Ghon Focus

Jonathan Strysko

The existence of Sam Perović was realized for the first time by his mother, Prudence Senoko, when she was seven centimeters dilated, her son’s head already engaged in her pelvis, her breath blooming with the smell of gin. Alec Perović, her husband at the time, had driven Prudence in his 1975 Fiat to Jwaneng Mine Hospital. Thinking his wife was picking up a prescription, Alec lit a cigarette and left the engine idling. Fifty-five minutes later, when Prudence hadn’t returned with her antacids, Alec switched off the engine, unleashed a string of profanities into the purple African sunset, and marched into the reception. The hospital receptionist immediately identified Alec as the white father to the mixed baby who had just emerged in Labor Room One. Alec was Serbian, a senior engineer who came to work in Botswana’s diamond mines in 1978, but right now he was simply a white man. Whiter now, as the blood drained from his face.

Sam Perović lay like a wet starfish on his mother’s chest. Prudence glistened with perspiration; her face decidedly indifferent to the new arrival. Alec used the doorframe for support as his heart swung like a caged animal inside his chest. The midwife fled, leaving the three of them alone, heaving in silence. They were like ghosts of themselves, hovering over their own bodies, unsure whether they had what it took to live the lives they had just been prescribed.

Fetal alcohol syndrome had barely made its debut in medical textbooks at the time. Nevertheless, Sam did have a flat philtrum. And a heart murmur (which he diagnosed himself years later as a medical student). But the constellation of stigmata ended abruptly there. He was a well-mannered child, never whined, never wept. Clever in math and reading, given the lead in school theater productions. Sister Bernadette Molefhi shed a tear when he sang “Send in the Clowns” for Acacia Primary School’s 1993 production of A Little Night Music and, feeling his talent might be wasted if he stayed in Jwaneng, arranged for him to enter Tiger Kloof in South Africa the following year.

Sam opted to attend his high school graduation instead of his mother’s funeral, when both events fell on the same day. Six months earlier, his older sister, Nicola, had given birth to her secondborn whom she brought home to her mother’s house for the confinement period customary in Botswana. Prudence and Alec were divorced by that time but still lived in the same house, which was large enough for them to stay out of each other’s way. Prudence was about as successful a grandmother as she was a mother, and by three months of age, the infant looked gaunt, having only just surpassed his birth weight. Ultimately diagnosed with tuberculosis, they admitted him to the pediatric ward at Jwaneng Mine Hospital, where he succumbed to his illness just hours after starting treatment. Tragic as it was, his diagnosis proved to be lifesaving for the remainder of the Perović-Senoko household who, after being instructed to wake up early and cough their sputum into jars, were all found to have latent or early TB and were promptly started on medication. The alcoholic liver of Prudence Senoko however did not take well to the isoniazid component of the regimen and when Sam came home to study for exams that October, he found his mother’s sclera as yellow as Ultra Mel custard, her gums bleeding, and a box fan blowing hot air onto her edematous legs. Sam greeted his mother by teasing her, the only dialect his family used for endearment. 

“Shebeen queen done partied out for the day?” he said, kissing her on the cheek. “Hi, mummy.”

He expected her to retaliate with something vulgar, an insult about his weight or the size of his nose, but she stared past him saying nothing, choosing to fix her gaze out the window to the purple jacaranda in full bloom in the backyard.

“That old woman is out of the mind,” his dad announced, entering the kitchen from the back door. “She want to join the black ancestors, isn’t it, Mma Senoko,” he said, washing engine oil from his hands in the kitchen sink.

Prudence chucked a bottle of Black Label at Alec. Alec dodged. 

“Ha! Missed!” Alec said, gloating as he fled out the back door. Sam reflexively started picking up the large pieces of brown glass and retrieved the broom from the kitchen to sweep up the smaller shards.

For the next three weeks, Sam studied for his exams at the kitchen table while his mother lay dying on the couch in the living room. In the mornings he mopped up spilled beer and vomit. In the evenings he fed the dogs and swept the fallen jacaranda blossoms into neat piles. Early one evening, thinking he smelled rain, Sam stepped out of the kitchen and into the back garden. The smell vanished, eclipsed by that of the usual: cow manure, roasted maize, and woodsmoke. He had the sense, as he always had in this place, especially at dusk, of being watched. He felt the gaze of the setting sun, the dogs staring up at him, saliva dripping from their jowls. The hornbill gawked from his perch atop the acacias. Even the trees, he felt, had eyes, carved like scar lines into their bark. When he left for graduation, he knew he would never come back.

