Generation

Emmanuel is gaunt.  He sits in my office and looks just enough like his former self for me to doubt what I see.  I try to avoid sizing up Emmanuel—looking him up and down like a runway model, but the opposite, but I don’t do a very good job.  Skeletons scare me. Emmanuel is too tired to be embarrassed by his past-present.  He is breathless and his eyes bulge.  He sits on the couch with his arms extended to prop his body straight.

It is I who should be embarrassed. Emmanuel had told me that he was sick two months earlier during one of my field visits to Zwedru, a town 12-hours in intact Jeep from Monrovia near the Ivory Coast border where the IRC does emergency health and education work.  Emmanuel approached me while I was on the office porch searching for a phone signal.  He told me that he had lost interest in eating.  He was wearing a loose hanging knit sweater in a country, which frankly is never cold.  “I am just not hungry,” he said, “I only want to eat rice and even that I don’t like sometimes.”

A Liberian not wanting to eat rice is like an Asian not liking soupy noodles.  It’s a problem.  But while I asked Emmanuel a series of follow-up questions:  presence of fever, diarrhea, vomiting, stomach pain, current medicines, allergies, previous similar illnesses… He responded only in the negative.  I reassured Emmanuel and told him that while I didn’t know exactly what was going on, the lack of other symptoms made me think that all was going to be okay.  I asked him to call me if anything new came up and to perform at least a routine physical exam with some basic blood work the next time he was in Monrovia, which was going to be in a few weeks.

Emmanuel and I had met last January on a jeep ride down to the Capital from Sannequellie.  He was answering two cell phones, which were constantly ringing, sometimes talking at two people at once.  “You wait.”  “Hello?” As our vehicle veered and bounced through the usual crater-filled road which is the Liberian highway system, he instructed his logistics field staff basically to fix, sell, turn, count or move it. His voice barreled through the jeep’s roar.  He was six foot two, handsome, muscular, brash and sure.  He was the biggest Liberian I had seen to that point.  He exuded power and I liked him because of his obvious ability to channel and control it.

“The doctor says I have Hepatitis B.”  Emmanuel says.

“That is strange,” I say, “because then you should be yellow and Hepatitis B doesn’t present like this. Do you have your lab results with you?

As soon as I say this, I know I have asked a stupid question.  In the almost two years I have been in Liberia, I have never seen a patient go home with written instructions from their doctor let alone documented laboratory results.  For Hepatitis B infection, I would have liked to see if the body was producing antibodies against the protein-core of the virus and antibodies to fight acute infection.   Emmanuel nods his head in shallow cycles back and forth.  “They just told me that I have Hepatitis B.”

“Hmmmm,” I say glancing to my closed door then back to Emmanuel, “I am going to ask you a question that I would ask anyone who has lost so much weight.  Have you ever been tested for HIV?”

“Yes,” Emmanuel says.

“And what was the result?”

“The test was negative.”

“When did you take that test?”

“A few months ago.”

“Good,” I say, “that’s an important thing to know.” 

I begin a quick but thorough exam with the only eventual finding that Emmanuel has lost even more weight.  I guess 30 pounds since Sannequellie.  Somewhere between looking for enlarged lymph nodes in the arm pit and tapping out the size of Emmanuel’s liver, I think selfishly, what the hell am I doing? Why am I the de-facto doctor for all IRC staff?  I am the Director of Health.  My job is to create systems, bring in money, look at our data and hire and fire people, not see patients.  I am tired of house calls.  Plus, I am a pediatrician!

Through the process, Emmanuel does not engage.  He only looks to some indeterminable point in the distance.  He is so trusting but also his mind is not here.  His absence brings me back.  The answer as to why I am doing this is that there is no one else.   I write down names for a few tests:  basic metabolic panel (is this guy diabetic?  Is he acidotic?), complete blood count (is he neutropenic?  Is anemia causing him not to think straight?).   “Emmanuel,” I say, “I need you to go back to the place you got your hepatitis tests and ask for the official results.  I also need you to do a few more tests so I can better understand what we are dealing with.  Can you do this this week and come back to me as soon as you are done?”

“Yes,” Emmanuel says,” I will do that.  I will do that.”

*        *        *                

It is four weeks later when I am told urgently by the Deputy Director of Operations, while walking down the IRC office stairway, that Emmanuel is very sick at home and can’t move.  A pang of realization hits me.  I had tried to call Emmanuel two weeks after we last met, but his phone was off.  But then I got really busy – visit to Lofa County, grant proposal, a few reports—and had dropped the ball.

“What should we do?” says Seleke, “can we send the JDJ ambulance to his house?”

“JDJ is a woman and children’s hospital,” I say, “we can’t use their ambulance, Seleke.”  I am annoyed.  I have spent months trying to curb inappropriate use of the ambulances at our hospitals, which for years have been used as private bus, taxi or limousine for staff.  I am not about to back track.

“Take one of our Land Cruisers,” I say, “pick him up at home and take him to Catholic Hospital where I can manage him.  If he goes to JFK then he will got extorted then lost.  Do not take him to JDJ.”

