A Day on the Town

 Sunday I had a great day getting out into the city. A friend who has lived here for two years offered to take me with her on a home visit and to her local bazaar for shopping and lunch. We first walked along very narrow streets to get to the house of an acquaintance of hers. Given how narrow the streets are, I was surprised by how ample the house and courtyard are inside the gate. We were ushered into a very nice living room and met three of the ladies of the house – an older woman, who I assume was the head of the household, and two younger ladies. One was the older woman’s daughter; she was dentist and spoke fairly good English. The other was her sister-in-law, a young woman about 20 years old. Here the woman moves in with her in-laws when she gets married, which in this case appeared to be a good thing. These women all seemed to get along very well. According to my friend, this young woman had married outside her ethnic group and her own family had not approved the marriage, but her husband’s family was very welcoming and accepting.

Most of our conversation took place in the local language, so I couldn’t follow along too well. The young woman had recently had a miscarriage and was very worried that she had some kind of infection in her blood. She brought out her lab results and showed them to me. For some reason, she had been tested for toxoplasmosis and brucellosis after her miscarriage. These are diseases that are carried by animal hosts and passed to humans. I’ve never heard of brucella causing fetal complications, maybe because it’s not that common in the US. Toxo can be dangerous for the baby if contracted late in pregnancy, and it is carried by raw meat and cat feces. That is why pregnant women back home are advised not to change cat litter. Here that is not an issue since cats are not frequent pets here. I very much doubt that toxoplasmosis caused this woman’s miscarriage. I’m not even sure she had been infected since her labs were equivocal – one initial test was positive for toxo, but further antibody testing came back negative. I did my best to provide reassurance and suggested she could repeat the testing before getting pregnant again if she wanted to be sure. But I explained that most of the time, this disease is short-lived and asymptomatic, so even if she did have it, she is almost certainly over it now and immune. I also reassured her that early miscarriages are quite common and that she is very likely to have a normal pregnancy the next time. I think the family was relieved that she was not sick, and hopefully they will not spend a lot of money pursuing further testing.

After visiting this family, we walked to the local bazaar. It reminded me very much of Bolivia with open fruit and vegetable stalls, street-side stores, all kinds of wares being offered. My friend is quite a resourceful shopper. She knew where to shop for the best bargains and good quality secondhand clothes and housewares. This bazaar is frequented almost entirely by locals, not foreigners, so prices are generally better anyway. My friend likes it because most of the shoppers on the street are women, so she feels more comfortable walking through alone.  We had ice cream at a local shop – it was actually pretty good. I was told all the local ice cream tastes like cardamom, and it did! We went into the curtained-off women’s area to eat. That ‘s the first time I’ve experienced eating in a separate room. At the hospital cafeteria, the women sit apart from the men but in the same dining room. At the nicer restaurants I’ve been to, men and women can sit together at the same table. At least in the market, the women can remove their burqas and eat in privacy. After shopping for a while, we had lunch at a small grill on the street and had beef kebabs, again sitting in a curtained off area in the back for women. I really enjoyed being able to get out in the “real” community.

 Finally, the day ended with a visit to a clinic and artisan institute. The programs are located in the old part of the city in a beautiful and historic building that has been gradually restored. Apparently, a few years ago the building and surrounding market were five-feet deep in garbage and sewage. People living in the area suffered from a number of diseases, including cutaneous leishmaniasis, a disfiguring skin infection caused by a parasite transmitted by sand flies. After the area was cleaned up, a monumental task, this disease practically disappeared. The building has some incredibly lovely wood work and quaint courtyards.

The clinic serves the local community with prenatal care, acute care, and minor emergencies. The medical director is a graduate of one of the family medicine residencies here, and two family medicine residents rotate through the clinic each month. The residency program has been trying to develop community outreach programs to encourage the local population to work together to identify and solve health (and other) problems. They do have group prenatal visits and have held a number of focus group discussions with various community stakeholders, such as women, store owners, leaders, etc. These meetings have helped to identify some of the issues and barriers to community action.

 

Next to the clinic there is an artisan institute. An international foundation has worked with the community to try to reestablish some of the traditional crafts of the country, such as ceramics, wood-working, jewelry-making and calligraphy. They have developed a three-year training program that is tuition-free for those applicants who pass the competitive entrance exam. We visited each workshop and saw exquisitely designed ceramic tiles, beautiful and intricate wood carvings, and colorful displays of calligraphy. There was some real talent among the students, and it is wonderful that these skills will not be lost as the country recovers and modernizes.

