Where There Is No Hospital

A book can save lives

IN SIERRA LEONE we always had a doctor when we needed one, and that doctor was my father. When I was a baby, a measles outbreak in the country caused scores of children to die. We—my brother, sister, and I—all fell sick. The spots even covered the insides of our mouths. We could neither eat nor drink. My father was upcountry fighting the epidemic and beyond reach by telephone, for this was the 1960s. So my mother, remembering what he had taught her, shook a bottle of Fanta to release the gas and let us sip the flat beverage—to rehydrate us and as a replacement for sugar and salts. Finally, she reached a colleague of my father’s who came by, and after checking us, put my brother on a drip. When it seemed we were through the worst of it, my mother ran to the expensive store across the street and bought imported cherry ice cream, spooning it half melted down our raw throats.

The first few years of my childhood, my father took over from a colleague a clinic in Koidu, a remote outpost, best known for diamond mining. Despite its mineral riches, Sierra Leone was then, and still is, one of the world’s poorest countries in the world, a so-called “health care desert,” to use the terminology of the aid agencies. During those childhood years, I had the usual range of ailments that come with life in the tropics. Despite my father’s entreaties, I refused to wear my sandals when I played outdoors and thus contracted hookworm. I cuddled my dogs and ended up with a tick burrowed deep in my ear canal, which my father extracted with long tweezers. He lanced my tropical boils; the scar left by one intervention is still visible on my neck. Sundays, we stripped to our knickers and lined up in front of our mother, who sat by the window for tumbu inspection. Tumbu flies, sometimes called mango flies or putzi flies, are a species of blowfly that lay their eggs in soil where the newly hatched larvae attach themselves to mammals: a reclining dog, say, or a child making mud pies. Then they burrow under the skin of their host and feed on blood until they hatch. My mother would scan our skin for evidence of the larvae in the form of a pimple, one with a pinprick-size hole in the top. She would reach into the tub of Vaseline petroleum jelly she kept by her side and place a dab upon the spot. Some seconds later the head of a maggot would appear—the larvae! My mother would squeeze the spot and out it would come with a satisfying little pop.

 

THE ONLY TIME I became seriously unwell was when I was ten. One morning I vomited my breakfast and for some days thereafter I lay in bed, feverish and nauseous. For a long time my sickness went untreated, as our house had been thrown into turmoil. My father had been arrested by the secret police. He had become a political activist and had already spent three years in prison as a detainee. Amnesty International declared him a prisoner of conscience, and his story is one I have told elsewhere. The thing is, I fell ill the morning after he was taken away. Unusually—especially for people living in a country like Sierra Leone in the 1970s—my family and even the local doctor I was sent to see decided my illness was psychosomatic. My father was strict about us taking the antimalarial Paludrine, and a packet lay on the sideboard by the table where we breakfasted, but no prophylactic is 100 percent. It was the rainy season in Sierra Leone, when malaria is at its height. The cousin who was taking care of me contracted malaria himself. He rubbed his face with menthol toothpaste, a home remedy thought to soothe fevers. My father had only been gone a few days and already we were unmoored. A year later, after his death, there was no longer a doctor in the house.

I cannot recall the first time I came across the book Where There Is No Doctor, which appeared on a bookshelf in our house. It could not have been before 1977, which is when the first English-language edition came out. I remember reading somewhere that the book had been inspired by the Latin American “barefoot doctors.” These were volunteer medical personnel who traveled to remote villages in the mountains to treat the sick and injured. They also trained local healers in the rudiments of Western medicine. This is broadly accurate, though the originator of Donde No Hay Doctor, which came out in 1970 in Spanish, was an American, David Werner, who had worked together with a group of volunteers and local paisanos on addressing the health care needs of the people of Ajoya, Mexico. Out of this partnership came the idea of producing a simple manual to provide essential, medically accurate information aimed at remote communities. Donde No Hay Doctor has since sold over one million copies and has been translated into nearly a hundred languages, including Tzotzil, Tswana, Pashto, and Pidgin.

