It was the third day of night call at 1 am, and the ED was slow. Our team was killing time in the workroom, half hoping for a patient to give us something to do and half ready to quit waiting around and just go to sleep. I was tired of wasting time, incapable of studying or resting, but I wanted a patient both for the experience and to have something to show for myself at rounds with our attending the next morning.
An hour later, there was still no patient, so I decided to throw in the towel. I went to bed wearing my pager, expecting that the night was over. I climbed onto the top bunk in one of the call rooms and passed out. 45 minutes later, I was awoken by my bunkmate to let me know that my pager had been going off for 15 minutes. I slid off the bed clumsily and made my way back to the workroom.
To my relief, my intern had been waiting for me to go see our patient. The new charge was a 10 year old boy named Miguel with upper respiratory symptoms, severe autism and a known seizure disorder. He was presenting with fever, productive cough and two recent seizures. We went down to visit him in the ED. I was flustered and groggy, and had to work hard to muster up my usual excitement at meeting a new family.
When we got to the patient’s holding room, we found a sweet-looking child asleep with his mom at bedside. Mom was clearly worn, with unbrushed hair and circles under her eyes. She was leaning over her son's listless figure, hands propped on the bed frame protectively. A teenage girl wearing a college sweatshirt and Uggs was curled up in a chair on the other side of the room.
We introduced ourselves, took a complete history and did a basic physical exam complicated by the fact that Miguel was both fast asleep and also developmentally delayed. He was definitely congested, and the X-ray confirmed pneumonia. This was his second ER visit in 24 hours, and on the car ride home from the first trip, he had his second seizure of the day. His mom, Anita, was clearly drained but determined to help him get well. She spoke quietly, and her body language made her seem timid, but all that was misleading. She was the mother of a sick child.
Before leaving the ED to put in orders, we had to inquire about Miguel’s behavioral issues—is he violent? Does he bite or kick? Does he ever need to be restrained? No parent of a developmentally delayed child enjoys this line of questioning, but it's our job to anticipate special needs and challenges. At this point in the interview, his sister woke up, uncurled herself in her chair and addressed us for the first time. "You know, he does bite sometimes, but it’s actually just his way of giving a kiss. He doesn’t even know he’s doing it and it doesn’t hurt at all.” She insisted that there was nothing to worry about. I was moved by her protective instinct for her little brother, and remember thinking how much she must love him to interpret a bite as a kiss from a child who’s likely incapable of showing affection. We left the family to put in orders for Miguel’s hospital stay. Satisfied that I'd finally gotten to see a patient, I went back to my bunk to catch an hour of sleep before morning rounds.
On night call, you don’t follow the patients you admit, so a couple of days passed before I went back to visit Anita and Miguel. As I walked in the room, I saw Anita struggling to hold her son up as he tried to stumble across the hospital room floor, dragging his IV pole with him. She looked up at me, tangled up in his limbs and wires, and laughed nervously. “He feels better so he wants to move around. He doesn’t understand that he’ll fall.” Together, we carried him to a chair. He had a blank expression on his face, the only look I’d ever seen from him. I spent some time chatting with Anita and tried to answer her questions. I left mother and son on the couch together, feeling overwhelmed by her love for him. It was the same way I felt that night in the ED with Miguel’s sister.
The next morning, we visited the family as a team during rounds, piling into his room and surrounding his bed. It was discharge day for Miguel, so the mood was light. He was sitting up in his bed and moving his wiry body from side to side, looking off in the distance. Anita was at his side as always, patting his matted hair. She told us he was happy today, and her spirits seemed lifted too. Then she bent down to offer him her cheek, and to my utter surprise, he turned his head to her and kissed it.
I was happy to be wrong.
Wednesday, November 11, 2009
Sunday, September 13, 2009
Questions in the ER
The ER is, not surprisingly, a hectic place. When I'm evaluating a patient, it's often hard to have a conversation what with all the traffic and talking and monitors beeping, pagers going off, and phones ringing. It's also an undignified place-most people lying on the gurneys didn't plan to be there, so they didn't have the luxury of wearing something comfortable, bringing things they would need for the 8 or 9 hours they might be waiting, or calling someone who loves them to keep them company.
Most people who visit the ER are on the patient end of things. Here's how it is from the other side: our team, on call for the day, gets paged that we have a new admit. Most of the time, we're either sitting around in the team room waiting for this call, or we're in the middle of taking care of the last call. When we're free, we look the patient up in the computer to see if he/she's ever been to this hospital before. We build up our clinical suspicion based on previous record: if she was in for liver disease last time, we're going to bring drugs and alcohol up. If she's an asthmatic, we're going to ask about compliance with controller meds. If we have no prior history to go on, we look at the ER questionnaire to form a picture in our heads.
Once we've gleaned all we can, we go down to visit our new charge. We pepper them with rapid fire questions. Are you experiencing any chest pain, sir? Palpitations? Shortness of breath? How about nausea, vomiting, diarrhea, or constipation? Does it hurt when you pee? And how about when you poop? What did your mom die of? Your dad? Cancer in the family? Oh, I'm sorry. What kind? Where do you live? Where do you work? In the event that you were incapacitated and could not make decisions for yourself, who would you like to make medical decisions for you? Would you like to have chest compressions or a tube put down your throat to help you breathe if you suddenly stopped doing so on your own?
