When Smoking Saved a Life

My first posting with Médecins Sans Frontières was in northern Uganda, not long after Idi Amin had been driven from power. For those who don’t know him: Amin was a brutal dictator whose eight-year rule left the country scarred by violence, fear, and neglect. His shadow still loomed large, and the hospital where I was sent — in Moyo, on the Sudanese border — was little more than a crumbling shell.

We worked with what we had: simple operations, endless deliveries, and rows of sick children. There was no electricity, and my predecessor had left before I arrived, so I learned my patients by reading the thin paper charts clipped to their beds.

At the end of my very first ward round, I came across a man of about thirty-five. He lay curled in a fetal position on a bare mattress on the floor, in torn clothes, in his own excrement. He didn’t respond. A nurse told me, almost casually, “He’s been here a long time. He’s dying.” There was no file, no history. No one knew what was wrong with him.

I stood there, uncertain. Nothing about him fit into anything I had ever seen before. And at that time, I was still a young doctor, trying to make sense of medicine in a place that bore little resemblance to what I had trained for. The smell was overpowering, the situation hopeless. But something made me kneel beside him. Perhaps tuberculosis of the nervous system, I thought. Not a perfect fit, but enough to justify a lumbar puncture.

Getting him to the laboratory upstairs was no small feat — there was no lift, only narrow stairs. When we finally arrived, the staff recognized him at once. “He’s had several lumbar punctures already,” they said. “All negative.”

I frowned. “Then why is there nothing in his file?”

They laughed. “Because he smoked it. He came in with tobacco but no papers. While he was still lucid, he tore off pieces of his chart to roll his cigarettes. Eventually he smoked the whole thing.”

I considered dragging him all the way back downstairs, but after so much effort it felt wrong to stop. We did the lumbar puncture anyway. Three seconds under the microscope, and the lab technician shouted: “Bingo!”

Sleeping sickness. Caused by a parasite that shimmers and wriggles in the spinal fluid. Once you see it, you cannot mistake it for anything else.

Untreated, the disease is fatal, and in this man it was already far advanced. The only treatment available at the time was melarsoprol — a drug based on arsenic, infamous for its risks. Some patients went blind, a few died. But this man responded at once.

Four weeks later he walked out of the hospital in clean clothes, smiling. His family had appeared to take him home. He thanked me over and over. I had, in a way, saved his life. But I knew the truth: his nicotine habit had done the real saving.

It was my first lesson with MSF — that even if you have no clue, even if the case doesn’t fit anything you’ve seen before, it is always worth looking again. And in this one, against all odds, smoking had saved a life.