The routine of death
====================

* Ilona Hale

Every morning report gives a revealing and sobering glimpse into the workings of a district hospital in Malawi:

From Maternity Ward: “…16 SVDs [spontaneous vaginal deliveries], 2 breech deliveries, 3 caesarean sections, 2 vacuum extractions, one set of twins, 2 NNDs [neonatal deaths], one fresh SB (stillborn), one MSB (macerated stillborn), 2 BBAs (born before arrival), one ruptured uterus.”

This is followed by the other wards where there are often several deaths a day.

Many of the deaths on the wards are not even reported let alone examined. The cause of death is often assumed or not even questioned. Perhaps the time it would take to do a death review would mean that another patient would die for lack of adequate care. Neonatal and stillborn deaths, in particular, don’t seem to warrant any explanation because they are just so common. Often resuscitation isn’t even attempted. Babies just die and everybody seems to accept this. Fetuses are not acknowledged as living beings and even newborns are not recognized with names until they have survived the early newborn period.

Beyond the actual statistics you hear the dull monotone with which deaths are reported, each one followed by the perfunctory “… body taken to mortuary very sorry may her soul rest in peace next patient 4-year-old female with malaria rule out meningitis.”

The tone accurately reflects the apparent lack of concern or emotion that surrounds patient deaths.

How can one continue to feel intensely for every death when you see several every day? How can you not build a wall, how can it not become routine?

![Figure1](http://www.cmaj.ca/https://www.cmaj.ca/content/cmaj/180/9/E27/F1.medium.gif)

[Figure1](http://www.cmaj.ca/content/180/9/E27/F1)

FIGURE. “I find myself avoiding death whenever possible,” writes Dr. Ilona Hale of her experiences as a physician for Voluntary Service Overseas Canada. Image courtesy of Femke Schrauwen

The nurses are not inhuman; just the opposite. No human could allow themselves to really feel each family’s pain and still function.

I find myself avoiding death whenever possible.

I try to avoid going down the hallways where I hear the mourners crying.

I shut off when I can. Beyond offering a critical ear to the case reports, alert for those which might easily be prevented in the future, I deafen myself and try not to think of the human reality behind the statistics.

But when I have to confront it, when I have to look into a mother’s fearful eyes to confirm what she knows already that her child has died, when I hear her wail of pain and see the small chitenje wrapped bundle wheeled out on a mortuary stretcher not meant to be carrying one so small, one whose life was not supposed to be over yet, then I know my heart is still alive because the tears come every time. 

For me, death can never be routine.

## Footnotes

*   *CMAJ* invites contributions to “Dispatches from the medical front,” in which physicians and other health care providers offer eyewitness glimpses of medical frontiers, whether defined by location or intervention. Submissions, which must run a maximum 700 words, should be forwarded to: wayne.kondro{at}cmaj.ca.