All this, and we met five minutes ago.
Then we move on to the physical exam: Can I unbutton your shirt? Roll up your pants? Take off your shoes and socks? Does this hurt? Can you feel that?
It is a whirlwind 20 minute conversation, after which we leave the patient as promptly as we arrived, go back to our computers to write the official admission note and put in our orders, and wait for the patient to get a bed on the floor. In the meantime, we think of questions we forgot to ask that will help us figure things out.
What all too often forgets to be asked:
How are you holding up? Do you understand the plan? What questions can I answer for you? Not do you have any questions, but what questions do you have. Did anyone tell you the results of your blood test/X-ray/MRI? You'd be surprised. And what do those results mean to you? From a 5-year-old kid in need of a tonsillectomy: you're going to cut my head off and take out my tonsils and then sew it back on. From a patient with pneumonia found to have a pleural effusion, or fluid in the lungs, on chest X-ray: this happened because i drank too much water.
At the end of the day, sure, it could be more elegant. But nothing about this process is elegant. When you are sick enough to show up to the ER, you are stripped to your very core. When you are on call for 18-30 hours, sometimes into the wee hours of the night, you are also stripped to your core. And for the most part, decorum aside, patients are simply glad to answer any question they think will help you solve what's happening to them.
We just need to remember to return the favor.
Most people who visit the ER are on the patient end of things. Here's how it is from the other side: our team, on call for the day, gets paged that we have a new admit. Most of the time, we're either sitting around in the team room waiting for this call, or we're in the middle of taking care of the last call. When we're free, we look the patient up in the computer to see if he/she's ever been to this hospital before. We build up our clinical suspicion based on previous record: if she was in for liver disease last time, we're going to bring drugs and alcohol up. If she's an asthmatic, we're going to ask about compliance with controller meds. If we have no prior history to go on, we look at the ER questionnaire to form a picture in our heads.
Once we've gleaned all we can, we go down to visit our new charge. We pepper them with rapid fire questions. Are you experiencing any chest pain, sir? Palpitations? Shortness of breath? How about nausea, vomiting, diarrhea, or constipation? Does it hurt when you pee? And how about when you poop? What did your mom die of? Your dad? Cancer in the family? Oh, I'm sorry. What kind? Where do you live? Where do you work? In the event that you were incapacitated and could not make decisions for yourself, who would you like to make medical decisions for you? Would you like to have chest compressions or a tube put down your throat to help you breathe if you suddenly stopped doing so on your own?
All this, and we met five minutes ago.
Then we move on to the physical exam: Can I unbutton your shirt? Roll up your pants? Take off your shoes and socks? Does this hurt? Can you feel that?
It is a whirlwind 20 minute conversation, after which we leave the patient as promptly as we arrived, go back to our computers to write the official admission note and put in our orders, and wait for the patient to get a bed on the floor. In the meantime, we think of questions we forgot to ask that will help us figure things out.
What all too often forgets to be asked:
How are you holding up? Do you understand the plan? What questions can I answer for you? Not do you have any questions, but what questions do you have. Did anyone tell you the results of your blood test/X-ray/MRI? You'd be surprised. And what do those results mean to you? From a 5-year-old kid in need of a tonsillectomy: you're going to cut my head off and take out my tonsils and then sew it back on. From a patient with pneumonia found to have a pleural effusion, or fluid in the lungs, on chest X-ray: this happened because i drank too much water.
At the end of the day, sure, it could be more elegant. But nothing about this process is elegant. When you are sick enough to show up to the ER, you are stripped to your very core. When you are on call for 18-30 hours, sometimes into the wee hours of the night, you are also stripped to your core. And for the most part, decorum aside, patients are simply glad to answer any question they think will help you solve what's happening to them.
We just need to remember to return the favor.
Saturday, May 30, 2009
Back in Nairobi
I just got back from Juba yesterday, so now I can blog in real time. This adventure is almost over and I'm really grateful for it. I am satisfied that we did the right thing by coming in with the Wharton team to do a careful assessment, asking some hard questions before jumping right in. Sure, you walk away wondering if this trip did any good, but you have to think long-term. It's not always just about feeling good.
And what feels better than practicing medicine? Seeing patients, prescribing medicine after a 15-minute interview, and doing surgeries is very rewarding, from what little experience I have. In Malek, another thing we did was set up a makeshift clinic with the small pharmacy of drugs we brought with us. People came in droves with health problems of every kind. It was uncontrolled madness and we definitely could have organized ourselves and our patients better. My mom and I interviewed and examined the patients with the help of translators, and Orin, Grace and John filled "prescriptions". Sush went to distribute vitamins to the women, and was apparently nearly accused of poisoning them (one of the women told him to swallow a pill himself so they'd know he wasn't trying to kill them all).
