May 4, 2000

Dear Friends,

Greetings from Malawi. My last newsletter was very upbeat and positive, I feel, as it told about a successful operation and had a photo of myself with the patient and others of our surgical team. This letter is an attempt to be honest and realistic about medical practice as a missionary doctor. For all doctors there are some patients we never forget. Here is the sad story of one of my patients.

I met her in October 1999, when she came to our hospital because she was not feeling well at all. She knew she was pregnant, but she had terrible nausea and vomiting. Our ultrasound revealed that she had a somewhat rare form of abnormal pregnancy called a molar pregnancy. There is no baby, and there is abnormal proliferation of tissue, which was supposed to become the placenta. At that time I performed a dilatation and curettage which was intended to empty the uterus of the molar tissue.

It is very important to keep on following these patients, so I emphasized to Esther that she must come back every month so I can check and make sure everything is all right. In the United States there is a very good blood test that can be done to follow the patient. We do not have this test in Malawi. She came back in November and December, and everything was all right. I wanted her to come back monthly. However, after that she did not come back until March. She said it was a long way, and the bus fare was too much. At that time there was more growth of the abnormal tissue in her uterus. This is a rare complication of the disease, called an invasive mole. I did another dilatation and curettage, but still the problem was not solved. Also, Esther was getting sicker and sicker. It seemed the only thing to do was to operate and do a hysterectomy in an attempt to take out all the problem.

The operation was a nightmare. There was a lot of blood loss and she did not do well at all during the surgery. We were able to get one unit of blood for her. I was not able to do all the surgery that I wanted to do because she was too sick to tolerate a long surgery. I was also distressed to see that the molar tissue was outside the uterus, so I knew that I was not removing all the problem.

She recovered slowly from the operation. We needed a chemotherapy drug usually unavailable in Malawi to fight and destroy the remaining molar tissue. I called Frank Dimmock in Lilongwe, our health coordinator for the PC(USA) in this part of Africa, to see if he could find a traveler who could bring some of this medicine out to us from the United States. Frank was able to find someone, but we would have to wait two weeks.

Meanwhile Esther was getting better but was having vaginal bleeding—not a good sign. I felt like the time was right to give her the chemotherapy, this special medicine, before she got any worse. I did not want to wait another two weeks. Then one evening I had a brainstorm. I had heard that there was a pediatrician in Blantyre, our neighboring city, who had some chemotherapeutic drugs she used to treat childhood leukemias. I thought she might be willing to loan me the medicine until our medicine got through from the United States. Yes, she was willing. So the next day our hospital driver went to Blantyre to get the medicine. There was a complication. These precious and expensive medicines were kept locked in a filing cabinet in the pediatrician’s office. The key to open the cabinet could not be found anywhere. The pediatrician also wanted badly to get into that cabinet to get medicine for her own patients. However, for three days we could not get to the medicine.

I was scheduled to travel to the northern part of the country on Good Friday. I still did not have the medicine, but Esther seemed to be holding her own. I was sorry leave for ten days and wished I could stay to try to get the medicine. But I felt I should go because a lot of other people, including patients, were expecting me to be at another mission hospital in the north. So I went.

I got back to Mulanje, my home, two days ago. Esther was not in her bed. I found out that she had had a massive bleeding episode on the Tuesday after Easter and had died quickly after that. She was 23 years old and left a husband and two small children. Everyone was very sad, including me.

Well, it is a sad story, but true to life. Most of the time we are not dealing with a rare disease. I feel like everyone tried their best for the patient. Sometimes that is all we can do. After that, it is in the Lord’s hands, and we must accept what happens.

What will happen to Esther’s husband and children? One good thing about Africa is that families pull together in emergencies. I am sure someone in Esther’s family is taking care of the children right now. I was not able to see any of the family after her death because I was gone.

How do I feel? Sad, but I know in medicine, just as in life, you cannot win every battle. I am glad I got to participate in Esther’s care, that I got to talk frankly to her husband, and I got to know her mother. I am sure that the family appreciates what we tried to do.

In missionary medicine we do the best we can with what we have. The patients and their families are so appreciative that we are often humbled by the respect they show us. What does the Lord require of us, but to do justly, love mercy, and to walk humbly with our God?

Dr. Sue Makin

The 2000 Mission Yearbook for Prayer & Study, p. 40