I think this was perhaps the most colorful day I’ve had yet. The streets of the old part of town are bustling with activity and lined with buildings of all colors and people dressed in a variety of styles with bright scarves. I tried to take some photographs, but once again it is difficult to capture the street scenes and be discreet. I guess it will have to live in my memory.

Recreation

This is a city of roses. All over the city – along the streets, in people’s yards, and in the city parks, roses are blooming like crazy. I’m not sure if it’s the soil or the climate, but they seem to thrive here, despite the freezing winters.

Yesterday, I visited the University, which is only a few blocks from the guesthouse where I am staying.  The campus is home to some 17,000 students (or so they tell me). It is a large area covering several city blocks. Upon entering the gates (where IDs are checked so no unwelcome visitors are allowed in), I was immediately struck by the grounds. It is like an oasis in the midst of a dirty, dusty city. Trees, grass, and flowers are everywhere, making the walkways shady and cool and giving the grounds a serenity and beauty that can only be appreciated from inside. We visited the fine arts building, where one of my expat friends is a professor of music. She is teaching a class on the jazz theory and history, and another on conducting orchestra. The orchestra is made up of faculty and 4^th year students, and we were able to sit in on their rehearsal. Today they played a folk-dance piece from one of the local ethnic groups. The piece was quite lively and included some chanting, lots of drums, strings (including one instrument I had not seen before called a rubab), piano, keyboard, and accordion.

After leaving the music department, I visited the university clinic, which is funded and directed by the organization with which I am working here. The clinic serves faculty, staff, students and their families. There is one doctor and a pharmacist. The pharmacy is stocked with basic meds. The doctor says they see 10 to 30 patients in the four hours they are open daily – mostly upper respiratory infections, sore throats, urinary tract infections and minor injuries. Today, while we were having tea (everywhere you go, you drink tea), an English literature professor came in to get his blood pressure checked. He spoke excellent English, and it was interesting to hear his stories about the university, as he had been teaching for 35 years. The university remained open under the Communists but closed for three years during the war when higher education (especially anything resembling western education) was severely censored. Much of the campus was destroyed, but it has since been rebuilt.

This man’s blood pressure was 160/110. He said he had been on a blood pressure medication for 10 years, but recently stopped taking it after receiving a “syrup” from a religious healer that was supposed to cure his hypertension forever after two or three days.  He had been on this new medicine for two days. We chatted a bit about the health problems of the country – stress, tension and other psychological problems brought on by years of war, instability and economic hardship. He asked my opinion, and I did my best to educate him about the long-term complications of high blood pressure, the importance of controlling it with diet and exercise, and the target of maintaining blood pressure under 140/90. He seemed to have never heard any of this before. I recommended he continue his previous medication since it seemed to have kept his blood pressure under better control. Hopefully it was not too out of place to say these things. He did ask, after all!

Walking back to the guest house after leaving the university was a bit uncomfortable. I haven’t been out on the streets much, so it was a new experience for me. First of all, there is an art to walking along the street without getting hit by a car, bicycle or other moving object. Then there is the dust, uneven street surfaces and garbage to contend with. In addition, we managed to hit the street just as the local schools were letting out at noon, and the street was flooded with teens, mostly boys walking in the opposite direction. We got lots of stares and comments (not sure of what nature). I felt a bit vulnerable, especially since my friend told me that the last time she walked down the street, they boys had thrown something at her. Fortunately that didn’t happen to me, but I was glad to get inside the walls of our guesthouse compound. Being female and foreign in this culture is going to take some getting used to.

 

Later that same day, I visited a local park built originally in the 1500’s by a Mughal emperor. The gardens are beautifully landscaped, and there are shops and restaurants on the grounds. Many families come here to picnic and enjoy the flowers. At the top of the hill is the tomb of the Mughal prince. Although the gardens have been destroyed and rebuilt, probably multiple times, much of the original architecture and layout has been maintained. For this outing, my friend and I were accompanied by the office manager. Having a male along definitely provides protection from unwanted attention.

