Research underway

Research Study Update: Please see previous blog for related information...

So,
I received word that a retroactive IRB will be possible for my study.
Now I just have a lot of international e-mails and phone calls with my organization in order to get all the paperwork in. Hopefully, sooner-rather-than-later. It's going to be a pretty interesting experience- this "international study on global health." Almost an international experience on its own.

I will keep you updated!

Pendleton Community Clinic, WV

Pendleton County, West Virginia is the third poorest county in the United States and is still recovering from a devastating flood a few decades ago. Throughout this trip I was bombarded with the inequalities of health services in Pendleton County depending on an individual’s geographical location. I became aware of inaccurate stereotypes that were associated with certain diseases that affected the entire livelihood of individuals infected. It was difficult to see the disparities in infrastructure, health services, and education in our country that is considered to be a highly developed nation. When deciding what service trip to attend, I wanted an experience that would provide the opportunity for me to understand the different aspects of society that contribute to creating health disparities in a community. I decided to travel to Pendleton because I believe there are important health disparities in the United States that have been forgotten because of the vast inequalities worldwide. By meeting and speaking with community leaders, our goal was to better understand the needs of the county. My desire is to have this initial experience be developed into a longer relationship ultimately serving this rural community.

Eat, Pray, and Love Ghana

Disclaimer: I have neither read the book nor seen the movie, "Eat, Pray, Love." Let's just put that right out there. So if you were expecting a beautifully written synposis, Roger and Ebert style, my apologies...you will read no such thing. However, as the much anticipated (self-proclaimed) blockbuster of the summer hit theaters last weekend after one too many previews on the television, the words started to sink in...and take on a new, perhaps more reflective meaning - very pertinent to the ISI and GHF experiences. I feel like the words EAT, PRAY, and LOVE can represent the 3 legs of the ISI/GHF tripod.

EAT - when we travel to foreign countries with a heart to serve, a part of our service to the people is to learn about their culture...and this definitely includes the local food (well, at least it did for us in Ghana). Eating is a mode of universal communication and it can often open the door to the culture of the people with whom we are interacting, so that we may better understand who the people are that we are serving.

PRAY - prayer was a huge component of my GHF experience. As we experience an up close and personal view with human suffering (maybe some of us for the first time), we are also confronted with some deeply profound questions that require us to communicate with someone or something greater than ourselves. In addition to questions, we are often deeply moved by the people whom we serve - their attitudes of gratitude, their humility, and joy despite homelessness, hunger, and no access to healthcare touch our hearts in a way that we find ourselves struggling to understand. Throughout my experience in Ghana, prayer served as an ongoing conversation with God in which I asked countless questions, apologized for my ignorance and arrogance, and shared words of praise and thanksgiving for the people of Ghana and the many lessons provided by their albeit brief presence in my life.

LOVE - In 1 John 3:18, it says "let us love not in word or speech, but in truth and action." One of my favorite, most convicting verses that continues to stir within me the desire to serve. As we participate in ISI and GHF trips, we are called to serve. In our service, we are acting upon the love that we have for others. We are moving beyond "the talk" and begin to "walk the walk." Of course it is a challenge - we are in a completely foreign place, may not speak the language, may have no idea what we are supposed to be doing...but I think if we go back to the basics - EAT, PRAY, and LOVE - we find what the ISI/GHF trips are truly meant to capture.

Bolivia

When I got off the plane in La Paz, my chest felt the same sensation it had 3 years ago. We had just landed at 13,325 feet, and I could tell that there was less oxygen in the air. It was my second time in Bolivia, one of the only international locations I’ve been able to return to more than once, and thus there was an odd sense of familiarity when we landed—the same majestic, white-capped mountains illuminated by the morning sun, the same outside walk from the plane to Immigration, the same dark olive green uniforms worn by the immigration officers.

