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. 

A New Week

Sunday is the start of our work week here. I had a really good weekend with time to read, pray, and rest. And this week has started off great. More on that later - I wanted to share a few reflections on patient encounters.

Most of the clinic patients have problems with gastritis, back pain, headaches, cough – problems very similar to my patients back home. (Almost everyone here tests positive for H. pylori – a bacteria that lives in the stomach and causes gastritis and ulcers.) There is also a lot of depression and anxiety and almost everyone (patients and staff) has a story to tell about someone close to them who was killed in the war. Many patients are suffering from post-traumatic stress disorder. Unfortunately, there isn’t a lot of mental health care available. The residency program is trying to emphasize a holistic approach to patient care, including psycho-social problems. But it’s hard to provide any meaningful counseling in a short medical visit without adequate training.

One patient I saw, a beautiful 20-something year old woman, was suffering from anxiety, insomnia, depression and severe headaches. As her story unraveled, we learned that her father and brother had been killed ten years ago in a bombing. She was the oldest child at home and was now supporting her siblings and mother by teaching school. Not only was she carrying the economic burden of her entire household, but she continued to have nightmares, panic attacks, and constant anxiety brought on by the traumatic events surrounding her father’s death. She stated that she had been severely depressed before and had attempted suicide eight years ago but failed. Recently, her life had become more stressful; she was hardly sleeping due to anxiety, which undoubtedly contributed to her headaches, and her work was severely affected due to tremors, palpitations, tearfulness and worry. The resident prescribed medication for depression and anxiety, but she needs so much more than that. Her emotional pain is much deeper than medicine or a short office visit can cure. 

And her story is just one of many similar stories I have heard during my short time here. Years of war, instability, economic hardship and uncertainty, and lack of resources and opportunities have spawned an epidemic of PTSD, depression, despair, anger and hopelessness. Often these problems manifest as a variety of physical complaints. Patients who come to the clinic with headaches, stomach pain, nervous tremors, and the like will usually, when questioned, admit to suffering from stress, depression and anxiety. Yesterday I attended a community women’s clinic where I helped to facilitate a discussion about mental health concerns.  More on that later, but it was very informative and helped me to understand the situation of women here a bit better.

Interestingly, one of the residents keeps asking me to come talk to his female patients with depression, anxiety and family problems. He says that maybe if a foreign doctor sees them they will think the medicine will work better. My immediate response is, ‘what can I possibly offer when I don’t even speak the language?!’  But it has been interesting delving into some of the family problems these patients are facing. Some of it is just typical conflict between sinners. But underneath much of it, you can see the cultural and spiritual forces at work creating strife and frustration. I have prayed for wisdom to know how to respond and what to say in these situations. I have tried to convey that medicine alone is not going to fix their problems – that change from the inside is needed. In the short time available in the clinic visit, through translation by the resident, I don’t know what impact my words or questions will have. So please pray that at least a seed will be planted.

In the midst of political, economic, and emotional turmoil, there are still many people here who demonstrate hope and a desire to not only see things change but to be a part of the effort to create a better future for their country. I am moved time and again by the personal stories of the residents and faculty who truly want to make a difference and help those in need. Although it is difficult for them to return to their home provinces due to continued unrest, they still hope and long for a day of peace when they will be free to go home and help heal and rebuild. I would love to see them truly empowered to love and heal and build through knowing the true Healer.

Discouragement

Today I read the blogs of some friends of mine who are serving in Africa, where the hospital is over-full, patients two to a bed and lying on mats in the corridors, many dying from malaria, typhoid and the like. I have to admit that reading about their experiences made me question what I’m doing here. The small hospital I am working in is not even full. There are few inpatients and even the outpatient department is slow compared to what I am used to back home. So far the problems I’ve seen are not severe - nothing like cerebral malaria or advanced TB.  Besides that, I feel completely superfluous. I am certainly not needed. In fact, in many ways I think I am a burden – needing someone to translate for me and asking many questions slows things down. I make little if any contribution. In addition, I am plagued by doubts about my abilities:  my medical skills and knowledge are inadequate; I am not sure I know how to be a good teacher; I know nothing about running a residency program; and even my community health experience is ancient. To top all of that off, I don’t have a clue how to relate to or share with people in this culture and context.  So what in the world am I doing here? Will I ever be "useful" in this context (or anywhere else for that matter)? 