You’d think death would become prosaic. And in a way it does. But life never seems to. 

The cover of the book shows a group of men in straw hats bearing a makeshift tented hammock across a river. Inside the tent, a patient—a man—is just visible. You can tell because his hat has been placed at his feet. Where There Is No Doctor is, in essence, a “how-to” manual. It gives advice on treating most injuries and illnesses, from the commonplace to the life threatening. It opens with a warning to readers not to believe an ailment can be caused by witchcraft, the evil eye, or cured by magic. An early section deals with folk remedies, those that work and those that do not. The examples given come from the Mexican highlands. One dispels the notions that the light of an eclipsing moon falling on a pregnant woman will lead to birth deformities. Another confirms as sound the belief that a newborn should not be bathed until the umbilical cord falls off. Garlic to treat worms is given the thumbs up, as is the sap of the papaya tree, whose fruit is especially good for upset stomachs.

In Britain there is a radio show called Desert Island Discs. Celebrities or distinguished people are interviewed about their lives on the imaginary premise that they have been shipwrecked on an island and allowed to take along “eight tracks, a book, and a luxury.” The conversation with the host is interspersed with bursts of music. The fact that the word discs appears in the title will tell you how old the enormously popular show is—it started in 1942. The castaways are given the complete works of Shakespeare and, in the early days, a Bible, though now they can take a Koran or other spiritual or philosophical work. They may also take one book of their own choosing. Dickens is a great favorite and so is Jane Austen. I would take Where There Is No Doctor.

When I was a schoolgirl I liked to read dictionaries, which I know to be an early pleasure to which many writers have confessed. Where There Is No Doctor evinces the same kind of satisfaction, except that instead of learning new words, you learn another language: symptoms and treatments. You might think of it as the kind of pastime in which only a hypochondriac would indulge, but in this you would be mistaken. The appeal lies not in the idea of being an invalid, but rather of being the doctor. I confess to paper mask fantasies. I’ve long envied people who possess the power to heal. Such purpose. A writer often thinks, What am I doing, sitting here alone, surrounded by people who don’t exist, writing books nobody has asked for? A doctor, surely, can have few such doubts. Whatever moral or ethical dilemmas their work presents, existential dread cannot be a bother. I have created doctors as characters for my novels, spent hours trailing real doctors down hospital wards, watched surgeons in an operating theater. I have seen teams work tirelessly to save a life. They will work and work, but the moment the patient is lost, the energy dissipates and the team moves on. You’d think death would become prosaic. And in a way it does. But life never seems to.

One day, in the hospital in Freetown, where I had been given permission to join an operating theater nurse on his daily rounds, I asked about the empty bed of a man I had seen the staff treat the day before. The patient had sprayed the room of the small pan-body in which he lived with insecticide and later entered holding a lit candle. The room transformed into a fireball, and as a result his body was 90 percent covered in third-degree burns. I recognized the wheelchair the nurses helped him into as one I had donated to the hospital. I had broken my Achilles tendon while racing a friend on a beach the year before and had self-diagnosed the injury to my rescuers, before passing out on the sand. In the end I’d wound up here, at this very hospital, run by helpful Italian aid workers, before being flown by my insurers back to the UK for surgery. When I recovered, I returned to Sierra Leone and gifted my crutches and wheelchair to the hospital.

“He died last night,” said the nurse matter-of-factly. Seeing my surprise, not at the information but the tone of his delivery, he softened and explained that the man had stood little chance of survival. To this day I recall the patient, his uncomplaining compliance with the staff, his scorched body, the way the pink of his flesh flowered under the blackened skin. He was a big man, tall and once strong, but the bodily trauma he sustained had overloaded his internal organs and caused them to shut down one by one. I remember the delicacy with which this particular nurse, Luca, had helped him into the wheelchair.

Where There Is No Doctor specifies that third-degree burns should be bathed in cool, boiled water to which half a teaspoon of salt and the same of sodium bicarbonate per liter have been added. The burns should be covered with Vaseline and a light, cotton cloth placed over the wounds. The book suggests treating less serious burns with honey or with the “inside meat of an aloe plant,” a nod to the book’s South American origins.