Hospice

Wednesday I had the amazing experience of making hospice visits with the hospital’s hospice program, called “Ham Dardee” – which literally means “to share pain”, or sympathy. The program was started a few years ago by a visiting doctor who was seeing many patients in the advanced stages of cancer. Often, people will seek treatment from various doctors, religious healers, even traveling out of the country for a cure for their family member, spending all of their money in a situation where there is no cure. Now, through Ham Dardee, patients can be cared for at home during the end stages of their life. Family members are trained to care for their loved one, and the hospice coordinator visits frequently and is always available by phone for questions or to handle problems that arise.

The hospice coordinator is an amazing local man who spent many years working with leprosy and tuberculosis patients. Because of this, he has a true gift for sensitivity and compassion. He is amazing because he is able to go into people’s homes – people of all different ethnic backgrounds – and interact intimately with the patients and families, including women family members. He is accepted as a father or brother and provides emotional support in a way I have seen few doctors do either here, at home, or anywhere else I have traveled. Not only does he support and teach the family, but he weeps with them, laughs with them, prays with them, and checks in on them often. He tries to be with the family at the time of death and makes bereavement visits for several months after the patient has passed.

In this culture, patients are not told their diagnosis or prognosis, even (and especially) if they are terminally ill. So any discussion of end of life care or hospice must be held with the family. At the hospital, the residents and faculty are frequently reminded and asked if they have any patients who would benefit from hospice. When a patient is identified, the hospice coordinator will come to the hospital to meet with the family and explain the patient’s condition, the lack of further treatment options, and the services provided by the hospice program. If the family agrees, he will go the patient’s house in the following days to help the family care for the patient.

Pain here is treated with Tylenol or tramadol. Morphine is available, but it is considered shameful to buy it in the pharmacy and might jeopardize the reputation of the person buying it. Once in a while, the hospital will send morphine with the hospice coordinator, but it is also dangerous to travel around town with narcotics, so it is avoided if at all possible. Since most patients here are not used to taking strong pain medications (unlike so many patients back home who take narcotics like candy), tramadol seems to work pretty well. Nausea is treated with promethazine; there is no Zofran.

I was able to accompany the hospice team to two homes. The first home was of a 45-(ish)-year old woman with breast cancer that had metastasized to her liver. She had been discharged from the hospital only days before. Her home was in a neighborhood just behind the hospital, but since there were no direct roads, it took us a while to get there, and even then we had to walk part way. When we arrived, we met the father-in-law, the patient’s sister, and all of her children. The oldest daughter looked about 15 or 16 years old, while the youngest was around three or four. The patient was lying on a mat on the floor, and we were told she had been in a coma for the past 24 hours. She was extremely jaundiced and emaciated. The hospice coordinator showed the family how to feed her, and she was able to swallow a few spoonfuls of juice. He explained that they should turn her frequently and keep her mouth clean. Then he told them that it was likely she didn’t have much time left. This was an extremely emotional moment, and I think all of us got a bit choked up. The eldest daughter was especially broken up. The hospice coordinator prayed; then the American doctor who was with us (who started the Ham Dardee program) prayed. The coordinator planned to visit daily and gave the family his cell phone number to call with any changes or questions.

The next family we visited had lost a loved one (brother, father, husband, son) the previous week from advanced esophageal cancer. The family served us tea, and we talked about their experience with hospice. The patient’s brother stated that he was very grateful to have the support of Ham Dardee; otherwise the family would have taken the patient to Pakistan or India for treatment, which would have cost more than they had and would have been to no avail. The hospice coordinator praised the patient’s daughter for taking such good care of her father in his last days. Again, prayers were said, emotions shared, and photographs of the patient prior to death were shown. The family all expressed their love for the deceased and their appreciation for the help of the program.  

Truly, it was an extraordinary privilege to see inside family life at a such a critical time - to visit people in their homes and see how they deal with grief, sickness, death – how they take care of one another. I have always wanted to be involved in hospice care for my patients at home. To help a person die with dignity in the comfort of their own home among their loved ones is an incredible service to the patient and family alike.  Now I can see how important it is for patients in a resource-poor setting too. In my other short- and long-term medical experiences in other countries, I have come across so many families who spend all their money and even go into debt to see doctor after doctor and buy all kinds of medicines that are useless because they don’t understand their loved one’s condition or are never told when to stop seeking treatment.