It wasn't that we didn't do any good that afternoon. I think we did. We de-parasitized, killed fungal infections, cleaned abscesses, and treated diarrhea. We tried to give clear instructions on how to take the meds, although communication is the most overlooked, most important factor in doctor-patient interactions (and is 100 times harder when you're being ambushed by mothers pushing their kiddos toward you). I can only pray that we did some good. But I am more convinced than ever now that medicine is NOT the answer for rural health, at least not in Malek.
Those kids need clean water to drink, and they need protein. Their bellies are obviously swollen with kwashiorkor. What good will pylotrip do for their ulcers without a proper diet? They need latrines, and they need sewage. They need vaccinations. They need to go to school. They need better housing to shield them from the elements, of which there are many in East Africa, home to a billion bugs and all those cool safari animals.
When we got back to Juba from Bor, we had a debriefing where the Warton team gave my mom and I their impressions of where Universal Unity should go next. They were all against building a clinic, as am I. Not because it's not needed, but because so much more, and so much more basic things, are needed more desperately. And because as a growing organization in its beginning stages, we don't have the know-how, the funds, the time commitment, or the managerial skills to make this happen. We're talking about a location where CRS, a behemoth of an aid organization with 10-year commitments to its subjects, is pulling out. What makes UU's chances better?
I'm not saying we should pull out too. Not at all. I think we should partner with Michael Lear from Real Medicine Foundation and send nurses to his nursing program at Juba Teaching Hospital. We can also help revise the curriculum and bring doctors and nurses in to help train for short periods of time (which is what we have to offer, since no one has stepped up to move to Africa permanently). I think we should refine our "Educate Refugees" project, which needs a lot of help before we take on something new (I knew this before we left for Sudan, and meeting former students in Nairobi only confirms it). In short, I think we should build capacity. In a few years, our students will be engineers and agriculturalists. We just met two high school graduates, Natalina and Mercy, who are hanging around Juba after sitting for the KCSE -- they would be perfect candidates for nursing school. In time, UU will be able to complete our promise to our students that we would help them find their way in life through education. It will be a more complete promise than simply paying their fees, and it would help us do what we've wanted to do all along: help Southern Sudan.
I'm mentioning this on the side, but the current peace agreement between the ever-warring North and South Sudan ends in 2011, at which time there will be a referendum. Kwai thinks the North will never agree to let the South be free for good, and I don't see why they would. He seems to think 2011 will bring war, at which time "you will see Kwai in uniform". With peace this fragile, building a clinic now makes even less sense. Better build capacity in a place where there is none, waiting for 2011 and its aftermath while continuing to educate students in Nairobi and hopefully soon in Juba.
And what feels better than practicing medicine? Seeing patients, prescribing medicine after a 15-minute interview, and doing surgeries is very rewarding, from what little experience I have. In Malek, another thing we did was set up a makeshift clinic with the small pharmacy of drugs we brought with us. People came in droves with health problems of every kind. It was uncontrolled madness and we definitely could have organized ourselves and our patients better. My mom and I interviewed and examined the patients with the help of translators, and Orin, Grace and John filled "prescriptions". Sush went to distribute vitamins to the women, and was apparently nearly accused of poisoning them (one of the women told him to swallow a pill himself so they'd know he wasn't trying to kill them all).
It wasn't that we didn't do any good that afternoon. I think we did. We de-parasitized, killed fungal infections, cleaned abscesses, and treated diarrhea. We tried to give clear instructions on how to take the meds, although communication is the most overlooked, most important factor in doctor-patient interactions (and is 100 times harder when you're being ambushed by mothers pushing their kiddos toward you). I can only pray that we did some good. But I am more convinced than ever now that medicine is NOT the answer for rural health, at least not in Malek.
Those kids need clean water to drink, and they need protein. Their bellies are obviously swollen with kwashiorkor. What good will pylotrip do for their ulcers without a proper diet? They need latrines, and they need sewage. They need vaccinations. They need to go to school. They need better housing to shield them from the elements, of which there are many in East Africa, home to a billion bugs and all those cool safari animals.
When we got back to Juba from Bor, we had a debriefing where the Warton team gave my mom and I their impressions of where Universal Unity should go next. They were all against building a clinic, as am I. Not because it's not needed, but because so much more, and so much more basic things, are needed more desperately. And because as a growing organization in its beginning stages, we don't have the know-how, the funds, the time commitment, or the managerial skills to make this happen. We're talking about a location where CRS, a behemoth of an aid organization with 10-year commitments to its subjects, is pulling out. What makes UU's chances better?
I'm not saying we should pull out too. Not at all. I think we should partner with Michael Lear from Real Medicine Foundation and send nurses to his nursing program at Juba Teaching Hospital. We can also help revise the curriculum and bring doctors and nurses in to help train for short periods of time (which is what we have to offer, since no one has stepped up to move to Africa permanently). I think we should refine our "Educate Refugees" project, which needs a lot of help before we take on something new (I knew this before we left for Sudan, and meeting former students in Nairobi only confirms it). In short, I think we should build capacity. In a few years, our students will be engineers and agriculturalists. We just met two high school graduates, Natalina and Mercy, who are hanging around Juba after sitting for the KCSE -- they would be perfect candidates for nursing school. In time, UU will be able to complete our promise to our students that we would help them find their way in life through education. It will be a more complete promise than simply paying their fees, and it would help us do what we've wanted to do all along: help Southern Sudan.
