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.