She laughed. Not ha ha laughing, but the laughter of levity – of realizing that crying does no good. Or maybe I just projected that onto her because I can understand how a tired smile and a laugh at the absurdity that six weeks or six months…hell six years…can repair what took thousands of people years to destroy.

She, was Sweden, a doctor finishing a six week rotation at the local hospital. She is a doctor who admitted to learning so much, most of which will be useless to her in her other life – her real life away from malaria and untreatable liver failure.

As we sat around our dinner table, bugs of varying sizes dive bombing the light bulb and then falling dazed into our hair and laps, conversation began with food…what would she eat when she returned home. We spoke of things we miss, trips we’ve taken, experiences we’ve had. And it was here that our conversation turned serious.

Sweden’s face contorted into a wry smile and she began to speak about her work here.

She spoke about women giving birth in the OBGYN ward, giving birth and bleeding…so much blood. And the nurses are tasked with massaging the uterus to coax it into expelling excess blood and returning to its normal size. But it is painful and the women cry out because they don’t understand what is going on. But instead of explaining the procedure the nurses turn away and answer Sweden, when asked why it hasn’t been done, “The mother is uncooperative”.

Sweden admitted to massaging a lot of uteruses back to size, confiding that with some explanation the women acquiesce- understanding, ultimately, that bleeding is not good for them. And it isn’t just the birthing process.

Just this week there was a woman who gave birth and the baby tested positive for malaria. Knowing the mother must also be infected she prescribed treatment for the mother and went in search of quinine for the newborn. Three days later, after passing the mother in the hall, she heard screaming. The mother’s temperature had skyrocketed to 42 degrees Celsius (through the roof in Fahrenheit and not unusual in unchecked malaria) and she was wrapping herself in blankets to fight her chills. Sweden checked the woman’s charts and sees that she had never received her meds. Incensed, she ordered the initial treatment again – this time through injection – and stood watch as it was delivered. Two days later, checking up on the mother after being out of town, she realizes her second dose was never delivered – the reason: medicine unavailable. A quick trip to the pharmacy, however, proves that to be untrue.

And what do you do with that? Someone denied treatment not for lack of treatment but…what…oversight? Laziness?

The stories are endless…a pregnant woman enters the hospital and it is determined that her large belly is not from her pregnancy (although she is in her second trimester) but is instead filled with fluid. The most likely culprit – liver failure. Sure enough, the woman has hepatitis. Sweden can offer no treatment and so sends her home to her family – to die.

“Will she live long enough to deliver the baby?” we ask.

Probably not.

The problems are complex and intertwined. Some of it has to do with training and education- both interrupted for 15 years during the war. Some of it has to do with funding, both the institutions where people work and the people themselves. It isn’t unusual for government workers to not be paid on time or given their entire paycheck. Then there is organization. Who does what and reports to whom. Fatigue. Foreigners are constantly coming in and out, staying for a few weeks and then moving on. Getting people briefed on what is going on is time consuming and exhausting.

And there is lack of accountability. Who is in charge? Who has the authority to make decisions and to deal with the consequences, good or bad, for those decisions?

And Sweden doesn’t seem to judge. In her quite voice she acknowledged that while she can’t imagine working any other way than what she does now, she doesn’t know how she could do it day after day –forever. She understands the exhaustion and weariness. How do you make yourself do all that you should when chaos is all around you?

It is all so big.

But all things aren’t dire. Sweden talked about her first few weeks at the hospital and the amazing nurses she worked with. How they gelled as a team and challenged each other on diagnoses and treatment. She spoke of being disregarded, initially, by older male nurses who now respect her as a doctor and the perspective she brings. She will take those experiences home with her as well.

It isn’t all blood and death.

But the death part looms heavy because here, as in all medical realities, mistakes translate into sickness and lost life. And while Sweden conveyed her thread of hopefulness…that she has gained perspective and is able to respect her Liberian colleagues despite their imperfections and in turn is learning to forgive her own…she understands the gravity of the work she and her Liberian colleagues have been doing.

Still, it settles. The heaviness of watching people come in for care she can’t provide or from illness she can’t prevent. And in the shadow of that, a soft and distant laughter escaping an almost sad smile feels the most fitting of responses.

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