From reading Where There Is No Doctor, I first learned how to suture a wound, how to set a broken bone, diagnose Zika (“fever, rash, body aches, and irritated eyes”), put a catheter into a man or a woman, and assess whether an unborn baby is in the breech position and, of course, deliver a baby. How many women’s lives might be saved in Sierra Leone, a country with one of the highest maternal mortality rates in the world, if everyone there had a copy of Where There Is No Doctor?

My friend Rosalind Alp suffered a miscarriage while working as a primatologist in Outamba-Kilimi National Park in Sierra Leone. Her camp was more than fifteen miles from the nearest road, then a twenty-mile drive on unpaved roads to the nearest hospital in Kamakwie. Alone in the camp, she woke up one morning to find she was bleeding heavily. She told me: “I used [Where There Is No Doctor] and discovered that I was having a miscarriage, which I knew was possible. I followed the instructions. You can lose a lot of blood. Your body is essentially reacting like you’ve had a baby. I had to lie down for a couple days. Panic and stress make it worse. The only thing I had to do was build the fires for food and light. I spent two days lying in my tent listening to BBC World Service and reading.” Afterward she safely disposed of the tissue and blood by burying it.

Back in Freetown, months later, an American medic told Rosa that she could have died, angry with her for not going to a hospital. Impossible, of course. In her condition, she might have died trying to make the journey. Instead, said Rosa, “I had the book—I stayed calm and did what it said.”

Hard lessons were learned. Or rather, lessons were learned the hard way.

I travel. A lot. My international family lives in multiple cities across the globe. I also travel for work to places where health care is not always easy to access: Mali, Burkina Faso, Kenya, India, Pakistan, and of course, Sierra Leone. I keep my yellow fever vaccination up to date as a matter of course, along with typhoid and hepatitis. “Where are you going?” a nurse asked me the last time I submitted to the needle, which surprised me because I have lived so long with the idea that you don’t have to be going anywhere particular to have a vaccination for a tropical disease. Alongside my vaccination certificate, mosquito net, malaria pills, and water-purifying tablets, inevitably I pack my copy of Where There Is No Doctor, or more accurately, I pack a new copy, because typically at some point on my last trip of this kind, I’ve given my old one away.

A friend professes himself surprised at the depth and breadth of my medical knowledge, and I have replied and indeed assumed myself that it is because my father was a medical doctor. However, I paid little attention to his work during the time he practiced; I was young. I used to tell myself that the knowledge must have hung like mist in the air and I absorbed it. Now that I put my mind to it, I realize that Where There Is No Doctor is the source of my knowledge. That, and spending so much of my life traveling or living in places where doctors are few and far between, where one must rely on one’s wits.

 

THE FIRST BAREFOOT doctors were trained by and worked in the name of the Chinese Revolution. In 1949, Communist Revolution China had about forty thousand physicians to serve a population of 540 million people. Most of the doctors lived and worked in the cities, leaving China’s massive population of peasants without health care. Millions suffered from bilharzia, caused by parasitic worms that make the belly swell. If left untreated, the disease may permanently damage vital organs. In China, the parasite was being passed to villagers through intermediate hosts: snails living in the rice paddies.

Mao was determined to revolutionize agriculture with the aim of increasing food production, and a healthy workforce was essential. Thousands of peasants, those with a basic education and themselves rice growers (hence the term barefoot) were trained in essential health care. In the field they taught basic hygiene, administered vaccines, and treated common ailments. The doctors carried with them a book, The Barefoot Doctor’s Manual, which detailed the treatment of a range of injuries and ailments, combining Western medicine with traditional Chinese practices such as acupuncture and herbalism.

