My heart is sore, like a bruise behind my sternum. Last night, a sixteen-year-old was brought to the clinic in shock after hemorrhaging for eighteen hours at home. Her grandmother, with sparse hatchling hair sprouting from her bald skull and cheekbones like bird wings, wrung her hands and murmured: “I had to collect firewood. I didn’t know what to do. Her brother was out. Her husband is in South Sudan.”

The patient? Unconscious, bleeding placenta previa at six months, demised fetus. We run fluids through two large-bore IVs. The medical team is serious, focused, organized. Last week, we rehearsed this scenario around a paper training doll, laughing at each other’s exaggerated role-playing antics. Tonight, the urgency is not dramatized. A midwife holds up a bag of fresh blood from the cooler, hours from expiration.

“Whose is it? Where did it come from?” someone asks.

A doctor replies, “We must have been saving it for her.”

Her extremities are cold, colder than the boxes with vaccines. She is sixteen years old and I am afraid she will die.

On speculum exam, I can see the placenta, a beautiful purple-brown mass extruding from the cervix, blood pooling into her vagina faster than I can wipe it away. Should I try an embryotomy or destructive delivery with the rudimentary tools we have, just to empty her uterus, remove the placenta, and stop the bleeding? The midwives look at me while I evaluate our available instruments: my headlamp, a speculum, regular ring forceps, not even a curette or electric vacuum machine. She is only dilated three centimeters. Anything other than an abdominal surgery with general anesthesia is too risky. She needs to be transported to the operating theater at our closest referral hospital, despite our deep misgivings about the care patients receive there.

Dark and hot outside, a crowd has gathered around her ambulance, a blur of faces in shadow. It is quiet, or maybe they are in fact talking, their murmured tide of speech rushing through the night. I can’t hear anything. I crouch in the corner of the converted Land Rover, tying IV bags onto the ceiling joists using rubber gloves with sweat pouring down my face, filling my mask. My headlamp slips down my sweaty forehead. I crawl out, over the girl’s body lying atop her bloody clothes, and watch the red taillights drive away. I walk away from maternity, away from the crowd of onlookers into the hot darkness, and cry. In the middle of the dirt parking lot under a brilliant scatter of stars, I smear my tears away angrily. Annie comes up behind me and places her palm between my shoulder blades.

“We did all we could,” she says. “It is out of our hands.”

We learned the next day that the hospital did nothing. They didn’t operate. They had no blood to give. She was not transferred to another hospital where they could operate or give blood because she didn’t have proof of refugee registration. The sixteen-year-old that we saved last night continued to bleed through the night and throughout the day. She lived until 2 p.m. And then she died. Should I have tried more to save her? I don’t think I could have delivered, even destructively, a six-month dead fetus past that bleeding placenta through a three-centimeter cervix. It would have been bloody and traumatic for the girl and for everyone trying to save her. She needed a C-section. I would have killed her had I tried to empty her uterus vaginally. She is dead from inaction, from inadequate healthcare facilities, from my lack of ability, from poverty and politics that value documents over lives, from a war that tears families apart and displaces people from their homes, from the vast inequality of resources in this world.

The entire team is angry and discouraged today. We find each other and shake our heads in frustration.

“They didn’t even try!” mutters Chayton.

“We saved her and they did nothing,” says Moises angrily.

We make a cup of tea and sit in silence under the fan. Then Annie tells us that the emaciated HIV+ woman who delivered an extremely premature baby one month ago died an hour ago. She had stopped eating and, apparently, had been hiding her HIV medication under the mattress. Her eyes were already dead when she delivered her skinny, sticky, alien-appearing one-kilogram baby. We calculated out weight-based doses of antiretrovirals for the infant in droplet amounts that seemed laughable and tried to figure out feeding. She was hypoglycemic and febrile at birth, and we were certain that the baby would die, but she lived twenty-four hours, then forty-eight, then several days. We weaned her from IV dextrose and antibiotics to NG feeds and kept her tied onto her mom’s wicker basket rib cage for warmth. I wrote about her, then deleted it, then tried again. How to possibly describe the sight of a skinny, hairless thirty-week preemie lying between deflated breast flaps on the chest bones of her cachectic mother?

Yesterday on the road I met a young woman holding a fluffy baby blanket. We spoke briefly and she let the corner of the wrap fall away to reveal a pudgy, clean, smiling baby. I wanted to reach out and squeeze the rolls of baby fat on the arms of this cutie, but I didn’t know if the gesture would be offensive, so I just made faces at her until she laughed her toothless gummed smiled. A fat baby! The first I have seen since I’ve been here!

Back at the table for dinner, the recitation of the day’s dead continued. Within hours of her mom dying, as though kangarooed to her corpse, the still-one-kilogram, now-one-month-old baby followed her to the grave. The concurrence of the baby’s death with her mother’s seemed as astonishing to me as the fact that she survived at all. “What are the chances of the two dying on the same day?” I ask Chayton.

He looks curiously at me. “The nurses knew the baby had no future.”

This is my only hint of assisted endings. I am laughably naïve. What did I imagine would happen to this ill orphan, abandoned by the mother’s family in a world with neither adoption services nor child welfare supports?

I don’t balk at Death. I know its shadow is cast on every live-born baby and lingers in the corners of the rooms of our human existence. The sweetest sweetness of life, of loving and creation, is in the knowledge that all of this is finite. But the hungry ghost of Death feasts more savagely on the poor. And this inequality— of preventable diseases and avoidable situations—enrages me. I cannot insert a tidy conclusion here (“This is why I am here, doing this work,” or “This is the fuel for the fire in my belly, to work in low-resourced setting both at home and abroad…”). There is no feel-good ending for this story. It is messy. Here I am in my white skin, feeling the soft privilege of my lifetime of safety. And the girl’s grandmother sits alone beside her tukul with firewood spilled on the ground. Her long bony hands are up beside impossibly thin ears, fingers tangled in wisps of hair, and she is crying a wordless lullaby for all her dead.

*All names have been changed to protect confidentiality.

Julia McDonald (She/Her/They/Them) is a full-spectrum primary care doctor from central Maine with a special interest in sexual and reproductive health. Named Maine’s 2019 Family Physician of the Year, they (usually) teach obstetrics, inpatient, and outpatient medicine at a residency program, provide abortions at two independent clinics, and maintain a long-term relationship with local clinicians in central America to teach and provide primary care in rural areas. They are currently working with a global humanitarian medical aid agency on the African continent.

In the last decade, most of Dr. McDonald’s writing has appeared in mainstream news media as advocacy for patients and published commentary on the (unfortunate) intersection of politics and medicine. One of their nonfiction essays will be included in the 2021 anthology Beyond Queer Words, an international anthology published by Beyond Words Publishing House based in Berlin, Germany, in both digital and print versions. You can follow them on Instagram: @drjuliamcdonald and blog: https://drjuliamcdonald.wordpress.com.

Photo: Darkness to Light by Maroula Blades