Okay, I know that is pretty much pride speaking. I want to feel needed, be useful, do something “important.”  I want to come home with amazing stories about what I’ve seen and done here. Instead, I have to be content to wait on my Father and trust that he has me exactly where he wants me right now. I’m clinging to the promise that he has a plan and purpose for me, that he has indeed prepared good works for me to walk in, and that he is able to equip me to fulfill that purpose and perform those works in his own way and time. If others are called to a different work and are being used in a different way, I should rejoice in that and not question my current circumstances. Even if I am not clear what he is doing with me right now, I need to focus on following him to the best of my ability here and now instead of thinking I should be somewhere else or that some other place and work are better. Certainly my experience here will be different from others’ because the context is completely different. I need to be faithful to make the most of the opportunity he has given me right where I am. End of sermon to self. Thanks for listening. Perhaps it will lead you pray for me more specifically.

One thing I have appreciated is the opportunity to interact with many like-minded individuals who are serving here. Many have been here for years, others for only a few months. All have struggled with discouragement at one time or another; it is a hard place to serve. There are constant challenges with political unrest and safety, establishing meaningful relationships in a distinct cultural and religious context (especially knowing that close contact with westeners could endanger these people some day). Uncertainty about the future of the country makes it easy to become discouraged as well. Recently, I heard that the funder of the hospital where I work was having trouble getting donors because people in the U.S. feel that the instability and uncertainty make it pointless to invest in the work here.  My interactions with fellow servants here have impressed on me the necessity of community and "soul care" among workers here, the importance of strong support back home, and the value of communicating the needs and stories so others will continue to invest in the work here.

So come back tomorrow for a few stories. 

First Week on the Job

Taken from inside car (hence reflection)

The hospital at which I am working is about 30 minutes from where I live (that’s with traffic and bad roads, so I have no idea how far it really is). There is a hospital driver who picks us up every morning -us being a couple local doctors who are on the residency faculty, the program director, myself and any visitors. Septermber-October is a very pleasant time to be in K, so there will be a number of other visiting doctors. The car is small, and male and female passengers should not sit next to each other ideally. However, it is okay for me to sit next to another female or one of the other expatriot male (if necessary), but not a local male. So often, the two local male faculty members end up sharing the front passenger seat (not so comfortable). Anyway, I always have to ask where I should sit so I don't make a cultural faux pas.

The drive itself is interesting. Along the way, there is this bombed out palace and some burned out old Russian tanks. There are mountains on both sides, mostly brown and not too tall. Although one day this week it rained in the city, leaving the mountains with a light dusting of snow and clearing the air somewhat. It was actually quite pretty.

Once at the hospital, there are separate entrances for men and women. I head up to the female resident room where I can change into my white coat (I wear a black coat anytime I’m outside) and join the residents for morning report. This consists of a quick update on the patients in the hospital, those who were seen in the emergency room and any new admissions in the past 24 hours. Then one of the residents or faculty give a short presentation. After this, everyone disperses to their various duties.

I started out in OPD – outpatient department. This is basically a walk-in clinic for non-emergency health problems.  Since I can't speak the language, I worked with one of the male residents. At first I wasn't sure how to interact, but after a day or so, I realized it was okay to ask questions and felt more comfortable conversing with him about various topics. The residents have been great about translating my questions to patients and including me in the history as well as the assessment and plan. Also, I wasn't sure if it would be appropriate to examine the male patients, but apparently there really isn't a problem doing a basic physical exam (heart, lungs, abdomen, extremities, ears, nose, throat...). I do think some of the female patients were relieved to have a female doctor present. 

Actually, I have been surprised at how open many of the women patients have been with male doctors. Some women come with male family members who do most of the talking, but some come alone. I suppose if I weren’t there, they would be seeing a male doctor alone, which I thought would be culturally inappropriate. Apparently there are women who refuse to see a male doctor. But so far I have not seen any problems with this. On the OB ward, the male residents only step in when necessary but often try to maintain the privacy of the patients.