I'm mentioning this on the side, but the current peace agreement between the ever-warring North and South Sudan ends in 2011, at which time there will be a referendum. Kwai thinks the North will never agree to let the South be free for good, and I don't see why they would. He seems to think 2011 will bring war, at which time "you will see Kwai in uniform". With peace this fragile, building a clinic now makes even less sense. Better build capacity in a place where there is none, waiting for 2011 and its aftermath while continuing to educate students in Nairobi and hopefully soon in Juba.
Tour of Bor and assessment in Malek
The next day was our only full day in Bor, so we had to make the most of it. We started by meeting IMA's team leader in Jonglei, Dr. Makina, and the state level minister of health, whose name I honestly don't recall. Dr. Makina is an MD/MPH, and the IMA (International Medical Agency) is the most important health care player in SS right now (the Government of SS, or GOSS as the cool kids call it, is broken and broke, and a multi-donor trust fund is the only money available for public services). It was a very informative meeting, and we got a lot of historical and
current information about Jonglei, Bor and Malek. The census data is shaky at best. But they were able to outline the biggest challenges they face, and where they think opportunities for aid might lie. It was a useful meeting.
Aware of our tight schedule, we first set out with Dr. Benjamin to tour Bor Town Hospital. The hospital is a converted barracks, staggering to meet the needs of its population. The buildings are dilapidated, and a few have been abandoned due to asbestos or massive bat invasions. There are makeshift buildings, such as the surgical ward, which is literally a tent donated by MSF. Inside, the heat and stuffiness are sweltering. I was shocked that either surgeon or patient could survive an operation under such conditions, but Dr. Benjamin said nothing. As in almost all other resource poor medical settings, they do almost all operations under spinal anesthesia.
Just as the conditions of Juba Hospital made me understand the dire need for health care in the capital city of SS, so did the conditions of Bor Town Hospital. But I was also struck by the distinct recognition that these people are doing the best they can with the resources available to them. There is no funding for salaries, yet they have four midwives. Their budget is hardly worth mentioning, yet they have an x-ray machine and an ultrasound. They do antenatal care. They have a lab where they run tests, and they treat patients based on the results. They do the best they can with what they've got.
After the hospital tour, we set off for Malek, a half hour drive from Bor Town. In Malek, we surveyed a couple of potential building sites. The team favorite was hands-down the site near the Nile with the open grass field, where Deng envisions planting crops to feed the patients of our proposed clinic. We then had to introduce ourselves to the village elders, which was a drawn-out affair of seeking to understand and to be understood. From our side, Orin did an excellent job of
being gracious and diplomatic. On their side, it was helpful (if not encouraging) to hear their reservations about our promises (and whether we would fulfill them, or disappear). It was also nice to know that they acknowledge our work educating their refugee relatives in Kenya.
current information about Jonglei, Bor and Malek. The census data is shaky at best. But they were able to outline the biggest challenges they face, and where they think opportunities for aid might lie. It was a useful meeting.
Aware of our tight schedule, we first set out with Dr. Benjamin to tour Bor Town Hospital. The hospital is a converted barracks, staggering to meet the needs of its population. The buildings are dilapidated, and a few have been abandoned due to asbestos or massive bat invasions. There are makeshift buildings, such as the surgical ward, which is literally a tent donated by MSF. Inside, the heat and stuffiness are sweltering. I was shocked that either surgeon or patient could survive an operation under such conditions, but Dr. Benjamin said nothing. As in almost all other resource poor medical settings, they do almost all operations under spinal anesthesia.
Just as the conditions of Juba Hospital made me understand the dire need for health care in the capital city of SS, so did the conditions of Bor Town Hospital. But I was also struck by the distinct recognition that these people are doing the best they can with the resources available to them. There is no funding for salaries, yet they have four midwives. Their budget is hardly worth mentioning, yet they have an x-ray machine and an ultrasound. They do antenatal care. They have a lab where they run tests, and they treat patients based on the results. They do the best they can with what they've got.
After the hospital tour, we set off for Malek, a half hour drive from Bor Town. In Malek, we surveyed a couple of potential building sites. The team favorite was hands-down the site near the Nile with the open grass field, where Deng envisions planting crops to feed the patients of our proposed clinic. We then had to introduce ourselves to the village elders, which was a drawn-out affair of seeking to understand and to be understood. From our side, Orin did an excellent job of
being gracious and diplomatic. On their side, it was helpful (if not encouraging) to hear their reservations about our promises (and whether we would fulfill them, or disappear). It was also nice to know that they acknowledge our work educating their refugee relatives in Kenya.
Finally on our way to Bor
After a few eventful days in Juba, we were ready to make the 200-km, 7 hour long trip to Bor Town on May 26. However, we were told that the police commissioner would not allow travel and that the roads would be blocked. Apparently, we had the good fortune of being in town for SPLA Day. While SPLA Day (SS Independence Day) actually falls on May 16, the celebrations are staggered across cities in SS to allow the president to be present for all the festivities. I thought it was strange that the capital of SS should have its SPLA Day ten days after the real thing, but whatever.
