The Essence of Medicine

Oli Otya? (“Hello?”): Life and Loss in Rural Uganda, directed by Lucy Bruell (USA, 2019)

Review by Professor Robert Abrams, Weill Cornell Medicine, New York

In the opening scenes of Oli Otya?, subtitles explain that a team of nurses from St. Francis Naggalama, a rural hospital in central Uganda, travels to outlying areas to treat villagers suffering from chronic or terminal illnesses. In recent years the team has been accompanied by a group from the U.S., headed by Dr. Randi Diamond, a palliative medicine professor at Weill Cornell Medicine in New York City. On the trip documented in this film, Dr. Diamond is joined by her husband, Dr. Howard Eison, a Connecticut internist; another Weill Cornell physician, Dr. Jemella Raymore; and a medical student, Lorien Menhennett. They are guided by Nafula Prossy, a Ugandan nurse practitioner who has been with the palliative program since its inception in 2014, and who translates for the American team, not only the language, but the cultural context and family background of each patient.

This film, directed by Lucy Bruell of the Division of Medical Humanities at New York University Medical Center and featured at the 2020 Sedona Festival, is something like a primer in the principles of palliative medicine. It can be understood, and used, as a textbook or manual that happens to have been created in a desperately impoverished part of the world. After introductory scenes that vividly display the privation of rural Uganda, we follow this palliative team as they go about their rounds to the remote homes of their patients. In circumstances where only critical interventions can be applied, for metastatic cancer, advanced HIV, severe burns, or treatment-resistant infections, the most important of all medications are analgesics, particularly oral morphine. If there is a central focus to this team’s mission (and it is indeed a mission without proselytizing), it would be the relief of pain. Gradually the viewer begins to appreciate that even in a developing country, it should not be necessary for any person to die in excruciating pain or without compassionate care.

But St. Francis Naggalama Hospital, itself far from the Ugandan capital of Kampala and frequently short of medicines and equipment, is a tertiary center by comparison to the facilities in the hinterlands; medical practices there are hopelessly ill-equipped, sparsely supplied or altogether non-existent. So the operating principle of palliative medicine under these conditions is that only the most critical tests are to be ordered and the most crucial medications prescribed. The palliative team must then fall back on what Dr. Diamond describes as “the essence of medicine.” The question in each case to be asked is: Will a proposed treatment help the person feel better for whatever time he or she has left? Such interventions might encompass a blood transfusion for an anemic dying patient, or a prescription of morphine for a woman with extensive burns and who has little chance of surviving. Emotional pain is addressed as well, for example, consoling a mother who has just lost her child, or helping another mother plan for her children’s care after her own anticipated death.

At times when even the minimal level of technical and material support cannot be provided, often for bureaucratic reasons, the frustration is palpable. Yet, as Dr. Eison reflects, the U.S. visitors must remember that they are guests in another country and must rein in their American “pushiness.” One must be creative and improvisational. In Dr. Eison’s words: “You make it up as you go along.”

At one point Dr. Diamond searches for words to clarify the core elements of the team’s role when Prossy, the nurse practitioner, questions why a boy with painful recurrent facial infections, who is healthy between acute episodes, does not fit their working definition of a palliative medicine patient. Palliation, it is explained, is properly directed to persons whose underlying condition is constant and fundamentally unalterable. But in other ways the reach of palliative medicine is broad: Alternative medicine and spirituality are accepted by this team. In an instructive scene, a patient reports that the herbs he applies to his skin have helped to keep dry a weeping malignant ulcer, suggesting a traditional intervention with a limited, realistic aim. Here no condescension is given or implied; whatever can be done to relieve pain is endorsed without prejudice.

The Essence of Medicine
Dr Howard Eison at the bedside of a patient

 

As a counterpoint to the somber subject matter, the photography in Oli Otya? (by Ali Musoke and Jarred Alterman) is brilliantly colorful, and the original musical score (by Samite) is both delicate and mesmerizing. But what is most moving about this film is its conviction that compassion, fortified by clinical wisdom, modesty, and morphine, still exists in the world and in the most unlikely of places. Furthermore, this is compassion without false reassurances. Dr. Diamond and her team promise their patients only that they will not abandon them and that they will strive to relieve pain; and they do not “walk on by” when they encounter a dying patient, as one family member says of other health professionals. It has always required great skill on the part of physicians to reveal the truth as fully as a person wishes while taking care not to destroy hope, and by this measure alone the team’s integrity is worthy of their patients’ trust. Along the way, there is an engrossing portrait of a collaborative professional marriage, whose partners, Drs. Diamond and Eison support each other through some very dark moments.

Oli Otya? also showcases the bittersweet rewards of work in palliative medicine. One of the team’s most memorable patients is a 12-year-old girl with a charismatic presence, a girl who in other circumstances would stand out with promise. She is beset by an obscure immunological disorder causing deep ulcers and abscesses that cover her extremities. Upon observing her struggle to walk, Dr. Diamond breaks down, overcome by the girl’s determination and courage. These emotions, we sense, have been building for a long time and after many deaths. But that is not the end of this anecdote: As the film closes, we see a dramatically improved but still chronically ill young girl walk, almost run, to embrace Drs. Eison and Diamond with an expression of triumphant joy.

 

Disclosure: Drs. Robert Abrams and Randi Diamond are both faculty members of the Division of Geriatrics and Palliative Medicine at Weill Cornell Medicine in New York City.

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