Ultimately, however, while many of the sights and sounds reminded me of my stay in Cochabamba, Bolivia a few years ago, I truly enjoyed getting to know new cities. Each one has a distinct character. La Paz is an eclectic mix of the traditional and modern, with 'cholitas' in bowler hats, colorful skirts, and shawls, alongside people in suits and ties, or name brand clothing. In order to cross the street, we learned to dart in between minibuses and taxis, and quickly realized that a red light is more of a suggestion than a requirement. Santa Cruz, in contrast, has a far more relaxed pace. There are no high rises or crowded streets as one might expect to see in the 'economic powerhouse' of Bolivia. It is also not the 'plastic city' that our teachers and host families in La Paz warned us about before we left. Palacios, the small rural village where the clinic was, consists of a few small houses, a store, and the clinic, which is essentially where the road ends.

Munasim Kullakita "Love Yourself, Little Sister"

In La Paz, each morning, we had Spanish class from 9 am- 1 pm, and then return to our host family's home for lunch. In the afternoons, we were able to volunteer four times with a local organization called Munasim Kullakita, or 'Love yourself, Little Sister' in the Aymara language, that works with girls who live on the street and have been victims of sex exploitation and trafficking. The organization runs two houses for these girls. The girls begin/ return to school, and also learn skills such as knitting so that they can eventually gain independence. The second part of the organization's mission is outreach. They have 'recruiters' who continue to go out and build relationships with the girls who are still living in the streets. They encourage them to take care of themselves, remind them of activities that the organization has three times a week, and notify them of days when they can get medical attention and/or a hot shower.

The second time that I went, Alicia and I walked around the streets with one of the organization workers. He told us there were three rules that we had to follow when we were with him: 1.) Don't carry any valuables or money on your person. 2.) Don't let yourself be pulled away from the group. 3.) Wash your hands thoroughly when you return. With those admonishments, I was nervous about how we would be received as foreigners, and did not know what to expect.

Initially, as we walked the streets with the organization worker, I actually couldn't tell which girls were living on the street until they flocked over to the worker to say hello. Most of them were high on some sort of toner, paint thinner, or nail polish remover, I’m not sure which. They would pour some on a ball of wool or yarn, and bring it up to their faces to inhale, all while talking with us. It was difficult to hold a conversation with them, and when they kissed us on the cheek in farewell, the odor was overwhelming. According to the organization worker, one of the largest barriers for the girls to leave the streets is their addiction to drugs.

While we were standing with one group, a girl stumbled out into the street, sat on the edge of the sidewalk and began wailing, her cries echoing down the street. The organization worker tried to see if he knew her by calling out to her and asking what her name was, but she would not respond; and none of the other girls seemed to recognize her. He told us that it would be better if we did not approach her since we were not sure how she would react. I looked back at her as we were walking away, and the image of her was burned into my memory-- her slight, hunched figure sitting on the sidewalk made no more than a silhouette by the bright sun. By the end of our experience that day, I grew to appreciate how much progress each of the girls in the house had made after leaving the street.

Trans Copacabana

Before we left for Bolivia, we were warned that we would have to take a 10 hour overnight bus ride to Santa Cruz from La Paz to meet up with the rest of the team. Little did we know at the time that, that number would continue to grow as we talked to people in La Paz. By the time we left for Santa Cruz, the number had grown from 10 to 15... to 17, until one kind woman told us that we should be prepared for 19 hours on the bus. Ultimately, our bus ride on the Trans Copacabana bus line was not as bad as it could have been, but it was certainly not one that I would necessarily want to repeat in the near future. Due to our fear of the bus bathrooms, none of us dared to try the bathroom even after more than 12 hours on the bus. Only when we stopped at a checkpoint the following morning did we venture outside to pay a couple bolivianos to use some squatting toilets in a small hut by the side of the road.