My father would have loved Where There Is No Doctor, and probably wished he had written it himself, had he ever found the time. For he was intimately acquainted with village life and practices, having grown up in the hamlet of Rogbonko in Tonkolili, in Sierra Leone, where my grandfather, a prosperous farmer, worked his land. As a child, my father had helped in the fields, fished and swam in the river, before he was sent away to school. He was not a barefoot doctor, but had grown up barefoot. As a doctor he worked frequently in villages like Koidu, which was six hours from Freetown, close to the border with Guinea. Very close, in fact, to the location of the start of the 2014 Ebola outbreak, which began on the Guinea side and coursed through Sierra Leone and Liberia. But more on that later.

One night, when I was a child, a man arrived at the Koidu clinic with his sick wife. In the taxi that brought them lay the body of their dead child. I was too young to remember; this story comes from my mother. After treating the woman and questioning the family about whether others were sick in the place they had come from, my father packed his medical bag and rushed out of the house. Off they went in our car, the couple cradling the corpse of their son wrapped in a cotton sheet. It was cholera. He had gone to trace the source of the outbreak and treat the many others who were unable to get to the clinic.

Many years later, in 2003, on a visit to Rogbonko, which I had come to know well, I put a copy of Where There Is No Doctor in the library of the school I had founded there and that is dedicated to my father’s memory. I gave another copy to my cousin, Morlai, who acted as our school administrator and who had grown up with me during the years my father was alive. Four years later the village was struck by illness; people in surrounding villages were falling sick too, dozens at a time, with uncontrollable diarrhea and vomiting. Morlai raced to his house to find his copy of Where There Is No Doctor. Cholera!

Morlai called the denizens of Rogbonko to the school for a community meeting, which he would go on to hold every day. He read aloud directly from Where There Is No Doctor about how to prevent the spread of the disease, which is passed through contaminated water. Boil, boil, boil the drinking and cooking water, which is the advice he relayed to me in the UK over the phone. The villagers pooled their scant resources to purchase oral rehydration salts. And though many hundreds of people died in the outlying villages, Rogbonko lost not a single soul out of the then seven hundred villagers.

In 2009, illness struck Rogbonko again. Just as my father had done many years before, Morlai worked to establish the source of the outbreak. The village lies in the oxbow of a river. In its lily-strewn waters, children play, women wash clothes, men and women fish, and everyone takes their daily bath. It is idyllic, except sometimes people, children typically, use the riverbank as their personal toilet. The river was the source of the outbreak, and poor hygiene practices the cause. The village had a well, but a poorly fitted pump meant it was frequently out of action and had failed again some months previously. The villagers had been fetching their water from the river. Morlai assumed this was another cholera episode and lectured the villagers again. Boil, boil, boil! Still, one way or another, the village needed expert care. The chief’s wife was the worst afflicted. Somehow Morlai got her to the hospital on his motorbike. She could barely hang on to his waist; they made frequent stops, and all the time he worried she would fall unconscious before they reached safety. The diagnosis from doctors at Magburaka Hospital, when it came, was not cholera but amoebic dysentery, the symptoms of which are similar.

Hard lessons were learned. Or rather, lessons were learned the hard way. I raised the money to fix the well, and in time we would also sink a second well at the other end of the village. The village dug new and better latrines—Where There Is No Doctor helpfully provides detailed plans. Nobody had died. We sighed and drew breath.

Then came Ebola.

In the spring of 2014, the first reports arrived of an Ebola outbreak in Guinea. I had planned a trip to Sierra Leone that summer. When I looked up the location of the epicenter, the town of Guéckédou in Guinea, I saw it was right on the tristate border of Guinea, Sierra Leone, and Liberia, close to Koidu, the regional trading center for rice, coffee, kola nuts, and palm oil. Trucks carrying goods travel in all directions across the border, south to Monrovia and west to Freetown. It didn’t take a genius to work out what that meant.