So on May 26, we pushed back our plans to travel and decided to celebrate the national holiday by going to the festivities. We saw some lively performances by men and women, singing and dancing in circles with colorful costumes and noisemakers of every kind. Older women sang about their days as female soldiers during the wars, and others marched and danced in rows, celebrating freedom. SPLA soldiers lined the field, their guns inexplicably pointed at the crowds. It was definitely a sight to see. Afterward, we got ourselves out of the blazing sun and ate lunch at a cute British sandwich shop (Juba is a place of utter social contradiction) where we saw some of the prime missionary/aid glitterati (Lebanese, American, Anglo, Japanese, Arab, you name it). Then, we drove home to Samaritan's Purse, rested until the sun let up, and went for a gorgeous hike in the mountains with Lori. Great way to spend a national holiday, Juba or not!
The next morning, we set out for Bor. We were traveling with police escort to ensure our safety, so we had to wait six extremely frustrating hours for our entire entourage to assemble itself. We had 21 armed soldiers with us. It was a bit ridiculous.
By nightfall, we were in Bor, which is more of a shanty than a town, despite being the capital of Jonglei State. We were taken to the Freedom Hotel, where Mach and many others had suggested we stay for our short trip (two days). My mom was horrified at the thought of sleeping in tents and found the communal bathrooms and showers equally horrendous, but with Sushant and I leaning heavily toward setting up camp as soon as possible, we decided to make Freedom our new base. It was a good decision, I think, and by the second night, we hardly noticed all the bugs in our tent!
So on May 26, we pushed back our plans to travel and decided to celebrate the national holiday by going to the festivities. We saw some lively performances by men and women, singing and dancing in circles with colorful costumes and noisemakers of every kind. Older women sang about their days as female soldiers during the wars, and others marched and danced in rows, celebrating freedom. SPLA soldiers lined the field, their guns inexplicably pointed at the crowds. It was definitely a sight to see. Afterward, we got ourselves out of the blazing sun and ate lunch at a cute British sandwich shop (Juba is a place of utter social contradiction) where we saw some of the prime missionary/aid glitterati (Lebanese, American, Anglo, Japanese, Arab, you name it). Then, we drove home to Samaritan's Purse, rested until the sun let up, and went for a gorgeous hike in the mountains with Lori. Great way to spend a national holiday, Juba or not!
The next morning, we set out for Bor. We were traveling with police escort to ensure our safety, so we had to wait six extremely frustrating hours for our entire entourage to assemble itself. We had 21 armed soldiers with us. It was a bit ridiculous.
By nightfall, we were in Bor, which is more of a shanty than a town, despite being the capital of Jonglei State. We were taken to the Freedom Hotel, where Mach and many others had suggested we stay for our short trip (two days). My mom was horrified at the thought of sleeping in tents and found the communal bathrooms and showers equally horrendous, but with Sushant and I leaning heavily toward setting up camp as soon as possible, we decided to make Freedom our new base. It was a good decision, I think, and by the second night, we hardly noticed all the bugs in our tent!
Juba
Our trip started out in Nairobi, after a nice layover in London (during which time Orin, John, my mom and I visited Sushant's family's home in Kensington Gardens!). We arrived to Nairobi the night of the 20th and stayed at the AIM Guesthouse, which houses humanitarian workers for $30 a night. It's a nice place with a lived-in feel. The only complaint I have is that the culture is distinctly missionary, and I am distinctly (vehemently) not. More on that later...this post is about our trip, not my soapbox!
We spent the next day in Nairobi (Friday) getting tickets to Sudan, which cost an arm and a leg ($550 roundtrip each). We also picked up more medicines to distribute in Malek, our proposed clinic site.
The next day, we finally arrived in Juba. Our flight was delayed four hours, and we were greeted by Dr. Benjamin Malek, known to us as the only doctor in Bor Town, the capital of Jonglei State, where the vast majority of our sponsored SS students are from. (Malek, and apparently all Dinka names, are words for cattle. Malek means brown and yellow spotted bull). We were also greeted by Kwai, who we worked with extensively last year, and who was instrumental in helping us implement the sponsorship program. It was good to see them again. We were also reunited with Mach, a strong-willed student who we interviewed last year but could not support. Mach ended up being extremely helpful to us throughout the trip, at every leg of our journey, whether it was car problems, police trouble, or the endless Jonglei cow herds blocking the roads. His left hand was burned at 6
months by a bomb during the war; he was rescued by his father and operated upon to salvage his thumb. Mach is one of the most determined people I've met, and he gets things done.
Once in Juba, we settled into our new accomodations at Samaritan's Purse, another hostel for missionaries. We spent a few days meeting with key contacts in the city who gave us invaluable information. My favorite meeting was with Michael Lear, who is launching a nationwide health care capacity-building project in partnership with the UN. I and the whole team envision a great fit between our interest in training nurses and doctors, and his desire to expand health care services. I quickly realized that Juba is a city whose presence is dominated by aid workers, whether they are NGOs or UN workers. SS relies heavily on this shaky support to get anything done.