El Centro Medico Humberto Parra

In the clinic, the patients we served could be categorized into three groups. First, there were the patients we could help immediately. These were the ones who came in for medication refills, parasite treatment, UTIs, and other manageable illnesses. On the other end of the spectrum, there were the patients who had more life-threatening illnesses such as patients who needed a pacemaker or radiation treatment. In those cases, the clinic was able to write referrals. Although the cases would then have to be sent for approval, there was a good chance that the patient would be able to receive a life-changing treatment. The most difficult cases for me were the cases in between where we didn’t have enough resources to make a definitive diagnosis, but the patients’ quality of life was not affected enough such that a referral to a specialist would be approved. It was frustrating that we could not offer any assistance, and that they would likely return to the clinic with the same symptoms over and over again. At the same time, I did find it rewarding to be part of the continuity of care for many patients with hypertension and diabetes. It was encouraging to know that they would continue to have access to care even after we were gone.

“Usted tiene Cancer”

In PCM-1, we learned how we should give patients bad news. We learned that it is important how you deliver the message, that we should be sensitive to the patient. However, my Spanish capabilities never felt more inadequate than when we had to deliver bad news at the clinic. How do you tell an 18 year-old girl with an 11-month old baby that’s she pregnant again when you’re not sure whether or not she wants another baby? How do you tell someone that they need a pacemaker because their heart might go into ventricular fibrillation at any moment? How can you explain to someone that they have cancer when all the words you know seem equally harsh, or scientific?

The patient came in with lab results from a hospital in Cochabamba for ‘follow up’ because she was still hemorrhaging. The lab results stated that she had cervical cancer, but no one had told her. I was working with Alicia that day, and when we went out in the hallway, we tried to plan how we would tell her. It was all for naught, however, because when we walked back into the room with the clinic coordinator and physician to explain the situation, the coordinator walked in and said, “Usted tiene cancer.” Just like that. I remember looking over at Alicia, both of us horrified, but it could not be undone.

My time in Bolivia demonstrated how easy it could be to become complacent by treating each patient with a cookie cutter method of counseling, and simply writing a prescription rather than addressing the root of the problem; however, I also learned how vital it is to remain vigilant, to treat the individual, and to give the patient a space to share their distress and pain, even when we, as medical care providers, might not be able to provide a treatment. In the end, it is the kindness and compassion that we show that is remembered.

Haiti

It is like looking through a dark woven blanket to bright light above. The night sky surrounds us, envelopes us as we gaze at the stars and planets. Fires flicker on hillsides around. Dozens of shootings stars streak through our vision. What wishes to make?

Morning comes early; the roosters are the only ones who arrive on time in Haiti. Bright sun heats up our concrete room, the light is blinding. Bread, peanut butter, and pineapple prepare and strengthen us for the final clinic day. Our truck, the beloved White Whale, bumps and winds its way to Dandann.

On my own and many patients to see, my excitement and nervousness brings energy for the day. The patients that have become routine to us in five days file in – cases of acid reflux, headaches, anemia, joint aches, hypertension, dental problems, vision impairments, malnutrition, vitamin deficiencies, dehydration, worms, scabies, and earwax impaction seem to be the major ones. My confidence increases as does my speed.

One man hobbles in using sticks as canes. He thinks that he is 69 years old, his eyes sunken, cheeks hollow, and bones poking through thin, outworn clothes. Asking what brought him to the clinic, he tells me, through my translator Louis, that he has pains in his stomach and all over his body. Haitians are a proud people, surviving through community and hard work so what he says next is difficult to hear. He openly admits that he knows these pains are from hunger. He eats only when people can bring him something, because of his limited mobility. He is unable to work, to support himself in any way. He has no family, his parents died many years ago and he never had children. His neighbors try to help, but they too struggle. He is not alone in his experience, but many do not share their stories. The pain on his face is apparent, I fight back tears. On physical exam, his belly protrudes, each of his ribs and spinous processes hard, sharp against my hands. Our ability to help is limited. We invite him to stay for lunch, share crackers and pretzels with him in the meantime. Tylenol and Tums are the best we have to send him home with. Louis is not only my translator, but a community leader and vows to look after this man.

