1) As busy as you are the local mufumu (witch doctor) is busier. He lines babies up and cuts the uvula. None of the kids have them here. At two weeks. Cut and cut. One after another with a blade. The local tradition is to cut the uvula of a young baby – Melino has his cut. We run into the mufumu on the hills, he says he can cure fractures by scarification. Huge goiters, we see his handy work. Small cuts into the thyroid, the abdomen. Anywhere there is pain or a mass. Scarification.

2) When young mothers come to Wednesday maternal health day, do not ask if they cut their child’s uvula. Ask them when, and at what age? And then proceed to tell them the risks.

3) The question with the most standard answer: How many children do you want to have?

Answer: As many as god provides. And god provides a whole lot of children. But as he giveth, he also taketh away. He definitely taketh away.

4) Because god provides a whole lot of children, the fourth one of a 28 year old woman comes out really  fast. The head, the stomach and slippery blood squishy beautiful mess in my barely 2 second before gloved hands. My first delivery since medical school in the middle of the night.

5) There was the woman who said she is 52 and has not had a period in 3 years. She thought she was pregnant. She was not pregnant. She had back pain and she thought the baby had grown so big inside her that his teeth were coming around the side and biting her back. I could not stop laughing. Try not to laugh. It is rude.

6) When your translator does not show up to work, wait patiently and without judgment. Often they are attending a funeral. Elvis, our translator’s cousin was murdered recently. He was a journalist who questioned government corruption. There are places in the world where dissent is so silenced that people are murdered for saying something. This is one of those places.

7) The 25 year old with shortness of breath who realized before we did that she was dying. TB with bacterial pneumonia. She asked to be washed clean, taken down to the outside dirt showers before she dies. And she was so short of breath but with an urgency she named names. A string of names for her husband to go tell them she loved them. And a string of names for her husband to tell that she is sorry. Forward on, try not to let them be the same name. the ones who you love and the ones you wish to apologize to.

8) There will be a roll call of patients who die. Memorize their names. Write them down and put them in your wallet. The wretched of the earth. If you write them down and live with them and make them matter to your life, and your life matters to someone and their life matters to someone, the one who died without so much as a thought in rural Burundi….maybe they can deservedly matter.

9) Watching a mother strap on her back her dead baby and walk the long mountain walk home… there is nothing ever that will depress you more and make you want to work harder.

10) Of so many dead there are those that surprise and mesmerize. That survive despite everything. Children that recover from cerebral malaria. The child that got discharged for malnutrition before you came and has eaten so much plumpy nut that he is now fat. And you mistake him now for Kwashiorkor. Swollen. But it is a fat kid and not fluid in his thighs. fat is wonderful. And Melino laughs, “Sri, that is not a malnourished kid. That is an American baby. ”

By Sriram Shamasunder, MD, DTM &H