1. Fitzgerald, Laura MSN, RN, CNM


Collapsing the insulating distance of global health.


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We cluster in the operating room, a pack of eager observers in scrubs. The Tanzanians wear government-issued green. I wear a navy blue set, my last relic of a nurse midwife career that ended a decade ago. I now work in public health for an international NGO. We talk about improving systems, quality of care. We focus on teamwork, communication, evidence. I tend to think about patients in aggregate now, a sometimes de-personalizing hazard of public health. The way I see it, I no longer care for women directly, but I support those who do.

Figure. Illustration... - Click to enlarge in new window Illustration by McClain Moore

In the OR, there's an undercurrent of contained excitement. All of us on the team-including the mustached surgeon, the pair of anesthetists, and a heavily pregnant OR nurse named Esther-have just spent the week in a rural hotel learning how to reduce infection rates after cesarean births.


However, today's procedure isn't a cesarean; it's an exploratory laparotomy. The team is scrubbed in, alert. One of the anesthetists reads from the World Health Organization Surgical Safety Checklist, just as we've practiced. Five billion people worldwide lack access to safe surgical services.


A lopsided mass bloats the torso of the woman on the table, and she is so gaunt that every tiny bump and bone looks exaggerated. Earlier, I saw her waiting in the corridor in a wheelchair-the spindly limbs, the bowed head, the bent back-and mistook her for a geriatric patient. Now I see she's young, younger than I am, surely.


The surgeon asks the woman about her weight. I understand just enough Swahili to decipher his question but can't grasp her answer. I lean toward the Tanzanian physician who leads our safe surgery program and whisper through a paper facemask, "What did she say?"


"She's lost close to 45 kilograms in the past year," he says.


One anesthetist injects sedatives. The other snakes an intubation tube between her lips. I watch the nurse Esther place metal kidney basins at the foot of the table. When she's finished, she rests her forearms across the top of her round belly, waiting.


The surgeon begins to cut. I'm surprised by the tender care he takes with each slice. An assistant stands opposite him holding the suction hose. They are expecting pus.


The surgeon works all the way down to the rectus muscle. Beyond that, he hesitates. He uses both gloved hands to palpate the internal landscape. I remember that from my midwife days, my hands feeling this way, then that, distinguishing head from butt, searching for the solid curve of a spine. The surgeon takes his time, moving under the incision, gauging contours, seeing through touch.


Our program director murmurs, "He thinks it's an abdominal pregnancy. Her last period was nearly 12 months ago." An abdominal pregnancy is rare-a fetus that grows in the abdominal cavity instead of the uterus.


When the surgeon finally enters the abdomen, the odor is immediate and sharp. The suction machine starts. The fetus is lifted out. He is gray, covered in a whitish film, eyes squished closed. He's been gone for months now, making his mother sicker and sicker.


Esther gets busy wrapping him up-a limp body in a green drape, just like his mother. Suddenly my eyes water. I want to hold him, to say something, but Esther is placing him in one of the metal kidney basins, and attention returns to the surgical field.


I think of my own two babies, giving birth to them. I wonder if this gaunt woman on the table ever felt those first fluttery kicks, if she ever suspected the exact nature of the misplaced mass growing inside her.


"Why didn't she have an ultrasound?" I ask the program director.


"She refused," he answers. "Said she couldn't afford it and fled. They couldn't find her. Then yesterday she came back, septic."


I wonder what scared this woman more-the prospect of surgery or the information it would reveal? I look around. Who will tell her, when she wakes up, about the bundle in the basin? Will they give her a chance to see him? Already, scraps of paper and gauze cover him.


Esther has lifted her hand to her pregnant belly again. "Are you OK?" I ask.


She looks at me for a moment, then gives a short laugh. "Yes, I'm OK," she says. Esther is cool, focused, a member of a skilled team that just saved a life. When I was at work as a midwife, I could be like that too.


Also, like Esther, I worked for the benefit of my patients, women whose names and stories stay with me still. Since then, stories of our "beneficiaries" come second- or thirdhand; they are impersonal, blur together. But in that Tanzanian OR, the insulating distance of global health collapses. And I realize I do this work as much for the Esthers of the world as for the women in their care.