The day is not done. I see dozens more patients before a father brings his children to my station; my penultimate patient. He is dressed in polka-dot pants and a wide brim straw hat with a ribbon tied around it. He is 32, his children are 8, 5, 3, and 13 months (and one more at home). Johnna, a missionary familiar with his family, explains to me his story. His wife died several months ago from an apparent ear infection, leaving him with the children. He has no money or source of income. The 13 month old has a cough and fever and the 3 year old something entirely different. He says there is something on her back, so we examine her by lifting up the large t-shirt that is her only clothes. A bony mass protrudes out, Dr. Buchta thinks it might be some sort of rib malformation, but cannot know for sure unless an x-ray can be taken. We tell the young father that he must take her to St. Boniface Hospital in Fond des Blanc so that she can be examined with better equipment. He nods understandingly and explains that the hospital is where his wife died and knows that he must take his daughter there, but has not been able to summon the courage to see it again. Again, I am overwhelmed with emotion as the struggles of my patients become clear. They are not simply medical, nor are they economic. The depth of hurt in this country is great. Each family, each person has a story. We are but a small piece of their lives, trying to make a positive change.

For this man and his family, we equip them with all of our vitamins that we have left, toothbrushes and toothpaste, antibiotics, stickers, and encouragement to have his daughter seen at St. Boniface.

At the end of the day, I am emotionally and physically drained. The White Whale brings us back to the orphanage, stopping to see a homebound patient on the way and pick flowers from the flamboyant tree. The children greet us with hugs and smiles. I relish in those times when I can see the joy through their eyes, see Christ through the light so apparent at the Mission. Dinner is a feast of rice, bean sauce, and chicken. We take for granted the provision of clean, safe water and gulp it down.

The sun sets in the hills and mountains that surround us. We debate on whether that planet is Mars or Jupiter, or maybe Venus. Darkness falls, twinkling stars replace the sun. Heat lightning strikes in the distance. It becomes quiet. A falling star blazes through the sky.

What wishes to make?

Reflection

As I look back on the time I spent in Zambia, I am very happy that I took the trip. The clinical experience I gained helped me to figure out how global service will fit into my career as a physician. The doctors that led our group served as excellent examples of how to be successful physicians, parents, spouses and humanitarians.

Throughout the first year of medical school, it is easy to lose sight of your career goals and become fixated on immediate academic obstacles. Working in Zambia refocused my attention on the future, and allowed me to enter my second year of school looking forward to my future career rather than dwelling on upcoming exams.

In Zambia, I expected to see pain, suffering, disease and starvation. I expected to find a nation of people in desperate need of help just to meet their basic day-to-day needs. I was surprised to find community after community of happy, welcoming people. I did not come across a single person who seemed to feel that they were underprivileged. It was amazing to see how happy they were with so little, when there are so many people in America that are unhappy with so much.

In the future, I plan to return to Zambia during my clerkship years and again as a physician. The ISI trip opened the door to a career punctuated with global health initiatives.

On Rounds

The men’s ward is a truly frightening place. There is a long, narrow hallway of concrete with little light aside from that which comes in from the doors at each end. Passing by the patients’ rooms, their sunken eyes stare up at me. God only knows what they’re thinking. Each room contains a row of beds and nothing more, windows with bars, and draping mosquito nets. The men are wasted away – some just skin and bones. There is so much AIDS here in Zambia, it’s horrifying. The stigma associated is still so bad that Dr. Lena never says “HIV” or “AIDS” around patients. Though most of them don’t speak English, they definitely recognize those words. Instead, she says patients have RVD – retroviral disease. The people are also plagued by malaria, tuberculosis, pneumonia – all things that no one should ever die of, but still, so many do, especially when their immune systems are compromised by HIV.

