For my medical elective I went to Kilimanjaro Christian Medical Centre (KCMC) in Tanzania, East Africa for 7 weeks. I spent most of the time in the paediatric department but also visited other departments to get a feel for medicine in general out there. I have decided to write this report about attitudes towards life and death, in particular how mine has changed as a result of my elective. Whilst this may sound a little morbid, the Tanzanian attitude to life and death was one of the aspects of African life that had a big impact on me and I felt it was an important issue I wanted to share. There are many ideas and descriptions of what death is. Some say it's the end of life, others a gateway to a better place, some merely the end of your existence on earth which is itself only a small part of the existence of your spiritual being. However you define it, in the West a lot of time, effort and money is spent in preventing it. People are living for longer, and previously fatal diseases are curable. We have the money, the power and the education to cheat the inevitable for a while. But if death is inevitable why try to put it off? In some cultures, old age commands great respect, but in others once you can no longer work you are a burden. A child dying is to be avoided if at all possible and great lengths are taken to prevent this occurring. If a child dies in a paediatric ward in the UK, parents often try to apportion blame to someone or something. There has to have been a reason for the death and 'it happens' is not a valid answer.
Two events happened whilst I was at KCMC. The first was the death of a young promising surgeon at the hospital. He was involved in a head-on collision between his car and a lorry. His wife and 6 year old son who were with him survived, but his injuries were too severe and he was pronounced dead on arrival at KCMC. He was only 31 years old. It was announced the following day and the funeral was arranged for 2 days time. I mentioned to one of the Tanzanian doctors that this wasn't long to do the post-mortem, have the inquest, and investigate the death. He looked surprised and said 'why bother? It won't bring him back to life, he's dead.' I was shocked but could see his point of view. Investigating every minute detail wouldn't bring him back and would only delay the grieving process for his family.
I attended the funeral, partly out of respect for him as a colleague, and partly out of curiosity as to what a Tanzanian funeral would be like. The hospital chapel was packed with people and I quickly realised that this was not going to be like England at all. Firstly my all black outfit was out of place – everyone was dressed in bright colours. When the coffin was brought in it was white with coloured bows, ribbons and flowers all over it instead of a wooden casket with little decoration. The service was in Swahili and hard for me to follow but seemed to consist of a funeral mass much like in England, with many of his colleagues and friends talking about his achievements, his good character and how much he would be missed. Then came the part I was unprepared for – they opened the coffin! I've seem dead bodies before but his was still a shock. Sadly, his face had borne the brunt of the impact and despite obvious efforts to reconstruct it, the scars and damage were obvious. I thought it was sad that the last memory everyone would have of him was a scarred, bloodied, swollen face instead of remembering the happy smiling man he'd been. Everyone then filed past the coffin to pay their last respects. I was gobsmacked – it took over an hour as there were over 2000 people there. Unbeknown to me there'd been many people standing outside who couldn't fit inside the chapel. Colleagues, patients, friends, family, local villagers, all united in the grief at the loss of a brother. The whole hospital ground to a halt that day. Clinics were cancelled, the operating theatres shut down as a mark of respect, and many doctors were too upset to work, leaving only a skeleton staff. The following day though it was business as usual. The grief was still there but so were the hundreds of sick patients. Life had to go on. I couldn't imagine the death of one doctor having such an effect on a tertiary referral hospital in England or the local community, however tragic the circumstances.
The second incident that stuck with me was a mother who arrived at the department one day carrying a small child. The child was obviously very sick, and examination revealed he was suffering from malaria, septicaemia, malnutrition and possibly meningitis. His mother had walked from her village to KCMC carrying her sick child – it had taken her 4 days. She had had to leave her other 5 children and elderly mother in the care of the eldest daughter (who was only 12).
Despite our best efforts the child died 3 days later. The mother paid her hospital bill (which cost her nearly everything she had and left her with not enough to feed her family back in the village) and left silently. No tears, no frustration, no blame, she just left. A little while later I saw her sitting in the chapel. I went in and found she was praying and thanking God for everything in her life. Still no tears or sign of emotion over the death of her child. Did she not care? I couldn't understand, what was she thanking God for? She had next to nothing, lived in a squalid hut in the mountains with no electricity or running water, her child was dead, she now didn't have enough money to feed her surviving children and she still had a 4 day walk ahead of her to get home. She got up to leave and saw me, obviously looking perplexed. She explained to me, “I'm still alive, I have 5 other beautiful children and my son has gone to a beautiful place where he is loved. Don't be sad, we'll all be together again one day.” Then she started on her journey home. What she lacked in material goods, she gained in love and faith. A faith that God would take care of her, that God loved her, and that everything happened for a reason as part of God's plan for her. I realised I didn't have such a deep conviction – when my father died 3 years ago I was just angry. My reaction had been 'why did you do this, what did I do wrong to deserve this punishment?' I should have been thankful I'd had my father for 23 years and asked God for support in my grief. I asked God then and there for the strength to be more like that Tanzanian woman.
So what is death? Is it the disastrous event to be prevented at all costs for as long as possible like in the West, or an unavoidable part of the circle of life that happens to everyone at some point as in the Tanzanian view? Should we mourn the loss of a friend or celebrate the joy their life brought to the world? Can death ever be a happy event? Is death acceptable? Before I went to Tanzania I would have agreed with the first statement. Life is precious, a God given gift that should be prolonged in as healthy a state for as long as possible. Now I'm not so sure that's 100% correct. As a doctor, my main duty is to preserve life but where do you draw the line between prolonging life and just extending an existence in a defeated body? Many people, both adults and children, die in Tanzania who would be cured if they were in the UK. An inordinate amount of money would have to be spent to bring the healthcare standards in Tanzania up to the same level that the West can offer, as well as improving education, infrastructure and changing peoples long held opinions and beliefs. You'd have to change part of the structure of what makes Tanzanians the people they are. And I found them to be a terrifically warm and welcoming people, full of love and faith. Western medicine makes it hard to believe, to have that complete faith that although what God gives he can take away but will never do so out of spite or anger. He always has a plan even if we can't see it ourselves. That's not to say that we should not make an effort to save life. God has given us the abilities to cure illnesses, and to prevent early death in many cases. We should use these gifts to the best of our abilities.
I think death is a challenge. You're born, you live, and then you die. The time between these may be long or it may be short, but you are here to do Gods will and follow his path. When that journey is complete, you are returned to the one who created you in his own image. Maybe the surgeon's role was to unite a community. Maybe the little boy's job was to remind me to have faith. Whatever our role is, death is not to be feared.
The average life expectancy in the UK is 86 years, in Tanzania it is only 49 years. Death happens there often but life has to go on for those left behind. It doesn't mean they don't care. I returned from Africa with a renewed faith, a thankful heart for how lucky I was, and a desire to use my skills as a doctor as well as I could, especially for the benefit of those who most need it instead of just those who can pay for it. Having little money or material goods doesn't mean you are poor and every person on this planet is precious.
'God grant me the serenity to accept the things I cannot change, the courage to change the things I can, and the wisdom to distinguish the one from the other.'Reinhold Niebuhr