We also visited Juba Teaching Hospital, which serves the estimated population of 300,000 with shockingly few resources. It has a program that trains nurses in basic care, but my mom and I flipped through their exams, and the curriculum is not at all up to par. Some of their textbooks date back to 1937! We were shown around by Magda, a fierce and stylish aid worker who clearly has a vision for the hospital and the people it serves.
As the clinic we are envisioning would most likely resemble what in SS would be called a PHCC (primary health care clinic), we went to visit one in a place called Kator to see what it looks like. The building itself was impressive; the structure was donated by an Italian NGO. However, what the place lacked was human resources; there were only two personnel there, and the rest of the place was totally empty. It was, of course, a Sunday. But in the capital city of SS, in a country where malaria is endemic and maternal and child mortality is the highest in the world, Sunday is no excuse for an empty clinic. The doctor who was there told us he sees about 1000 cases of malaria a month, and receives only 60 treatments from the government. They expect those 60 treatments to last three months. It's a joke.
Malaria nets are also a tricky business. In the cities, it is easier to implement net use. But in the villages, many people live in cattle camps. The tribal way of life is wholly centered around cattle. It is their wealth, their religion, their ideology. They sleep near their cattle in tents of their own making, and are suspicious of people who advise them to drape strange netting over their shelter. It's not impossible to implement change, but often here in SS it seems pretty
close.
We spent the next day in Nairobi (Friday) getting tickets to Sudan, which cost an arm and a leg ($550 roundtrip each). We also picked up more medicines to distribute in Malek, our proposed clinic site.
The next day, we finally arrived in Juba. Our flight was delayed four hours, and we were greeted by Dr. Benjamin Malek, known to us as the only doctor in Bor Town, the capital of Jonglei State, where the vast majority of our sponsored SS students are from. (Malek, and apparently all Dinka names, are words for cattle. Malek means brown and yellow spotted bull). We were also greeted by Kwai, who we worked with extensively last year, and who was instrumental in helping us implement the sponsorship program. It was good to see them again. We were also reunited with Mach, a strong-willed student who we interviewed last year but could not support. Mach ended up being extremely helpful to us throughout the trip, at every leg of our journey, whether it was car problems, police trouble, or the endless Jonglei cow herds blocking the roads. His left hand was burned at 6
months by a bomb during the war; he was rescued by his father and operated upon to salvage his thumb. Mach is one of the most determined people I've met, and he gets things done.
Once in Juba, we settled into our new accomodations at Samaritan's Purse, another hostel for missionaries. We spent a few days meeting with key contacts in the city who gave us invaluable information. My favorite meeting was with Michael Lear, who is launching a nationwide health care capacity-building project in partnership with the UN. I and the whole team envision a great fit between our interest in training nurses and doctors, and his desire to expand health care services. I quickly realized that Juba is a city whose presence is dominated by aid workers, whether they are NGOs or UN workers. SS relies heavily on this shaky support to get anything done.
We also visited Juba Teaching Hospital, which serves the estimated population of 300,000 with shockingly few resources. It has a program that trains nurses in basic care, but my mom and I flipped through their exams, and the curriculum is not at all up to par. Some of their textbooks date back to 1937! We were shown around by Magda, a fierce and stylish aid worker who clearly has a vision for the hospital and the people it serves.
As the clinic we are envisioning would most likely resemble what in SS would be called a PHCC (primary health care clinic), we went to visit one in a place called Kator to see what it looks like. The building itself was impressive; the structure was donated by an Italian NGO. However, what the place lacked was human resources; there were only two personnel there, and the rest of the place was totally empty. It was, of course, a Sunday. But in the capital city of SS, in a country where malaria is endemic and maternal and child mortality is the highest in the world, Sunday is no excuse for an empty clinic. The doctor who was there told us he sees about 1000 cases of malaria a month, and receives only 60 treatments from the government. They expect those 60 treatments to last three months. It's a joke.
Malaria nets are also a tricky business. In the cities, it is easier to implement net use. But in the villages, many people live in cattle camps. The tribal way of life is wholly centered around cattle. It is their wealth, their religion, their ideology. They sleep near their cattle in tents of their own making, and are suspicious of people who advise them to drape strange netting over their shelter. It's not impossible to implement change, but often here in SS it seems pretty
close.
Universal Unity in South Sudan!
I haven't blogged for awhile, but I'm on a trip to South Sudan right now so it's a good time to resume. I just finished my second year of med school, survived the boards (I think) and have two weeks before third year starts (the advent of a professional life...sort of). Since I'll be journalling our trip periodically, and we won't have much internet access for the greater part of the trip, I'm going to lump everything together :).
This year's Universal Unity trip to East Africa is very different from previous ones. Last year, we went to Kenya and interviewed Southern Sudanese (SS) refugees living in and around Kakuma camp. It was a very good project for an NGO in its incipient stages--it allowed us to come for brief periods, to manage the program remotely when we were not in country, and to feel satisfied that we were making a difference.
This year, the NGO's leader (and my mom) had the vision of taking UU's involvement with the SS cause a step or two or a million further: she wants to build a clinic in the village of Malek, where many of our SS refugee contacts are from. Enlivened by the Lost Boys' passion for helping their people, she wanted to bring quality health care to people who have no idea what that phrase even means. Naturally, since we've never even been to Sudan, we had to travel their first to do an assessment. That is what our two-week trip now is about.
