“At its best, medicine is a service much more than a science.”
- Paul Farmer, MD
The local people standing in line waiting to be seen at the clinic.
Long lines form when the global health team arrives. In El Salvador, people arrived in the backs of trucks and then waited hours for one of our provider groups to assess their stomach pains, headaches, or dental problems. The men, all in long pants despite the heat, talked while women in bright dresses tended the children. In rural Kenya, women in cotton print wraps and men in tattered clothes came from all directions by foot, bicycle, or “boda bodas” (the ubiquitous motorcycle taxis), waiting on long benches in the equatorial sun. At the medical center in Eldoret, Kenya, the hallway adjacent to the ENT Clinic was packed with people from throughout the region wearing US-donated t-shirts bearing the names of sports teams, universities, and companies – shirts re-sold to them by roadside vendors.
There is no way we could ever operate on everyone who shows up. What could we possibly offer to so many people?
“This is crazy!” I said to one of our hosts. “We’ll never get through them all.” During a typical work day at home, I see several patients, prepare Epic notes, mark diagnoses, check billing codes, click all of the boxes, and close the charts. If I am lucky, I can get through twenty people.
Salvadorans heading home after clinic.
“We told them that the Americans would be here this week so they showed up.” He shrugs. “No problem.”
The ENT Clinic in Eldoret, Kenya is an exercise in controlled bedlam. The handwritten records focus on medical problems rather than billing. Scans and ultrasounds, when available, remind me of our technology from 1980. We jam two or three patients in the same exam room and the Kenyan and US doctors, nurses, and medical students peering over each others’ shoulders; there is no HIPAA or pretense of privacy. Patients for whom we have something to offer nod and move to the nurse’s desk to schedule surgery. Patients for whom we have nothing nod and head home.
At the end of the day, I look down the hallway. There are several people who have likely been waiting since early in the morning. “They will come back tomorrow.” And they do.
At home, I become annoyed when I must wait twenty minutes for an appointment; I know that some patients wait longer than that to see me. I wonder how it feels to wait hours for an opportunity – maybe the only opportunity – to see a specialist and then be told to return the next day or, maybe, never at all.
I think that I become a bit more tolerant of waiting during our overseas trips. This came into focus for me on the way home from our first mission experience. We were returning from El Salvador, having seen dozens of patients who had been unfailingly gracious. At the end of the final day of the mission, the lines were still growing. My wife, Kathi, who dusted off her nursing skills for the trip, accompanied an interpreter to talk to the people lining up. “Lo siento (I’m sorry),” the interpreter said. “The clinic can see no more patients. The doctors and nurses must return to San Salvador now and will not be back until next year.”
“That’s all right,” one of the women responded. “We will return next year, as well. Thank you for coming to help us.”
The next day, we were in Houston, waiting for our connecting flight and Kathi was telling the story to our traveling companions. As she spoke, the gate agent announced that our plane would be delayed several hours because of a major storm disrupting air traffic all along the eastern seaboard.
Immediately, an irate traveler with a sunburn strode up to the counter. “This is outrageous!” he shouted. We all looked up as he berated the agent. “We are heading back from our vacation in Mexico and I must be at work in the morning. I demand that you re-route us or get us on another airline! We refuse to wait!”
The gate agent apologized and said that there were no options; all of the airlines had been affected by the storm. The man paced the waiting area, returning to the counter at intervals to loudly register his displeasure. Finally, he announced that he was taking his family to a hotel and that the airline had better cover his bill. Off he stormed, family in tow.
“What a contrast!” Kathi noted. “Imagine if every one the Salvadorans who waited had reacted that way.” We were not blind to the grinding poverty in El Salvador and had heard stories about the people’s lack of opportunity, safety, services, and health care (a process Paul Farmer terms “structural violence”), but we had all noted how grateful the patients had been during our one-on-one interactions.
After the angry man and his family left, a plane did arrive and we did make it home that night.
Maybe the airline passenger’s ire was more noticeable to us because we were transitioning from such a starkly different environment. As Farmer has noted, “the voices, the faces, the suffering of the sick and the poor are all around us. Can we see and hear them? Well-defended against troubling incursions of doubt, we the privileged are precisely the people most at risk of remaining oblivious, since this kind of suffering is not central to our own experience.”
For us, each of our global health opportunities has opened us to viewing life through a different lens. At each stop, the lines have been long and colorful. Our memories are filled with people, each one hoping that they will be rewarded with a word of hope and healing when their time of waiting is finally done.
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Thanks to the MCW Moving Pens and to Kathi for valuable advice. Quotes in this essay are taken from Pathologies of Power by Paul Farmer (University of California Press, 2003).
