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Being Present

Suddenly my attention was drawn to a flurry of activity around one of the graves-in-waiting. And my heart sank. An hour before, while trying to steal a little sleep, I had suddenly sensed—in that place between waking and sleeping—that one of my patients, Ayisha, was gone. I'd been afraid her death was imminent, and I hadn't seen her on this morning's rounds because of my own malady. The activity in the cemetery confirmed my fear.

Ayisha had arrived in Galaha with her father on my second day there, and right away we knew this beautiful little girl was in trouble. Five and a half years old, she'd already survived the most vulnerable years and looked well-nourished. She had probably been quite healthy until this illness, but now, after two or three days of travel and high fever, her condition was poor and deteriorating rapidly. Barely conscious and unable to drink anything, she was dehydrated and had had no urine output for some time. Worse, she had classic neck signs of meningeal inflammation and suffered frequent small seizures—tremors that passed briefly but repeatedly through the left side of her body.

A spinal tap had gone smoothly, and we were overjoyed to find that her cerebrospinal fluid was clear. Our lab was limited, but we were able to test for white blood cells and (using an assay called the Pandy test) for protein, which if positive would strongly suggest that she had meningitis. Although both tests were negative, we couldn't ignore her condition; her fever was almost 103 and rising.

So we treated Ayisha for suspected meningitis with our best broad-spectrum antibiotics, worked to control her fever and seizures, and offered every supportive measure, including fluid resuscitation, that we had available. We entertained the possibility that she had TB-related meningoencephalitis, a complex condition more often seen in children than adults.

Over the next two weeks, Ayisha rallied briefly but then deteriorated further. Through it all, her father remained at her bedside—holding her, bathing her, and

Above, the small exam room Rufsvold used in Galaha—featuring one of the only working sinks in the clinic. Below, a "no guns" sign at the clinic entrance.

I expressed how sorry I was that we had not been able to save Ayisha. He said he knew we'd done everything we could to care for his daughter. She was now in Allah's hands. It was all right. I really wanted to believe him.

sponging her down in an effort to cool her fevered body. We explained, and he accepted, everything we were trying to do to save his little daughter. His love for Ayisha needed no translation. I felt privileged to be helping to care for her, then moved to tears when our efforts didn't seem to be enough. In such situations, one grasps for an antidote to the inevitable, gnawing sense of inadequacy. I found my antidote in the love and compassion and acceptance that Ayisha's father exhibited throughout her illness.

And so, on this particular Sunday, I set out for the hospital to find Ayisha's father. I didn't know what I would say, but I just knew that I needed to make contact with him. I found him in the small outbuilding

that served as our morgue, where they were washing and preparing Ayisha for burial. One of the Afar-speaking nurses came with me. I greeted Ayisha's father in the traditional Afar way of showing respect, by kissing the back of his hand

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