I’m still trying to get to know the residents and faculty. I was really pleased on my third day when one of the female residents made an effort to include me in an emergency appendectomy and then pretty much took me under her wing to make me feel comfortable. I hope to get to know her and the other female residents better over the next weeks. They all have interesting stories to tell I’m sure.

This is now my sixth day (Friday and Saturday are the weekend days) and I have had some great experiences. Besides the appendectomy (which was open, not laparascopic), I've helped with two vaginal deliveries, newborn exams and resuscitation, lots of gyn exams, insertion of an IUD, and a circumcision of a 2-year-old. The latter was a new experience; I've only ever circumcised newborns. Circumcising a wide-awake toddler under just local anesthesia was something! Occasionally, when outpatient clinic is quiet, I wander into the ultrasound suite and get to watch and do abdominal and pelvic sonos. Most have been normal, though we did pick up one acute appendicitis. I can't say I've seen anything unusual or terribly different in terms of the medical problems or general approach to patients, except that it is more routine to cut episiotomies here and I have seen the midwives using fundal pressure to facilitate delivery. Oh, and they do not have amniotomy hooks (to rupture membranes); instead they use needles. (I would definitely be more worried about injuring mom or baby with a needle, but I guess they are used to it.)

I am humbled at how eager everyone is to include me and give me learning opportunities. It is a teaching hospital, and the faculty and even residents all like to teach. So far I have received tips and hands-on teaching in anesthesiology, surgery, ultrasound, OB. I guess I wasn’t sure how much I would be allowed to do, but I am being treated just like one of their residents, which is great. It is also humbling to see how much I still have to learn. The residents here are much more experienced and comfortable with surgery than I am, and they all learn to do ultrasounds – these are great skills to have for someone working in a rural district hospital in a resource-poor country. 

Today I gave a talk on pediatric developmental milestones to the residents. I used a participatory activity borrowed from my residency program and included chocolate for incentive. It was fun and I think well-received. And hopefully it gave the residents a chance to get to know me a little better.

Okay, this was a really long blog. So I will stop and save more stories for next time.

First Impressions

View from street en route to work

My first impression of K is that it is dry and dusty. The surrounding mountains blend in with the brown landscape and brownish air. (I’m not sure if the air is brown from pollution or dust, probably both.)  Like so many other parts of the world I’ve been, in traffic is crazy with no obvious rule or reason: cars, trucks, people on foot and on bikes, herds of sheep – all trying to make their way along or across the roads with no signals. Most of the roads are in poor condition. If once asphalted, they now are potholed and dusty. So travel anywhere takes a lot longer than it would at home. 

View from my roof

Of course, as a woman, I immediately noticed all of the women in blue burqas or long black coats, some completely covered except for their eyes, others wearing scarves that show their faces. Even the young school girls have long black robes and white head coverings. Though I’ve seen plenty of pictures and knew what to expect, it is different to experience it in real life.  I have not yet gotten used to wearing a scarf over my head, and still haven’t figured out how to keep it from slipping off. Fortunately, there are places I can take it off - inside the guesthouse or in the female residents’ room at the hospital. It is nice to see my colleagues face to face, though it is amazing how much personality can be expressed with just the eyes. In some ways, I appreciate the safety of anonymity that comes with covering up; in fact, I wish I could wear a burqa just so I wouldn’t stand out as a foreigner.  On the street, even wearing my black coat and scarf, keeping my head down and avoiding eye contact, I feel vulnerable. 

View from my roof

In general, I still feel very uncertain about how to act and interact here. As a western female, I am considered a “third gender.” Supposedly I have more freedom to interact with both western and local men than the local women do. With my fellow expatriots, I can relate more or less as I would to men back home.  And I should be able to talk to my local male colleagues at the hospital more or less as equals. But I don’t quite feel comfortable yet. It is hard to be constantly aware of my expressions, gestures, tone of voice, eye contact, body language, head covering, etc. Do I greet everyone I pass in the hospital? How friendly should I be? Since I don’t speak the language, it’s hard to do much more than say hello anyway. At least with the women, I know I can be more relaxed, so I’m focusing on that for now.