Because of our desire to do a thorough assessment before investing in what's sure to be a large-scale project, we are partnering with business students who recently graduated from Wharton. Orin, Sushant, John and Grace are a vibrant, intelligent, seasoned bunch who are well-versed in international development, logistics and strategy...all of which we at UU are lacking. It's been great so far, and we are learning a lot from each other.
This year's Universal Unity trip to East Africa is very different from previous ones. Last year, we went to Kenya and interviewed Southern Sudanese (SS) refugees living in and around Kakuma camp. It was a very good project for an NGO in its incipient stages--it allowed us to come for brief periods, to manage the program remotely when we were not in country, and to feel satisfied that we were making a difference.
This year, the NGO's leader (and my mom) had the vision of taking UU's involvement with the SS cause a step or two or a million further: she wants to build a clinic in the village of Malek, where many of our SS refugee contacts are from. Enlivened by the Lost Boys' passion for helping their people, she wanted to bring quality health care to people who have no idea what that phrase even means. Naturally, since we've never even been to Sudan, we had to travel their first to do an assessment. That is what our two-week trip now is about.
Because of our desire to do a thorough assessment before investing in what's sure to be a large-scale project, we are partnering with business students who recently graduated from Wharton. Orin, Sushant, John and Grace are a vibrant, intelligent, seasoned bunch who are well-versed in international development, logistics and strategy...all of which we at UU are lacking. It's been great so far, and we are learning a lot from each other.
Thursday, February 5, 2009
"It's the education, stupid"
I was recently reading a magazine article (it might have been Cosmo at the gym, don't judge) that cited education as one of the most important predictors of health and long life. My thoughts immediately drifted to the hundreds of Southern Sudanese kids who I communicate with daily as they plead for money to attend school. The emails are desperate, often in all capital letters with scanned documents to legitimize their requests. They address me as sister, and my mom as mum.
It's all about education.
That's exactly what I think in the very different but distantly related context of the soda wars in the highlands of Chiapas. Traipsing through the mountains for our interventional stove study last year, my classmates and I were awed to find that Pepsi and Coca-Cola were duking it out in literally every community in the mountains. It was cheaper to buy a bottle of soda than a bottle of purified water. And it wasn't just soda, but all kinds of processed foods, including chips, cookies and other diabetes-inducing goodies. Considering my personal history as a Berkeley grad, an MPH, a med student and a (closet) hippie enthusiast, it may seem surprising that what bothered me most about the whole situation was not the presence of big business in the communities, but the poverty of health education that rendered the Chiapanecos unable to make healthy choices.
Big business can bring a lot of good, but it has to be consumer-driven, and to drive consumption, consumers need information. WIthout education, how can they make healthy choices? By shielding them from the evils of a cool, crisp, wonderful bottle of Coke? Why is it that they can't handle the responsibility of junk food, and we can? I don't even want to know what inhabitants of developed countries like the US and Britain would do without carbonated beverages and convenience foods. Besides, if we protect underdeveloped communities from consumer goods that happen to bring them diabetes, what else will we deprive them of? Antibiotics that kill shigella, because they create resistance? That doesn't make much sense.
Back to the Southern Sudanese. I always thought of education as important because it allows you to buy things that you need to be healthy: a place to live, a balanced diet, clean water, soap, etc. But that isn't the only reason education is healthy. Studies show unequivocally that educated women are not only healthier themselves, but also nurture healthier families, than their uneducated counterparts. And by education I refer to more than knowledge about boiling drinking water or washing hands after using the latrine. I am talking about the sort of education that opens your eyes and your mind to different spaces, whether they are social, physical or entirely abstract.
It's obvious how important health is to a community. My dad always says if you don't have your health-physical AND mental health-you don't have anything. And if education is a great predictor of health, then it's a very worthy and economically sound goal to focus resources on improving access to and quality of education.
Obama has already signed off on long-awaited SCHIP expansion plans. That's great. In our current health system, people need insurance to get care. But I didn't have to go as far as Southern Sudan or the highlands of Chiapas to prove how desperately we need to meet a basic standard of education right now. I don't have to look much further than a 10-mile radius from my current home at UC Irvine. The quality of public education in America is appallingly poor. And in other countries, it's often a combination of poor quality, poor access, and high expense.
So while health is a vital resource for living, let's not forget about the things that lead to health. Education is one of those things, and it's an investment whose return is more profitable than we apparently realize.
Wednesday, January 14, 2009
Lobby Day 2009: CA Health Professional Students for Single-Payer Health Care
Early this week, about 500 health professional students from all over California gathered in Sacramento to urge senators and assemblymen to vote yes on Senator Sheila Kuehl's bill for universal health care, SB840 (HR676). After a day of student-led training on how to talk to legislators, we formed groups to create streamlined presentations, marched up to the Capitol for a rally, and set off to our various appointments in the Capitol building. I have lobbied before, several times, but it's always good to remind myself that as a health professional student, I have a political voice and I should make that voice heard.