The stench is absolutely suffocating. Sometimes I can hardly stand it. Clearly, Dr. Lena has gotten used to it – nothing seems to faze her here, and that gives me hope. I know that if I was forced to, I too could adapt, but this initial difficulty is really troubling. I feel so guilty because I want to care for these men, I want to help, but how can I if I’m scare to be near them? And I am scared. I’ve never felt disease so close to me before – disease is the inescapable presence, bearing down on me in every room. Everywhere I look, I see it. I feel it. I step outside and gasp for air, but still, it’s there – the stench, the sickness, the death and the rot. And I don’t know what to do.

Today was a better day, spent mostly in the children’s ward and malnourishment ward, which is basically just an extension of the children’s ward, since everyone here is malnourished. Children tend to start crying when we come on rounds, our white faces and white coats, strangers in a strange place. Big steps, however, were made today when I realized that the crying eventually dies down, and just like with children at home, it helps to come at them sideways. I smile at them out of the corner of my eye and wink. Some play coy, hiding their faces in their mother’s chest for a moment, then looking back up, smiling, to see if I’m still smiling at them – a game played back and forth.

One baby boy, about 2 years old, cried and clung to his mother when we tried to examine him. The baby had pneumonia, and it was impossible to listen to his lungs while he cried. I rubbed his back and gave him the end of my stethoscope to hold. He eventually took it, touching it carefully at first and then shaking it in his fist. I traded him a pencil for the stethoscope, and I was finally able to listen to his chest. I made several little friends in the children’s ward today, and I feel as though my hope has been renewed.

The First Baby, Cont.

Finally, it was my patient's turn to deliver, but the baby was slow coming. The mother was only 15 years old. Dr. Fee said her malnutrition and underdeveloped hips, combined with the fact that it was her first baby added up to a long labor. I felt a connection with the young girl, it being each of our first deliveries. I stroked her arm and swollen belly, whispering words of encouragement. She stared up at me with big brown eyes, full of fear and pain, and she cried out for her Mama.

Hours passed, and as Dr. Fee and I waited, the midwife informed the doctor that the girl would need a particular medicine after delivering. I asked Dr. Fee what that meant, and she said that the girl was HIV positive. We had been informed that the HIV rate in this are of Zambia is around 16%, so I wasn't surprised by this news. I wasn't scared either, though I probably should have been. I just wanted the baby to come.

Finally, the baby was close. The girl pulled off her shirt, as it is their custom to give birth naked. I put on sterile gloves and assumed my position between her legs, gently tracing the crown of the baby's head with my fingers. Dr. Fee stood by, calmly instructing me, and before I knew it, I was sliding the baby out. What happened next is a blur.

As the baby slid out, I was hit in the face by a wave of fluid that entered my mouth and eyes. I spat, completely stunned, the baby in my hands. I told Dr. Fee that it was in my eyes and she told me to put the baby down and go wash my eyes out in the sink. I did as I was instructed. I think that it was then, eyes wide open, splashing water into my face, that I began to panic. She was HIV positive and I could get it through my eyes from her amniotic fluid. I began to shake I think. I finished at the sink and walked, stunned, to the crib where Dr. Fee was taking care of the baby - a very, small but apparently healthy baby boy.

I stood there, trembling with silent panic, until Dr. Fee finished. Shaking, I said, "She's HIV positive. I can get it through my eyes." Dr. Fee told me no, no, it was the other woman, the other woman who had been silently moved into the empty second bed who was HIV+, not the girl whose baby I had delivered. I broke at that moment and began to cry. "Are you sure?" I asked her. She checked the girl's papers, and she was negative. I fell onto Dr. Fee's shoulder, crying for only a moment, trying to shake it off as best as I could. I was so afraid. Dr. Fee had a rapid test performed on the girl to confirm her status, and she was HIV negative. For a moment, nothing else mattered besides holding the new baby.

I'm sitting in our cabin now, having showered and rested, and I still feel so shaken, so afraid. I love Africa, but today, I'm ashamed of how much I fear this place.