worth that they actually have in the eyes of others is very much dependent on their capacity to have and to display mental and physical resilience. And it’s a source of considerable distress if they feel or others feel that they are weak or cowardly. Cowardice is something that is not acceptable.”

The same could be said of the medical community: lack of toughness is reviled. 

Of course, some degree of emotional distancing is necessary. I remember in my first week as a doctor being asked to verify the death of a patient. It wasn’t someone I had cared for, and I knew nothing about him. Yet as I examined him and looked around at the cards in his room and the wedding band on his finger, I knew that he had been beloved on the earth. A tear crept into my eye and I had to steady myself before returning to the ward.

Now, years later, such sentimentality is rare. I am called to verify: I listen for heart sounds, respiratory effort, and feel for a pulse at the neck. I check for response to pain and shine a torch in the pupils: they will be fixed and dilated. I feel calm in this ritual, this short formal island of peace in a busy shift.

I find that as I work, I join the ranks of doctors who to some degree shelter themselves from the grief and illness we daily see with fascination for the pathology which drives it. I meet an old man with a non-resolving pneumonia, a long smoking history, a lump in his neck and finger clubbing. He has just lost his voice. There is a cold satisfaction in knowing the diagnosis in advance of the CT report: a lesion of the recurrent laryngeal nerve secondary to metastatic lung cancer. 

In A Fortunate Man, John Berger’s archetype of the country doctor John Sassall describes his earliest vision, as a child, of the sort of doctor he thought one ought to be:

“All-knowing but looking haggard. Once a doctor came in the middle of the night and I could see that he slept too — his pyjama trousers were poking out through the bottom of his trousers. But above all I remember he was in command and composed — whereas everybody else was fussing and agitated.”

That is the sort of doctor I still think one should aspire to be: dogged and calm. It is a doctors job to help and to heal, and warmth and compassion are part of that. But the fundamental mechanism by which we help people is by making accurate decisions. I have worked with colleagues who have cared immensely about their patients, have stayed late to talk to them, have brought them books and puzzles. But they have been unable or unwilling to make difficult clinical decisions. Such people are impossible to work with.

There were times in The Gambia where I lost faith in myself as a doctor. But when you are ragged you are not the best judge of your own performance. I spoke to my supervisor to explain I’d been struggling and she said she hadn’t noticed any major problems. So I staggered on.

Slowly things began to lift a little. A few months in, I had come to appreciate some of the limits of the service and what my part in it could be. I diagnosed patients with tuberculosis and HIV and linked them into national treatment programmes, I worked with a Dutch team of doctors to bring their patients into our clinic when they needed out laboratory facilities, and I did my best during the long on-call shifts. I continued to try to do what doctors do everywhere: to heal those who can be healed, and comfort those who cannot.
Of course, the gulf between what ought to be and what is remains unacceptably wide. It is too easy to die in The Gambia. Perhaps I was naive to attempt to mend a small section of it. But I hope in time this experience will be part of a larger learning process - one which will make me wiser should I return to the region some day.

How should I feel about the despair I experienced? How should I feel about crying over the wedding ring of an unknown dead man? Should doctors allow themselves to be perturbed in the course of their work? Should we suffer? 

In the end I am just a person. With all the weaknesses, frailties and small joys inherent to the form. I believe there is a scale of wholeness among humans. In time we are all torn. The test of life comes after that when you discover you must find a way to repair yourself.

*

In my last year of high school, my friend Innes Cameron died following complications of a heart transplant. The news was broken after I had performed at the school Burns night. After my turn to sing I was taken to a room where my friends had begun to keen and weep. It was an awful place.

That night I went to Innes’ house with my Mum and Dad to see his parents. My parents are GPs and my Father was Innes’ doctor. I thought it was a terrible idea and pleaded with them not to go. Surely they would want to be left in peace on this worst day of their lives?
I was totally wrong. I cannot recall what was said, but I can remember the sense of warmth and shared sorrow in the house when we came. I think my parents mostly just listened and were there. Which sometimes is all you can do, and all you need to do.  

On the last day of high school his family came and our year assembled in one of the small courtyards to plant a tree and leave an inscribed sign beside it. I was the head boy and one of Innes’ good friends so had agreed to give a eulogy. I had thought about it and worked on it for weeks beforehand because I wanted to say something that was true. When it came my turn most of the year group had left and only his family, the head girl and the rector remained. I got started but choked-up quickly and found it almost impossible to get my words out. I struggled through the speech, sobbing badly and proceeding at an agonisingly slow, broken rate, until I reached the end.
It was by far the most difficult thing I have ever done. At the time I remember being angry with myself for blubbering and not getting through the reading better. But I know now that it meant something to Innes’ parents and so when I think about it I am no longer disappointed.        

One other episode from that time which I remember clearly was the playlist at Innes’ funeral. We had banded together our knowledge of his music taste and raided his ‘most played’ iTunes section and we filled the village church with Paul Simon, Neil Young and Sufjan Stevens. When the hearse pulled out onto the main road our school year lined the car park and Love Lockdown by Kanye West was playing loudly through the church window.

We got down to the cemetery at Pattiesmuir and walked up a short rise to the spot at the back where he was to go. He was buried where the other young people were. I think they give them the best patch so their families have a nice place to come back to.
Everyone looked out over the hedge to a field and to the hill beyond that, and back at each other and at the fresh earth piled up neatly. Everyone looked very neat too, but we were also in a bit of a mess.
The usual committal words were spoken, then people took up the strain on lengths of red rope and lowered down the coffin. As the ropes ran along through their hands and we watched on silently I had an odd feeling, which was that somehow Innes wasn’t completely gone and that I would see him again sometime and we would continue our ironical, gently mocking conversations just like we always did.
I know that doesn’t make any sense but the impression held me quite distinctly at the time.   

That was eleven years ago, and though I can think of Innes smilingly now, I still have a lump in my throat. In that time I have lived in six countries and moved house a dozen times. I became a doctor, and am engaged in the long process of trying to become a good one. The road is not always smooth, but I am reminded of lines in one of Innes’ favourite books - Peter Camenzind by Hermann Hesse:

“I began to understand that sorrow, disappointments and sadness do not exist to make us worthless and undignified but rather to bring us to a full state of maturity and enlightenment.”

Should doctors suffer? Of course we should. How could we not? Because we are human first of all: just very small mammals the condition of whose life is sometimes to experience terrible pain.

Now I am well again: able to write, to work, to be a friend. I feel fortunate, having worked in West African conditions, to have a place within the NHS. Treatments are generally available, seniors are contactable and competent, I can communicate directly with most patients, and I am paid. There are limitations, pressures, and fracture lines in the service. But I’m glad to be back. 

For the rest, I’m grateful to my family and close friends and to time - which in its slow weltering heals many things. My expectations of myself and what I am capable of enduring has been, for the moment, somewhat chastened. But perhaps that’s part of growing up: understanding the difference between ends and means, goals and resources. I can expand the latter without giving up entirely on the former, but there will always be limits. I feel gratitude now, even for the bad parts of my recent experience.

Sometimes I find myself humming beside the river in Inverness that line from Trains To Brazil by Guillemots:

“Can’t you live and be thankful you’re here.
See it could be you tomorrow, next year.”