7 •Hard Conversations

Traveling abroad sometime afterward, I fell into a

conversationwithtwodoctorsfromUgandaandawriter
from South Africa. Itold them aboutSara’s case and
askedwhattheythoughtshouldhavebeendoneforher.
To their eyes, the choices we offered her seemed
extravagant. Mostpeople with terminal illnessin their
countries wouldneverhavecome to thehospital,they
said.Thosewhodidwouldneitherexpectnortoleratethe
extremes ofmultiplechemotherapyregimens,last-ditch
surgical procedures, experimental therapies—when the
problem’sultimateoutcomewassodismallyclear.And
the health system wouldn’t have the money for it.

But then they couldn’t help but talk about their own
experiences, and their tales sounded familiar: a
grandparent put on life support against his wishes, a
relative with incurable liver cancer who died in the
hospitalon anexperimentaltreatment, a brother-in-law
with a terminal brain tumor who nonetheless endured
endlesscyclesofchemotherapythathadnoeffectexcept
to cuthimdownfurtherandfurther.“Each roundwas
morehorriblethanthelast,”theSouthAfricanwritertold
me.“I sawthemedicineeathisflesh.Thechildrenare
still traumatized. He could never let go.”

Their countries were changing. Five of the ten
fastest-growingeconomiesintheworldareinAfrica.By
2030,one-halftotwo-thirdsoftheglobalpopulationwill
bemiddle class.Vastnumbers ofpeoplearebecoming
able to afford consumer goods like televisions and
cars—andhealthcare.SurveysinsomeAfricancitiesare