My edition of Where There Is No Doctor does not contain a section on Ebola. I do not know if editions available in other countries—specifically those in Africa—do, but if they don’t, they soon will, as 2014 marked a major comeback for the disease, which killed eleven thousand people in Sierra Leone, Liberia, and Guinea. By listening to news reports, scouring social media, and talking to people back home, I mapped the disturbingly fast approach of the disease as it moved toward Makeni, more or less dead in the center of the country, and through which many major routes pass. Though it lies surrounded by farmland and forest, Rogbonko is only a few miles from Makeni. To travel by road is to go the long way round. The people of Rogbonko canoe across the river and meet the path on the other side from where it marches past the rice fields and winds around neighboring villages until it reaches a place we call Mile 91, some distance south of Makeni on the road to Freetown. Mile 91 is a junction frenetic with life. It is where we stop on our way north to refuel and purchase cold drinks, roasted peanuts, and skewered meats. Motorbike taxi (okada) riders wait for clients there, and poda podas crammed with travelers on their way to provinces for family events pause there to allow passengers a moment to stretch and disappear into the bushes. It is a perfect place for a virus to hitch a ride on a bike or a bus and fan out in any or all three directions across the country.

The days of waiting reminded me of how I felt so much of the time during the decade of war Sierra Leone endured in the late nineties. Both then and during the Ebola outbreak, it seemed my heart was never still. The news got worse and worse. My stepmother, in Freetown, shuttered her house and sent the staff away to their own homes, keeping on a single housekeeper. There was an air of Victorian England about it all. I imagined the house, in half darkness and silent, with nobody there save an elderly couple, a housekeeper, and her daughter. Elsewhere, there were funerals and mourners, the sound of weeping, soon to be replaced by the sight of white body bags thrown into mass graves by men in masks and hazmat suits. I had friends on the frontline. An aunt who ran a small clinic for pregnant women volunteered; another returned from the UK to oversee the national response; the staff at the hospital where I had spent time joined the fight. Once, I saw Luca on TV, demonstrating how nurses and doctors were hosed with disinfectant as soon as they left the Ebola wards.

Morlai called and texted often in those days. Many days, outside my home was parked a radio car in which I would be interviewed for news programs. As a Sierra Leonean, a former journalist, and someone who was in daily contact with people in the country, I became a conduit to the outside world. One day Morlai called, the worry in his voice evident—the virus had reached the hamlet of Rochain, just a few miles from Rogbonko. We talked at length that day, me in my study in London, him leaning against his motorbike, close to the sugar-refining factory whose Chinese owners had fled the country, and that was the closest place to the village he could pick up a signal. We decided that the village should self-quarantine. Nobody would be allowed in or out until the danger had passed.

The river that all but surrounds Rogbonko provided a natural boundary, a moat. Lookouts were posted on the single road into the village with orders to turn back travelers. And if Where There Is No Doctor didn’t contain an entry for Ebola, their experience with cholera and amoebic dysentery had taught the villagers to trust professional advice. Morlai made one last trip out of the village and returned with a truck loaded with enough rice to feed everyone in the village, for the fields that lay across the river were now out of bounds. He also bought buckets, chlorine, and scrubbing brushes, and placed one at the door of each house. The villagers would remain sequestered for an entire year.

I was not there when the end of the Ebola pandemic was announced. I know there were celebrations across the country.

I no longer need to imagine what it might feel like to endure months of isolation and then to see family you have missed, attend a wedding, go to work in the fields or visit the market for the first time, to meet a one-year-old you have never hugged.

None of us does.

 

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Aminatta Forna is the author of four novels and a memoir. Her most recent book, The Window Seat, an essay collection, is published by Grove Press.

Comments

  1. This article has everything and is a pleasure to read. Aminatta’s life experiences are endless and in many ways shaped by her father (and her mother too) and she is blessed with the ability to write in a gripping skilkful way. This unique combination turned a simpke book into a “must have” book even where there are Hospitals. If Dr. Spock’s book did so much good for expectant mothers, this book is exactly as Aminatta has presented it, a life saver where there may have been no hope. Her father may not have written it as he may have wished, but Aminatta might just as well judging by this priceless article. Thank you Orion for giving Aminatta this opportunity to speak to us once again, and to share her thoughts and understanding of life. Aminatta wonders why she would sit and write a book nobody has asked for. Well, long may she continue to do so because when she does we find ourselves reading some good stuff we didn’t know we should have asked for from her.

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