“Don’t take him to JDJ?” Seleke asks.  I want to slap Seleke across the head.

“Have Mousa take Seleke to Catholic Hospital and to call me when they are close,” I repeat, “I will meet them when they get there.”

It is normally strange for a doctor who doesn’t work at a particular hospital, to dictate the care at that hospital, but this is Liberia, there are no doctors, and I have given sufficient pineapples to Catholic Hospital staff and enough calls to their Medical Director for them to know who I am and what I am about.  In the emergency room, I am greeted by a confused Emmanuel who tries haplessly to get out of bed but is too weak to do so but just strong enough to risk falling onto the floor.  He is confused and now he is yellow.  He isn’t oriented enough to know who I am and he doesn’t talk.  Five of Emmanuel’s family is present, including his wife who is young and obviously in the last stages of pregnancy.  It looks as if she could deliver on the spot.

“Emmanuel, what’s going on,” I ask, “why are you in the hospital?  The hospital is for the sick.”

Besides the jaundice, cachexia and disorientation, Emmanuel’s exam hasn’t changed. We are able to draw one of two important lab tests (the hospital is out of the other reagent). Emmanuel’s hemoglobin is 2.  Normal is 12.  Simply put, Emmanuel needs a transfusion of blood or he will die. 

There is a flurry of confusion and chaos.  “But Emmanuel has O- blood!”  “The hospital is out of O- blood!”  “Who in the family has O- blood!” “He needs blood now!”  “He just pulled out his IV!”  “Emmanuel sit still!” 

The family determines that Emmanuel’s uncle has O- blood.  I take the man outside and explain to him that he needs to verify his blood type but with a match and a two-liter donation, he will be helping out Emmanuel immensely, literally buying us time to figure out why Emmanuel’s blood level is so low. The uncle is receptive and patient.  He stands with another man who I think is his brother but turns out is one Emmanuel’s friends.  Both wait for me to finish, then the friend says drawing us in close and speaking in a hushed voice, as if we are in a football huddle, "We need to tell you something.  Emmanuel has HIV.  I think he has AIDS.  This has happened before.”

The story all the sudden makes sense.  The weight loss.  The non-specific symptoms.  The Hepatitis B.   Now the confusion.  “Emmanuel has known his status for three years,” says the friend, “but he didn’t want to know, you know what I mean?”

“But he told me he was HIV negative just a month ago,” I say, “Is the family aware?  Why didn’t they tell me?  Why did we go through this process?  We could have saved so much time.”

The friend shrugs but seriously, “This is Liberia,” he says, “people don’t want to know what is HIV, especially if they have it.”

“And Emmanuel’s pregnant wife?” I ask, “What about her?”

“She also has the virus but I don’t think she is taking medicine.”

“Oh, God,” I mutter.   I don’t believe in God.

It turns out that Emmanuel has been cared for in the past at Redemption, which the IRC supports so we move to take him there immediately.  There is an international infectious disease fellow working in the HIV unit at Redemption this month.   Monrovia also has a special blood bank for seropositive individuals and on our way to Redemption, we simply stop at a shack of a facility behind the JFK hospital and grab 2 units which we pack in a square cooler as if it were beer.  The paradox of Liberia: It has everything and nothing.

Mousa drives like a mad man.  The IRC Land Cruiser doesn’t have a siren because it’s not an ambulance so Mousa lays on the horn. There is heavy traffic to Redemption so Mousa chooses the lanes for oncoming traffic to navigate and the experience is terrifying.  I have a headache.  I am glad guns are illegal in Liberia from the gesticulations of angry drivers we garner.  But we get there.  We connect Emmanuel to the appropriate people and service.  We hand over the blood.  We hug Emmanuel and tell him we will visit him tomorrow and to be strong and take care.

Emmanuel dies 8 hours later.  The friend calls me the next morning while I am readying for work.  He asks if I can arrange a ride home for him from the hospital where he is stuck, “Emmanuel died,” he says, “He died at 4 a.m.”

“I am sorry, but I can’t arrange a ride for you,” I say.

For the next four weeks, we care for old Emmanuel through his unborn son.  We make sure that when he is born that the mother makes clear with the letter we have written that the staff knows her HIV status.  We write out the name and dose of the anti-retrovirals that are to be given to the baby for the first 6-weeks of his life. We arrange for an alternative to breast-feeding since the family can afford formula and breast feeding in this context would pose unnecessary risk of transmission. I visit Emmanuel’s wife at the hospital the day of discharge.  I congratulate her and she appears genuinely happy but reserved.  I speak with her mid-wife to verify that we are in agreement with the care to date.   I do an exam of Emmanuel junior under the gaze of a packed room of new mothers and their family members.  There is an eerie absence of men.

“What’s up Emmanuel Junior,” I ask.  The baby is handsome and active.  He is attentive and appears to enjoy the exam process.  “Your father was a strong interesting man.”  I am focused, slightly confused, but present with Emmanuel’s new baby boy.