Two More

by Matt Ingham, SOM ’10

Second Prize 2010 Gerald F. Berlin Creative Writing Award

The chaotic fury of an African morning wanes as we step inside another of the tattered, one-room blue tarps dotting this squatter settlement strangling the Zambian capital. Sprawled in the corner, crunched between all his family’s worldly belongings, is an emaciated young man, breathing heavily, his bony abdomen and chest alternating in rhythmic succession as they mark tenuous time.

A woman rushes to greet us with a desperate, hopeful smile. This is Issac, she says, her second son, and the only man left in her family. The fate of the others is left unsaid, for to mention the cause of their death would only sow needless shame upon them.

To my astonishment, however, she meekly offers that Issac has started trekking the endless kilometers to the government dispensary a few weeks earlier. But this was years after the sentinel signs of his illness appeared, months after he could no longer work and it has been awhile since his dignity slipped away. He looks slowly askance as she offers this disclosure.

I cannot tell if Issac is incalculably stoic or has just given up on his already short life, but his eyes reflect a suffering isolated from fear. He is almost mute, his mouth paralyzed by a thick coat of thrush. I am immediately overwhelmed by the wave of anticipation his mother’s eyes cast upon us. He isn’t breathing well, she offers the three white medical students listening tentatively to his distant lungs.

“Andrew presents to clinic following his diagnosis of…” I arrest my note, overcome for a moment by the weight of this story, remembering vividly the tale of a day that seemed, at age seventeen, to set a whole life in orbit, then pulled inexorably towards disease.

His father walked out in violence, and his mother cried endlessly, with each tear a piercing dagger. Amidst his parent’s violent disapproval, and their subsequent unbreakable aversion to the truth, Andrew sank deeper into depression, alcoholism and isolation. In the depths of deception – as only the internet could provide – or in dark, anonymous parks, he offered far too much to any stranger willing to yield him some form of false validation, and not infrequently at a violent price.

Then, at some point so appropriately unbeknownst to him, he made the one inevitable mistake among many that led him here and burdened him in an instant with a life now forever restrained by anguish. “It’s my fault,” he insists softly, “I was stupid.”

By way of our hired taxi, Issac is one of the few from the Chazanga settlement to reach the University Teaching Hospital. And atop the weight of human suffering we have seen by noon today, this effort on Isaac’s behalf seems futile and certainly unsustainable given the lot of so many others. I force myself to accept that any one life made more comfortable, or, failing this, more hopeful, is morally right. Even if that hope is false.

We pass throngs of Zambians streaming forth on the road’s shoulder, returning from a day trading their wares for pennies in the capital city, or hauling goods to sell back in the settlement. Traffic slows as we approach a shiny shopping oasis anchored by a posh South African-owned supermarket from which a trail of Zambia’s elite emerge amidst armed security. We refuel at a British owned station where Zambian employees peer suspiciously – and with a hint of disgust – at our cargo. We pass an army of Land Rovers and various other tentacles of the countless NGOs sustained by an epidemic. Nearing the hospital, we pass beneath looming billboards preaching, in English, the merits of abstinence. Looking at Isaac, his head slumped over the window, I wonder whether he benefited from the twenty million dollars in US funds spent on abstinence, as compared half that sum spent on condoms and education.

I almost wish I could tell him about this.

With ease, I query the computer for Andrew’s genotype, CD4 count and viral load. I dictate them, their significance registering briefly, then cast aside. Earlier, as I attached the relevance of these figures to his disease, his eyes flickered with helplessness, and, for a moment, anger, but I assure him that his mortality is distant indeed.

Andrew’s intermittent cough prompted, despite his relatively high counts, an array of obscure viral and fungal markers, in addition to a chest scan, which I note are pending for follow-up. “Might as well,” my preceptor had offered in academic justification. Andrew seems momentarily reassured by this show of technological firepower.

He shuffles out alone. This man has built walls of incalculable strength around so much of his life, and his diagnosis now rests safely inside. He insists that to share this news with his parents would, in sickening paradox, merely provide additional evidence for their prosecution. And of the people he has met in these last years, he knows almost none.

He is alive, but he is far from the living. There is a raging fire in his house, and all the doors and windows are locked. But he laughs when I ask him. “Of course not,” he says confidently, with a reassuring laugh. “I can’t even stand the sight of blood.”

A day after we deposit him, Isaac is once again at home. Something is mentioned of disseminated Kaposi’s sarcoma involving the lungs, for someone has noticed a bluish lesion on his skin. There has been no imaging, no induced sputum, no bronchalveolar lavage, no blood antigens, no empiric antibiotics, and no PCP prophylaxis. And his money for food and medications had quickly run out.

Five days from our initial intrusion, we return to join Isaac’s mother, now, at last, totally alone. Isaac has died at home in his small corner of the earth where we initially disturbed him. I feel an incredible urge to know what his mother was doing, was saying, when his chest stopped moving.

I am awoken from my thoughts by the home-based care worker, who informs us that offering a small gift is customary after a family member’s death. But I quickly decipher this is not custom and these are not gifts. This frail women’s very survival is now at stake.

I want her to cry. I want her to explode in fury. But she does neither. I am angry and foolishly self-righteous and I have at least twenty indictments to offer on behalf of her son, but she seems to accept only one.

We step back onto the noisy, chaotic gravel path weaving its wave through the windswept tarps and fragile clay shanties. Children shriek and play raucously. An idle chicken squawks by, and a rowdy man emerges at midday from a nearby bar. For just a short moment, I give thanks that Africa is so incredibly noisy. Like at home, suffering, anguish and fear can be so easily drowned out and so easily ignored.

But it is noisier here.

I had never taken the stairs this far until today and I am out of breath but the scene before me obviates the need for any questions. Nurses withdraw lines and turn off a melody of equipment. They seem careful not to move too quickly, thus offering their respects with a slowed, solemn pace and a forfeiture of time – a nurse’s most valued commodity. To me, this pace has always seemed, when a patient’s family and friends are absent, to be yet slower.

There is rumored to have been a note full of illogical apology. In the computer, I cannot avoid the Tylenol level, below which I see a chest CT and some obscure infectious disease results anxiously awaiting to be read. I have at least ten indictments to offer, myself among them, and there is no one there to listen.

And it is too quiet here. I move into the room.

Partially fictionalized account inspired by actual events.