A paediatrician in Guinea-Bissau: To accept what I cannot understand

Our international staff are often working far from home, with people and environments that are very different from their own. Here Mårten, a paediatrician from Sweden, blogs about a baby and his mum, and why a shared understanding can be just as vital as access to medical care...

Women and children on the neonatal ward in Guinea-Bissau

Saidu is four months old and has been admitted to the ward for severe skin infection, malnutrition and oral thrush infection. He’s been here for almost two weeks. We offered his mother an HIV test, which was positive, and she started treatment immediately. Saidu is scheduled to start his treatment as soon as he recovers from the infection.

Saidu has been getting better and was about to go home when he had difficulty breathing and fever. We found he had pneumonia and started him on a new course of antibiotics. He is alert and breastfeeding well, but he needs oxygen and is therefore in our department for critical patients.

Image shows babies on the ward.

Photo: Mårten Larsson / MSF

For the past two days Saidu’s mother has been hoping to go home with the boy because the cashew nut harvest has begun. This harvest is economically important in Guinea-Bissau. One of our domestic doctors who spoke her language, Fula, persuaded her to stay.

But today, when I arrive at ward, the bed is empty. I’m told that the mother disconnected the oxygen and left with the child, who still had breathing problems. Our doctor went out on the road and found the mother and tried to convince her to return to the hospital, but she said her mother had died and she had to return to her village.

About one hour later I’m in the emergency room, where we had just finished successfully resuscitating a newborn, who was now yelling loudly. Then I hear a woman cry and scream hysterically inside the ward. Immediately afterwards, the nurse enters with Saidu, who is floppy, gray and lifeless. 

 I do not know why this mum did as she did and I cannot judge her either

I´m told the mother came back with the child, who stopped breathing somewhere along the way. We do not know how long he has been lifeless, but probably 15-20 minutes or more. I decide to make a resuscitation attempt anyway and we begin to give breaths and cardiac compressions, secure venous access and give adrenaline.

After 10 minutes there is still no indication of breathing or heartbeat and the baby boy’s pupils are wide and stiff. We finish.

Outside the open window, the mother stands and cries and screams with despair. The same doctor who talked to her earlier is standing by her and tries to talk to her, but she is so desperate she cannot talk.

They have different ethnicities, cultures and customs

Several of the other mothers gathered outside the emergency room take care of her, offering her comfort and mourn. After a while she takes the little body, wrapped in colorful fabrics, home to the village.

I ask my colleague later if he thinks the mother understood the seriousness of taking off and he assures me that she did. I ask if there was anything else that forced her to return home and risk the life of her child, but although it certainly meant a financial failure not to attend the cashew harvest, he could not come up with any other motive. The fact that her mother died was according to him something she said to be allowed to go home and even if it was true, it is hard to see that as a reason to risk the life of her own child.

It is difficult to understand why you would expose your child to the kind of risk this woman did. I would like to think that she either did not understand the risk or that her absence from home meant an even greater risk to the family's well-being. Many families are dependent on the cashew crop to survive, as they invested in growing cashew that yields higher returns than other crops. Perhaps her decision means that the rest of the family could be supported for the rest of the year? But this is just me speculating. I can only accept that I do not know why this mum did as she did and I cannot judge her either.

Communication is a problem. The cultural difference between me and my colleagues from Guinea-Bissau is huge, but the difference between them and many of our patients feels even bigger, as they have different ethnicities, cultures and customs.

We must continue to ask, listen and inform, to try to improve our mutual understanding, but sometimes we just have to accept that we don’t reach all the way.