The only problem is I hate politics.
My dad always says that you can't hate politics because it's ubiquitous: wherever you have two people, you have politics. I can't deny that. Yet, it is so frustrating because reason and logic are either absent or so abstract that their relation to humanity is tenuous.
Our first legislative meeting was with a Republican senator from the Riverside area. We met with his aide, who explained to us kindly and patiently that there was a Political Divide between the Republicans and Democrats on the issue of single-payer health care (in case we hadn't heard). So, if there ever came about a bill that would fix the health care financing crisis (he clearly didn't think SB 840 was a candidate), the Democrats would oppose it purely because it isn't single-payer. And likewise, the Republicans will vote against anything that overhauls our current system. They would rather just plug up the holes.
Now, what about economic efficiency? What about hypertensive patients and diabetics showing up at ER's with blindness and gangrene What about babies dying? What about ranking the lowest of industrialized nations in something so wholesome and universally important as child safety and security?
None of those points, as salient as they are, had a fighting chance in our conversation, because the truth is that they don't matter. Political realities are what matter.
Our next legislative visit was more promising, as it was with an Assemblyman who had not yet voted on the bill. We got to inform his aide that the bill was being reintroduced with Senator Mark Leno (he thought it died with Kuehl), and he listened to our arguments, showed his concern for the issue, and said he would present it to Assemblymember Dutton. He was dubious about Dutton's support for a single-payer solution, but it was the best we could hope for.
The march and rally was overall successful. It was an empowering experience. My only complaint was that a big deal was made of the fact that both Kuehl and Leno are the first openly gay Senators. There was a lot of cheering when that point was made, and it made me angry on a personal level, as well as on a professional level. I came to support SB 840 and health care justice. Insofar as that is a Democratic cause, fine, lump me with the left. But I am NOT in support of every leftist cause, and was offended to be associated with something I don't believe in. Furthermore, I think it hurts our cause as lobbyists to introduce unrelated topics. It makes us seem like nonspecific liberal/hippie protestors who are against The Man, as opposed to future health professionals serious about changing the broken system we're about to inherit.
Was the event a success? Depends on how you measure it. We got 6 more co-authors of SB 840, and educated dozens more legislators about the issues. But Lobby Day is also about empowering students to engage in the political process. A couple of classmates and I are conducting a survey to assess changes in knowledge, attitudes and skills as a result of participating in the two-day experience. Despite my criticism, I am glad I went for the impact it had on me and my future career. I will probably never become a physician-politician, but my involvement in Lobby Day has made me recognize the respect and responsibility of my professional voice.
The only problem is I hate politics.
My dad always says that you can't hate politics because it's ubiquitous: wherever you have two people, you have politics. I can't deny that. Yet, it is so frustrating because reason and logic are either absent or so abstract that their relation to humanity is tenuous.
Our first legislative meeting was with a Republican senator from the Riverside area. We met with his aide, who explained to us kindly and patiently that there was a Political Divide between the Republicans and Democrats on the issue of single-payer health care (in case we hadn't heard). So, if there ever came about a bill that would fix the health care financing crisis (he clearly didn't think SB 840 was a candidate), the Democrats would oppose it purely because it isn't single-payer. And likewise, the Republicans will vote against anything that overhauls our current system. They would rather just plug up the holes.
Now, what about economic efficiency? What about hypertensive patients and diabetics showing up at ER's with blindness and gangrene What about babies dying? What about ranking the lowest of industrialized nations in something so wholesome and universally important as child safety and security?
None of those points, as salient as they are, had a fighting chance in our conversation, because the truth is that they don't matter. Political realities are what matter.
Our next legislative visit was more promising, as it was with an Assemblyman who had not yet voted on the bill. We got to inform his aide that the bill was being reintroduced with Senator Mark Leno (he thought it died with Kuehl), and he listened to our arguments, showed his concern for the issue, and said he would present it to Assemblymember Dutton. He was dubious about Dutton's support for a single-payer solution, but it was the best we could hope for.
The march and rally was overall successful. It was an empowering experience. My only complaint was that a big deal was made of the fact that both Kuehl and Leno are the first openly gay Senators. There was a lot of cheering when that point was made, and it made me angry on a personal level, as well as on a professional level. I came to support SB 840 and health care justice. Insofar as that is a Democratic cause, fine, lump me with the left. But I am NOT in support of every leftist cause, and was offended to be associated with something I don't believe in. Furthermore, I think it hurts our cause as lobbyists to introduce unrelated topics. It makes us seem like nonspecific liberal/hippie protestors who are against The Man, as opposed to future health professionals serious about changing the broken system we're about to inherit.
Was the event a success? Depends on how you measure it. We got 6 more co-authors of SB 840, and educated dozens more legislators about the issues. But Lobby Day is also about empowering students to engage in the political process. A couple of classmates and I are conducting a survey to assess changes in knowledge, attitudes and skills as a result of participating in the two-day experience. Despite my criticism, I am glad I went for the impact it had on me and my future career. I will probably never become a physician-politician, but my involvement in Lobby Day has made me recognize the respect and responsibility of my professional voice.
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