So there you are in, say, northern Cameroon, the only doctor for 76 000 souls, sitting at your sweat-stained desk at 3 on any given afternoon. It is 45 degrees C in the room and the ceiling fan, creaking gently through its whir, swirls all that warm air around you in the sickening sort of way, yet you can't bear to turn it off.
Last time you looked there were still 2 benches full of people waiting outside your door. Over in the maternity the woman who had miscarried would have to be attended to, and a nurse just came to tell you that the 8-year-old boy bitten yesterday by the carpet viper was bleeding from his gums again.
You have seen 43 patients since early morning. Among them were a couple of toddlers weighing less than an average Canadian newborn, several others with lobar pneumonia, and 3 adults with tuberculosis. A shepherd with stab wounds to the chest was carried in while you were examining a young woman with an eroded breast tumour the size of a cantaloupe.
An entire family — father, mother, dying infant — had tested positive for HIV and had to be told. There was a new case of meningococcal meningitis, the 103rd of the current epidemic. The delivery room was busy because of 2 women, 1 of whom was a 14-year-old who kept insisting emphatically that the baby was “coming out of my bottom.” She finally delivered, via the usual route, by vacuum.
You work in half-a-dozen languages, some more easily than others, but you sense that the bewilderment you sometimes feel has little to do with language. Today you ask a young man how long he has been having his abdominal pain.
“Yes, yes,” he replies.
“The pain,” you repeat, pointing to his abdomen. “How long have you had it?”
“Six months.”
“Six months?”
“Yes, yes. Six years.”
“Six years or 6 months?”
“Yes.” He nods vigorously, appreciatively.
You leave it for the moment. “Are you feeling pain when you urinate?”
“Yes, I am having diarrhea.”
“Diarrhea?”
“Yes. Every other day.”
“Any blood in the diarrhea?”
“Yes, yes!” He nods vigorously, appreciatively. “I feel pain when I urinate.”
Evening approaches and the waiting room fails to empty. Now as soon as patients enter the consulting room you have to start thinking about getting them out. You start forming your diagnosis by the way they walk across the room or by the timbre of their voice, by the way the babies cry. You greet your 55th patient of the day, a grey-stubbled, ramrod-straight villager who probably carried an antique rifle and half filled someone's discarded army fatigues during the Biafran war.
“Good afternoon. What is your name?” you begin.
“Blama Meina, sir!”
“Blama Meina,” you repeat, writing.
“Present, sir!”
Startled, you nevertheless ask calmly, “What is the problem?”
“I am coughing.”
“Since when?”
“My wife went to visit her sister.”
“Yes, but since when are you coughing?”
“In Moubi. Her husband — the sister's husband, that is — died.”
“That's when you started coughing?”
“When would that be, sir?”
Here you allow yourself a deep inspiration. “Blama Meina — ”
“Present.”
“When did you start coughing?”
“When did I start coughing?”
“Yes, that's it.”
“Two weeks ago.”
With great relief, you make a note. “Are you coughing up blood?”
The patient bends over and rolls up a trouser leg. “My knee hurts too. Here.”
You look, you feel the knee, you manipulate it, and it seems to be a perfectly fine, normal knee. “Did you injure it? Fall? Knock it?”
“No, no, all by itself, it just started hurting. Swelled up like that.”
You look again, checking from all angles. “Where do you think it's swollen?”
Blama Meina peers down at his knee, squeezing it repeatedly in his fist. “Oh well, maybe not today.”
“Blama, are you coughing up blood?”
“Who, me?”
You check over your shoulder to see who else might be in the room. “Yes, you.”
“What?”
“Are you coughing up blood?”
“No.”
“No blood?”
“No blood. Not much.”
Eventually, somehow, you complete the history and then there is the physical. “Breathe deeply,” you say, putting the stethoscope to his chest, and he inhales deeply. And holds his breath. You wiggle your stethoscope on his chest to get him to breathe out; he doesn't understand so you shake him gently and finally say, “Breathe out, breathe out!” and he does, and then you try to show him that when you say “Breathe deeply” it means in and out. You show him, and a minute or so later he's got it. When at last you come to the end of the exam, you send him for a sputum smear. You watch him go and even more carefully you watch the next patient enter, searching in the way he walks, the way his shoulders move, for any clue that might help to shorten the next encounter.
One day a correspondent from Canada asks you to describe a typical patient contact in Africa and how this might differ from a typical patient contact in Canada. Almost impossible, you think, but then, just for the fun, you begin with the heat.