Nine years later, Sam sat in a lecture hall on New York’s Upper West Side, listening to a lecture entitled “Mycobacterium tuberculosis and nontuberculous mycobacteria.” He took notes like someone who didn’t come from a country where TB was the number one killer, as if TB hadn’t ripped through his own family.

“During your internal med and psych rotations, you might encounter patients with TB,” the lecturer said, looking at her watch briefly before moving on. “Remember, when you hear hoofbeats, think horses right? So, rule out your pneumonia and your malignancy first, then send off sputum for acid-fast staining. It’s more common in homeless people, prisoners, and those with comorbidities and substance abuse issues. You want to especially be screening patients who are immigrants from endemic regions. Remember, the BCG vaccine can cause a falsely positive PPD skin test. These people are gonna need antibody testing and a chest X-ray. Now, on to radiologic findings.…”

The lecturer advanced the slide to display a chest X-ray snagged from an old textbook.

“This is what is called a Ghon focus. This is a radiologic sign of someone with early TB disease. You see the opacity there on the right between the upper and lower lobes? That’s a Ghon focus representing primary disease. Now, at this point, this person isn’t symptomatic or contagious. They’re oblivious to the fact that a deadly disease has started eating away at their body. Later, you’ll see cavitations like these.…” She advanced the slide again. “And at this point, the patient might or might not be symptomatic, but they for sure are contagious and at risk for spreading TB to others around them, especially household members.”

The radiograph of a Ghon focus was on the final exam, and Sam, having not revisited that chapter in the textbook as he should have, incorrectly identified it as “adenocarcinoma,” along with 75 percent of the class.

Sam opted to attend his own wedding rather than his med school graduation, when both events fell on the same day. Sam met Gwen at the gym in Washington Heights. He overheard her spelling her surname at the front desk when she had forgotten her gym card, and asked her permission to venture a guess at her nationality, impressing her when his guess was accurate. Gwen’s family had moved from Zimbabwe to London after her father, outspoken against Mugabe in the 1980s for state-sanctioned violence in Matabeleland, was granted asylum status after being tortured to the point of blindness in his left eye. Her father got a job as a geometry teacher, but it was Gwen’s mother who ultimately catapulted their family into financial security by starting a successful home-care agency. Gwen moved to New York for her Master’s in Psychology and stayed for her PhD.

Gwen had noticed him before, Sam. She had taken mental note of his regular presence on the treadmill between nine and ten on weekday evenings. Sam usually wore a gray shirt and basketball shorts. Short afro and glasses, a flat upper lip hidden by a mustache and goatee. She would have guessed he was Puerto Rican or Dominican, with his light complexion, not thinking he could be from Botswana, a country bordering her own homeland.

Sam was kind and self-deprecating, a good listener and unbothered by extended silences. Gwen was shocked when she learned several months into the relationship that Sam could sing, since he actively avoided any form of the spotlight. Gwen found relief in the fact that they were both from southern Africa but she especially liked that they didn’t need to explain this part about themselves to one another. They didn’t need to talk about Africa at all really, and mostly, they didn’t. They needn’t interrogate each other with a million questions about the beauty and trauma of their childhoods, as Americans are prone to do, usually out of decorum, not genuine curiosity.

While their friends went out, Gwen and Sam stayed in. They watched British crime shows and Bollywood together. Gwen suggested they go vegan, but both of them relapsed one week in, Sam running out into the bitter cold of January to buy a pint of Häagen-Dazs at the corner bodega as if attending to a pregnancy craving. Gwen would occasionally savor a glass of wine, particularly if it had been gifted by a friend. Being from a strictly dry Pentecostal household, she could never bring herself to stand in line to buy alcohol at Trader Joe’s. Sam was comfortable around alcohol but didn’t drink, which Gwen respected. Sam was very good, however, at acting inebriated, Gwen noticed, a persona he would put on from time to time on karaoke nights, singing show tunes and boy-band hits with unusual abandon. Gwen laughed until her abdominal muscles couldn’t take it anymore, until she begged him to stop. 

As Sam toiled through residency, Gwen completed her PhD and decided to turn her thesis into a book. The book, to which she gave the title Gut Punch, explored the ways in which trauma-related anxiety can somaticize as gastrointestinal symptoms, years and even decades after psychological trauma occurs. This was inspired by her own father’s struggles with irritable bowel syndrome, which she was convinced had been triggered by cortisol surges initiating inflammatory signals related to relived memories of his own torture. The book launched with a small reading attended mainly by friends but was instrumental for her as she applied for a position as assistant professor.