I remember on one of my many trips to Bolivia seeing an older man who had lung cancer. He had been to the city to see countless specialists and eventually to the cancer hospital where he received chemotherapy. Now, chemotherapy is extremely expensive even in Bolivia and unlikely to have any significant impact on the course of the patient’s disease, except maybe to buy a few months of life. Once the family’s money ran out, they brought the patient home without completing the treatment. They brought him to see the American doctors thinking we would have some better type of treatment. The best we could do was arrange for oxygen and pain control to keep the patient comfortable. How I wish a program like Ham Dardee had been available!

In a little over two years, Ham Dardee has served over 30 patients. The future of the program depends on the ability to train new caregivers and on the availability of funds. Patients and families will not be able to pay for hospice services, and there is no health insurance here. So the program relies completely on gifts from generous and compassionate donors. In addition, the entire program is built around this exceptional hospice coordinator. How will they ever be able to replicate his personality and unique gifts?  They are looking for new caregivers, but how do you train someone to show respect, compassion, and sensitivity to the emotions of family members?  Can you expect others to be completely accessible 24/7? This kind of work requires a mature, selfless person who is willing to set aside religious, cultural, educational, personal and economic differences and give of themselves to make others feel comfortable and cared for. Perhaps this can be taught and modeled, but I’m not so sure; where do the seeds of compassionate care come from? My hope is that the family medicine residents at the hospital where I am working can understand the benefits of hospice and become advocates and catalysts to change the system. Please pray with me for the families touched by this program to truly know God’s peace and comfort and for the program to have a lasting impact.

Encouragement

(Warning:  this is a really long post!)

Sunday I began my third week here focusing on community health. Providentially, on the way to the hospital, we were joined by a nurse and long-time worker here (over 20 years). She was going to the hospital to accompany the midwives to their weekly mobile clinic in one of the urban neighborhoods. The community health team goes to a different clinic each day of the week. The term “clinic” is loosely applied here, since several of the sites are actually in someone’s home; only one is in an actual clinic.  (More on the details of the community health program later.) Every two weeks, one of these “clinics” hosts a women’s group meeting to discuss a health topic of their choosing. One of the family medicine residents is supposed to go to these meetings to give a short talk and answer questions. Well, again perhaps providentially, yesterday the resident was unable to go because she was presenting a case in morning report and didn’t finish in time. It turned out to be one of the most interesting experiences I’ve had yet.

First of all, I was thrilled to actually be out in the community, to see more of the city up close. Because until now, I have pretty much seen only the road to and from the hospital, a couple of grocery stores, and the tourist street with all the souvenir-type shops. This trip was quite different. Once off the main streets, the roads are really awful. Few are paved; most have deep ruts and potholes. I am told that when it rains or snows, or when the snow melts, the streets are ten times worse. To top things off, the streets are so narrow in some places that only one car can get through. If you meet a car coming the opposite direction, someone has to back up. Of course there are no sidewalks either. The walls of the houses back right up to the street, creating almost a tunnel effect. In the section of the neighborhood we went to, the streets were actually paved with deep trenches on one side, making it treacherous to turn corners in our small hospital minivan. Taking the turn too sharp or wide could leave half your tires in the ditch with no way to get out. Actually, I think this much happen frequently, because just the other day, our driver hooked our van up to a smaller car to pull it back onto the road as if he’d done this many times before.

Anyway, the venture into the streets of K was a real treat. I wish I had pictures, but it is really hard to take photos here. I couldn’t ask the driver and team to stop since we were running late and you can’t just pull off the road since other than the ditch or ending up in someone’s house, there isn’t any space off the road. Taking photos while driving is pretty much impossible given the road conditions and much jostling and bumping. Also, taking photos is a good way to call attention to oneself, and this is not a good idea in the current situation. Expats who have been here for many years and are wiser and more experienced tell me that you never know which people on the street are or are not friendly towards westerner/foreigners.  So – sorry, no photos of this amazing scenery.

The mobile clinics serve only women and children – primarily prenatal care, family planning and immunizations. This particular clinic was in a house, which I didn’t realize until later, though I guess I should have.  Either the furniture had all been moved out or there isn’t any furniture in the rooms we used.  I didn’t see any evidence of daily household activities, and I couldn’t tell which of the women actually lived in the house. At any rate, in one room, the nurses and midwives set up their stations – registration, blood pressure, a table for physical exam and ultrasound (they use a portable sono to check for intrauterine pregnancy and estimate gestational age), and a station for vaccination. I was called into the other room almost immediately to meet with the women’s group. About 20 women were seated on cushions around the perimeter of the room. Did I mention that since the resident wasn’t able to accompany us, I was asked to lead the talk? Yeah, so I had to come up with an outline and plan for the session on the way to the clinic. The topic was mental health (chosen by the women themselves at their last meeting) – not my strongest area of expertise or even comfort. My first reaction to being asked was ‘No way!’, but then I really saw it as an opportunity to get to know some of the local women and their problems and concerns, as well as a chance to share the Father’s love with them.

