(...) The temple-hospice which I will describe, Wat PhraBatNamPhu, has, by unit volume, more harmful microbes than any competitor. When I arrived it appeared to have an aura; the buildings and people mysteriously illuminated, imposing a silence and anguish upon its visitors. Microbes...microbes, they were everywhere, from tuberculosis to 'flu, from staphylococcus to treponeme pale. Worse still, there are the hundreds of other germs, almost unheard of, since they are only found amongst those who are severely immunocompromised.
Originally a Buddhist temple Wat PhraBatNamPhu has become, through some vagary of history, a hospice. A place where living AIDS wreckages, already rotten, are discarded. It is an eccentric arrangement for European eyes. Of monastic past there subsists only the superior and a few monks. They are generally HIV-positives, valid enough to be assigned to the offices of funerals. This 'temple' looks more like a holiday resort, with little cottages laid out around an exotic garden; except here people come to die.Generally, patients arrive in the ward and die within a few days. Some are not so fortunate, their symptoms might improve and they must wait. The cottages are there for those with a longer wait. At least that was how it was when I first worked here in 1996.
Some die on the day they arrive, sometimes from psychological causes. If not, then they die from the rotten air of the wards.From the moment of admission, one's prognosis becomes bleak. The air of the wards is so contaminated that anyone with advanced HIV infection must lose hope. But, and I insist on this point, the psychological shock can be sufficient to cause death. When a patient arrives, he must first go down a corridor in which there is a stock of seventy coffins; empty on one side and those already inhabited by corpses on the other side. The pickup truck to the crematorium comes twice a day. The patients see this before they are even admitted to a ward, a ward full of hopeless cases... I have seen some patients die, not in the first hours following their arrival, but within minutes! A few stick in my mind; As they approached what would have been their beds, they suffered cardiac arrest before even getting there.
Death comes in like the tide. She erases bodies like they are sandcastles on the beach. Sometimes they fight, sometimes they are killed by surprise. Sometimes there are weeks in which no one dies, even those who should die, who defy the rules of life. There are other days when seven, eight or nine pass away.They die in waves, peaks and troughs.At that time the prevailing trend was for us to lose a whole third of the ward in a single week. The turn over of patients was very high, yet the ward would still have more patients at the end of the week than the start because they were being admitted continuously, also like the tide. (...)
(...) Soft death, brutal death, painful death, sad death... almost always unjust death. Dead from misunderstanding love, from having trusted, from being ignorant; or, too often merely from having obeyed the conjugal duty. Even though they are dying from an illness of love they die alone. Not one in ten has the company of a mother, brother or spouse.At present there are more men than women in this hospice, but this trend is changing, as Thailand's wives contract their husband's infection.The majority of them young, between 25 and 35 years old.The procedure we go through after a patient dies is fast. The cadaver is washed, his orifices are plugged with wads of cotton wool, he is dressed in clean clothes, and then is put in a coffin taken from the stock. In the coffin the corpse has a new small pillow and a shroud made of raw canvas. On closing the coffin the cadaver is usually still hot from his fevers.
I remember one anxious mother's question as I started stuffing her son with the cotton wool, he had just breathed his last:
- Are you sure he is really dead ?
Too fast, yes, I acted too fast.One time I was called by a French volunteer to see to a favourite patient of hers.It was too late he had already suffered too much. But because he is still suffering, I decided to give him an injection all the same. However, on trying to turn over his body to administer the drug, he couldn't support it and simply died from the movement.We were both very uncomfortable, presenting this distressing spectacle to those bedridden onlookers. Immediately we started to prepare his body for the coffin, thus turning the page as quickly as we could.But the French volunteer, like the mother before her, said suddenly :
- Are you sure he is really dead?
And I answered miserably:
-Don't worry If he wakes up, he will spit out the cannonball of cotton wool, "pop!" like a Champagne cork.
We both got the giggles. It was ridiculous, obscene Our laughter was cut short, as we discovered shamefully that we were being observed. A hidden Japanese journalist was filming the scene. Yes, I was nervous, too nervous In spite of months of experience. (...)
(...) To this day I have accompanied the death of over two thousand five hundred patients. I am never afraid anymore, but I cannot get used to it either.In the first years, if they died in my presence, I usually prepared the body for the coffin myself. These days I am less generous.A few seconds ago that mouth was speaking to me, moaning, breathing. Now the only sound is the metallic noise of my forceps on his teeth as I fill his mouth with cotton wool.A few seconds ago the only way I would denude his ass was in the case of absolute necessity, thereby respecting the thousands of rules of modesty and preservation of honour. Now I fill it with cotton wool.The existential thrill. Mortals are the plaything of the gods.In the space of just a few seconds, the whole universe can topple in to metaphysics. Time is endowed with powerful resources.
(...) When I arrived in the hospice in 1996, I was totally naive. I came with nothing; no money, no medicines, no wages with which to employ people, nothing but a photocopy of my diplomas.They were the cause of my misfortune. From the very beginning my job was a little different from that of other volunteers. Volunteer yes, but with ethical duties attached. I was condemned to play a role which didn't satisfy me.
I quickly realised that my function must be, on the one hand, to help patients die more comfortably; but on the other, to recognise in other patients their potential to live for months or even years with just the cheap and available medicines.To fulfil my first duty was relatively easy: symptomatic medicines, conversations, massages and nursing care made me directly useful.In my other role, I found it harder not to make mistakes. If my victims didn't die immediately from a bad medical decision then they could end up with a long and agonising death as a result of my attention. There have, alas, been some astounding victories to absolve me from these cruelties, a few brilliant victories. On occasion I was able to restore months or even years of life to a few miserable wretches. Sometimes those beautiful years or months can be appreciated more with the foresight that one's time is short.
Of course, I only had the power that was granted me. My knowledge of Thai culture assured me I couldn't ask for more than that. I had been taught a trick whereby I wouldn't abuse my Thai hosts : always to imagine myself a Papuan doctor offering his services free of charge at a hospice in... Berlin, for example. It couldn't be easy ! And the Thais have more right than the Germans to be racist and proud of their identity. To get any bargaining power I had to enter the hearts of the Thais.In the beginning I was pitiful. I was given a room to share with an HIV positive monk, whose flesh seemed delightful to the voracious mosquitoes. Each one I crushed left the stain of blood, his or mine ? I don't know.
Over the months I have been presented with many medicines to use in the wards, things have improved. But I have never been fortunate enough to obtain morphine. After seven years I still don't have morphine with which to treat my patients, but we witness more than 500 agonizing a year ! I have been able to inject more and more drugs, both palliative and curative as time passes by. I have taken risks when there have been no other reasonable alternatives, with no laboratory to make sure diagnoses. It only took me a few days to discover I was not clever enough for such duties. My patients were suffering from incredible and strange illnesses. I had never come across most of those illnesses before, many of them, with bizarre names, are very rare. Conditions like 'progressive multifocal leukonencephalitis', 'vacuolar myeloneuropathy', 'inflammatory demyelinating polyneuropathy'
Initially, of course, I was very very confused! I even came across unknown illnesses. I listed some syndromes for which I invented names since they seem to have been ignored by the medical literature. 'Moult syndrome' to distinguish from 'Lyell Syndrome' and 'Superficial Staphilococcal Scalded skin Syndrome'; 'Spastic Tongue Syndrome', 'Black Syndrome', the terrifying 'Cochonoma Vaginalis' and 'Cochonoma Penis', and other horrors of which no textbook speaks. (...)
paul yves wery - firstname.lastname@example.org