Covid-19 brought changes for the Perović family. After ten years of marriage and two previous miscarriages, Gwen conceived rather by accident during the first lockdown. Sam had specialized as a pulmonologist by that time and was among a group of authors reporting the first Covid-19 case series describing radiologic findings associated with severe outcomes. He was an early advocate for prone positioning and steroid therapy and authored those protocols for his hospital’s ICU. Despite being on the front lines, Sam and Gwen avoided getting sick until Thanksgiving of that year. Gwen was virtually asymptomatic, which was a blessing, being five months pregnant, but Sam ended up having to leave work for several weeks, suffering the symptoms of what Gwen suggested might be long Covid. When finally convinced to see a gastroenterologist, Sam was given a provisional diagnosis of long Covid and irritable bowel syndrome, the same thing Gwen’s father had been diagnosed with, a coincidence not lost on her as she reviewed her husband’s medical paperwork.

But when Sam’s abdominal torment became biblical in caliber, and the toilet bowl stained dark red with his own blood, he was scheduled for a colonoscopy. Inside of Sam, the cobblestone appearance of his colonic mucosa held the definitive diagnosis. Sam had Crohn’s disease. 

He failed a trial of steroids and found himself hospitalized with an acute Crohn’s flare the week before his daughter, Nomsa Perović, was born. Despite Gwen’s objections, her parents strapped on their N95s and braved the flight from London. They were in their seventies but hell-bent on welcoming their first grandchild. Sam was too weak to attend the birth, but the ward nurses permitted his father-in-law, a gentle bald man with an eyepatch, to stay with him while Gwen’s mother held her hand through every contraction in the labor and delivery ward two floors up in the same hospital. While Gwen’s episiotomy was being sutured, Sam’s first infusion of infliximab was being hung, a miracle drug which sent Sam into remission within days. Sam came home one week after Nomsa and Gwen. As Gwen and Nomsa settled into a feeding rhythm and Sam slowly began eating again, Gwen’s mother and father nursed them all to health. Their Washington Heights apartment smelled like love: sadza and veg, peanut butter rice, steamed dumplings, and sour milk.

Sam stayed in remission on the infliximab, but caught Covid again that spring and this time his cough lingered for weeks, made worse by seasonal allergies. At her four-month checkup, Nomsa’s weight was noted to have not changed since the last visit. 

Gwen’s brows furrowed when the pediatric resident at the clinic broke the news. He asked a battery of anxiety-provoking questions, advising Gwen to increase her protein intake and ensure Nomsa fed at least eight times a day. They returned a week later and the week after that and she still hadn’t gained weight. They added formula as well as iron and multivitamin syrup. But the next week Nomsa had lost, not gained, fifty grams. The pediatric resident typed “Failure to thrive” into the computer and an algorithm appeared. Blood was drawn, an X-ray was taken.

Gwen fidgeted in her seat in the clinic waiting room, Nomsa glued to her breast. She overheard the discussion happening between the resident and his attending in the next room over. The resident suggested the white haze on the X-ray could be the thymic shadow. The attending pointed to the same opacities in the lateral film. “I don’t think so, look there. It’s the donut sign. Perihilar lymph nodes. I saw a lot of this in India.”

The resident reappeared in the exam room, offering Gwen a pained smile. “So I know you said you haven’t been in contact with anyone with TB, but have you or any household members recently traveled to a region where TB is common? You said you were from Zimbabwe, yes?” 

“Yes, but no, we haven’t traveled anywhere like that recently.” Both Sam and Gwen, and Gwen’s parents, hadn’t set foot in Africa in over twenty years. 

“Is there anyone in your household who is coughing, having night sweats, or fevers?”

“My husband, but he just had Covid and he also has allergies.”

When Gwen arrived home that afternoon, she told Sam about the X-ray. He squinted at his phone as he pulled up the lateral film on his Haiku app, abducting his finger and thumb to get a closer look at the inside of his daughter’s chest. Sam saw exactly what the radiologist saw and reported as “perihilar lymphadenopathy, possibly consistent with pulmonary tuberculosis in the right clinical setting.” He had the urge to immediately order a CT scan, but the patient being his daughter, he didn’t have the luxury of calling the shots. His mind instead wandered to the more obvious epidemiologic questions: How? When? And from where?

Like dust settling after the August winds in Botswana, Sam saw the story play out in his mind’s eye like a sped-up film reel, like a life cycle of some masterful parasite. The coughing, the on-and-off fever, the infliximab, the PPD skin readings he had always self-reported as negative, deluding himself into being reassured that the twenty millimeters of induration was falsely positive, due to the BCG vaccine he had received at Jwaneng Mine Hospital, just hours after his birth.