Fortunately, there was a young pediatric resident present who has been involved in community health initiatives. He was able to translate for me and help lead the discussion. The expat nurse who went with us also spoke the language fluently and helped to translate and add her insights along the way. Mental health actually turned out to be a great topic because it opened up a whole world of discussion about what life is like for these women day to day. In my last blog I shared about the common problems of depression, anxiety and PTSD that I encountered in outpatient clinic. I heard much more about these issues in the group meeting, and I was able to facilitate a discussion about coping with and overcoming these emotional problems.

To start things off, I asked the group to share some of their specific mental health concerns. Interestingly, the first person to talk was an older woman (I would guess around 60s). Her main concern was forgetfulness - forgetting where she put things, going into a room and completely forgetting why she went there. Many of the other ladies expressed similar problems. The older woman then proceeded to ask us (the expat nurse and myself) for a job so she could help her children to go to college; she wanted to send her son to Australia to study, and she had no money, a husband who “did nothing” (from the sound of it, he was suffering from PTSD), and only occasional odd jobs for income. Every time I asked a question, this woman continued to dominate the discussion talking about her economic problems, and this lead to a host of other comments about economic struggles. Obviously, financial insecurity is a major stressor and contributes significantly to depression and anxiety for these women. Since most women here still don’t/can’t work outside the home due to cultural, religious, and educational limitations, you can imagine the powerlessness and helplessness they must feel not knowing how they are going to feed, clothe, and educate their children. It seems like this is an all-consuming concern, as these women want and desperately hope to see their children have a better future than they have.

As the discussion developed, several other women shared about other issues such as strained family relations (especially with in-laws, with whom most of them live), fear of a resurgence of war and violence, their family’s health, husbands being out of work, etc. Almost all of them had been touched in some way by the war – parents or siblings killed or injured, having to move to a different city or even country temporarily due to war, or simply living in fear of violence coming too close to home. When asked about symptoms, many described sadness, frequent tearfulness and crying, insomnia, palpitations, nervousness, headaches, irritability, hopelessness and guilt. I did spend a little time talking about the signs and symptoms of depression, anxiety and PTSD. But most of the time I tried to get the women to do the talking.

At their previous meeting, they had been given the “homework” assignment of thinking about available resources and possible solutions to their mental health problems. Unfortunately, they did not have a lot to say about this. Trust between women, even family members, is not common, so most women do not feel that they have anyone they can share with when they become depressed or anxious. They don’t get out of the house a lot; there aren’t mommies’ groups or baby showers or bible studies or prayer gatherings or girls’ nights out, none of the activities that I would count on to provide emotional or spiritual support. They can’t just call up or email a friend for advice or encouragement. Most women move into their in-laws’ house when they marry, where they may live with parents-in-law and various brothers-in-law with their wives and children. Often there is conflict, especially with mother-in-laws. So to whom can these women turn if they need help? In consultation with my two colleagues/translators, I tried to suggest/encourage these women to help take care of one another, to encourage mutual trust and support, to try to replace hopelessness and helplessness with focusing on the good – counting their blessings, finding things to be thankful for and praise God for, reaching out to help others in need. We also talked about things like exercise, relaxation techniques and prayer as ways to deal with stress and anxiety.

As I write this, I pray that this session was a blessing for the women in that group. I hope each woman went away feeling like someone cared about them enough to listen to their worries and problems. I tried to convey the idea that each of them has value, dignity and unique gifts that God has given them. Of course, all of this was through translation and pretty much off the top of my head with only 2 weeks of experience in this country to draw on and about 10 minutes of preparation. But honestly I feel like this was a divinely appointed (and anointed?) activity. I wish I could have a second meeting with these women to see what fruit if any might have sprung up from the discussion. I guess I will have to leave it in the Father’s hands. I am just grateful for the opportunity; I never expected to be able to interact with women here in this way, and I loved it! This is the sort of thing I long to be doing, and it just sparked a whole lot of ideas and excitement about future possibilities.