The next day, Sam and Gwen had PPDs placed on their forearms and chest X-rays taken. Golf-ball-sized swellings appeared on both of their arms. Sam’s X-ray revealed two noticeable cavitations in his lungs, one at the right apex, the other on the superior aspect of the left lower lobe. 

Gwen’s X-ray showed hers as clear, except for a “small opacity in R lower lobe, possible pulmonary infiltrate versus artifact.”

But Sam knew it wasn’t an artifact. He could now identify what he wasn’t able to on his final exam twelve years earlier: a Ghon focus. The primary lesion indicative of early pulmonary TB.  

He immediately knew what he would never be able to prove: that these tubercular bacilli burrowing holes in his lungs, and now the lungs of his wife and his firstborn child, were not from the streets of New York. They weren’t from one of his many patients on whom he had performed bronchoscopies over the years. They had originated from his past, that place he had been avoiding his whole life, the place where children awoke in the middle of the night to screaming, where bottles were flung across rooms, and dust crept in through the windows at night. The bacilli had been his silent travel companions, now given a new lease on life when infliximab, the monoclonal antibody so adept at treating his Crohn’s, had attacked his TNF alpha, breaking the levees keeping the TB bacilli at bay within his lymph nodes for decades.

Following initiation of antitubercular therapy, Nomsa started putting on weight again and Sam’s coughing fits became shorter and less frequent. The Perović family finished their six-month course of medication together on Nomsa’s first birthday. They celebrated with cake, the three of them at home. Amongst a flurry of birthday messages on his phone featuring kittens blowing out candles and minions dancing, Sam noticed a WhatsApp notification for a voice note from his sister, Nicola.

“Hi Sam, it’s about Dad. He took a spill feeding the dogs yesterday and now they say he’s got bleeding in the brain and probably a stroke. They’ve got him on the breathing machine at Marina. Anyway, I thought I’d let you know so you can keep him in your prayers.”

Sam played the message again, his jaw tightening.

He thought about what it would mean to not respond to the message at all. About what it would mean to simply keep his father contained within his prayers. About how he might talk to God about his father. 

But Gwen heard the message too and now insisted that Sam go. “It’s time,” she said, “and we’ll go with you.”

When they landed in Gaborone, the body of Alec Perović was already being loaded into a hearse bound for Jwaneng. He would be buried early on Saturday morning next to his ex-wife. Nicola sat shotgun while her twenty-seven-year-old son, Prince, was behind the wheel, driving in the caravan behind the hearse. Prince was just eighteen months old when his younger brother died of TB, perhaps the luckiest of the family to have been afforded an early diagnosis and lifesaving treatment. Sam and Gwen flanked Nomsa in the back seat, Gwen’s left breast dangling over the car seat for Nomsa to access at will during the two-hour journey to Jwaneng. 

The sun was starting to die as they hooked a right at the bottom of Kanye hill and began traveling on the well-paved road to Jwaneng. As the salmon-pink sky darkened to a felty purple, a bathroom break was requested by Gwen. Nicola seconded the motion and called ahead to the driver of the hearse and both cars slowed to pull over under a large jacaranda. The men got out of the car first, shining their phones on the ground to scan for scorpions. Sam emptied his bladder onto the thorns of an acacia shrub. Gwen and Nicola did their business next to the open car doors as the men stood guard. 

Gwen changed Nomsa’s diaper and handed her to Sam, offering everyone a squirt of hand sanitizer. Nicola poured rooibos from her thermos on the roof of the vehicle and opened a packet of tennis biscuits. Everyone shared in what felt like a kind of holy communion. One-year-old Nomsa swatted at her father’s glasses and he indulged her in the game, craning his neck from side to side, dodging her pudgy hands. Sam folded his glasses and put them in his pocket, his eyes squinting into the blurry horizon, a watercolor mix of tangerine and sauvignon. 

As Gwen took a sip of tea, she noticed her husband drinking in the sunset through his closed eyes. She knew something was shifting inside of him. She could see him breathing in this smell he knew so well and once dreaded, the sweet smell of woodsmoke, roasted maize, and cow manure.

Sam was becoming aware of something true. This truth that, in order to be the father to the child he was holding, he would need to forgive the father whose body lay lifeless in the vehicle in front of him. And to forgive his father, and, yes, his mother, he would need to forgive the land. Forgive the soil and the trees, and the birds and the dogs and the sunsets. Forgive the things that blossom, molt, and decompose. Forgive the smell of woodsmoke and cow manure. All of it. You had to forgive all the things that bore witness to your pain and still said nothing.