It was 5:45 in the morning on a Monday after a full weekend of call. Thoroughly exhausted, I shuffled into the elevator and was met by the stench of stale clothing mixed with cigarette smoke. A painfully thin teenager exited, looking lost. I allowed him to wander out, grateful to be spared his odor. I was apathetic, overtaken by a weariness I vowed as a medical student never to have.
Morning rounds passed without incident. All our CABG patients were more or less stable. I collected each patient’s overnight events, vital signs, laboratory values, daily chest xray, ekg, fluid balance and wound status. With my attending’s blessings, I titrated their blood pressure drips to protect their blood vessels, kept them sedated and paralyzed if they were mechanically ventilated, fed them benzodiazepines if they were alcoholics, and added or subtracted tubes and lines as needed. Eager for a post-rounds lull, I sank into a chair in the cardiac care unit and opened my email. Because I was still around, a nurse asked me to renew some orders for electronic housekeeping. Then the pager rang with a consult, and my lull was over.
The consult was for Roy, a gentleman with a history of a recent 4-vessel CABG who needed to be on anticoagulation. He was being followed regularly at his coumadin clinic, where his INR was checked biweekly and blood thinner dose adjusted accordingly. According to the primary team, the lab called him at home and instructed him to come to the hospital immediately for an INR level of 17. On questioning him, they found that he had been taking twice the prescribed dose of coumadin.
I went to the patient’s room to do a full history and physical exam. Roy was an 78-year-old gentleman with scraggly hair and pockmarked skin. He was probably about 5 foot 7 but his stoop cut him 3 inches. The only part of his body that suggested any reserve was a small round belly. He was the kind of person I would pass on Broad Street without noticing. But just like the CABG patients I looked over so meticulously each morning in the unit, this man was once equally carefully looked after in his immediate postoperative period. Now he was back at home with a chronic pericardial effusion, failed kidneys, and an INR that could cause him to spontaneously bleed from any vessel or orifice at any moment. I asked him why he doubled up on his coumadin dose. The question made him suddenly energized, and he angrily replied that he takes all his medications twice daily, so why should coumadin be any different?
After my assessment, I called my attending and we reviewed his echocardiogram. He had a loculated pericardial effusion, stable in size over the past few months. The fluid around his heart was sticky, which meant that effective drainage would be extremely risky. We revisited him at dialysis that same afternoon to complete the consult. He was sleeping restfully in the corner, paying no attention to the whir of the dialysis machine or the Married…With Children rerun playing on his mini television.
My attending put his hand gently on Roy’s shoulder to say hello. After several nudges the patient awoke, grunting. His breathing was labored. His blood pressure and oxygen saturation were borderline acceptable—his heart could barely tolerate the fluid being drawn off. My attending knew the patient well, and other than the INR, was not fathomed by his current state. “Doc, I can’t go on like this,” Roy said. “My lady, she’s 70, she can’t keep running after me. She’s tired. I can’t put her through this. And we got a 6-year-old to get to school every morning. You gotta do something.”
In that moment, Roy was transformed in my eyes from an old man on the street to some kind of selfless hero. With all his health problems, he wasn’t thinking of himself. In his mind, he was running on empty not because the sticky fluid in his heart bag was preventing it from pumping, but because he was a burden on his family. He was sick of tiring his wife, not sick of his heart or his kidneys tiring him. In that moment, the senselessness of his coumadin overdose melted away, and he was wise and kind. Ignorant of things that I knew all about—coumadin dosing, target INR, how to correct a supratherapeutic INR, simple and loculated effusions—but far beyond me in things that matter in life's bigger picture. Nurturing relationships, fulfilling duties, making personal sacrifices, and that too in the face of extreme physical limitations—those are things I knew very little about.
Life as a doctor is selfless and selfish at the same time. You are selfless for your patients and your surgical team, but you are selfish in the face of life outside the hospital. Every effort requires a sacrifice, and by definition, the act of giving to one cause means taking away from another. The taking away is always from outside the hospital, including sleep, sunshine, recreation, and, most importantly, loved ones.
What gives me hope in the face of sacrifice is the knowledge that even when we think our hearts cannot possibly expand to encompass everyone and everything in front of us, it can. Yes, there may be fluid around it. The fluid might even be sticky, too sticky to get rid of. The heart can accept this and make room to expand.
It can make room, if we let it.
Tuesday, March 13, 2012
Sunday, January 22, 2012
In memory of Gai Anyuon
I just received an email from John Alier, the pharmacist at Malek Clinic , that Gai Anyuon, former UU student and nursing school graduate, passed away from tuberculosis. We had hired him to be the nurse at the clinic, but when he discovered he was suffering from TB he left to Kampala for treatment. We were all hoping he would eventually return in good health. He is second from the right in the above photo, which was taken in a truck lot right before he escorted all our cllnic building materials from Kampala to Sudan last May.
Like most Sudanese, Gai was reserved and quiet. But he had an inner strength in him I will likely never fully understand. We met up with Gai in Kampala after landing in Nairobi, our home base. He helped us with our shopping for building materials and participated in our endless evening meetings to discuss how the clinic would be run. He was painfully thin and frail, and had a hacking cough that in retrospect I should have considered might be TB. I thought he had pneumonia but he vehemently denied being sick. He probably desperately needed the job.
We sent frail Gai with all of our wares in a 20 ton truck on the 10 hour drive from Kampala to Malek. He didn't complain once about his health or comfort. He asked for a reasonable sum of money to eat food on the way. He went without basic needs for 2 days while the rest of us traveled far more comfortably to Sudan. He dealt with treacherous border officials, keeping the goods safe and fending off thieves and bandits. He didn't have an inch of flesh on his bones, but he never complained.
Gai was a knowledgeable nurse. I never saw him in action but through our conversations about how to provide health services to the people of Malek, it was clear that he was an intelligent clinician. He anticipated challenges that we would face and brought them up early, so that we could conquer potential roadblocks. My mom and I were definitely outside our element providing health care in a Sudanese village, so Gai's practicality was important (of course, along with Deng and John Alier, too). But again, even though Gai often brought up needs that we could not address due to the rural setting or financial constraints, he was accepting of the limitations and ready to improvise.
I don't know much about his personal life, but I know he was a husband to an "educated" wife, as he described her. I pray his family is safe and well. His quiet perseverance in the face of significant personal and professional challenges is a humbling example to me that I won't forget.
Thursday, December 1, 2011
Holding Pressure
It’s been awhile since my last writing and it will probably be awhile more before I’m in that thinking frame of mind again. But there have been so many poignant moments so far in residency that each one deserves its time to be savored. It is for me as true as ever that medicine is a labor of love for the beautiful rawness of humanity.
As the intern, lowest of the low and even more so because it’s surgery residency, for me to be in the operating room is no small feat. Even if all I’m doing is removing a catheter (the procedure takes five minutes tops), I’ll take it. The other day, we had three such cases scheduled. Having become nonchalant about these “surgeries”, I was somewhat annoyed—after you yank the catheter out, you have to hold tight pressure at the neck so the punctured vessel can clot off. For fifteen minutes. In fifteen minutes, I could complete 5 other necessary tasks! Instead, I’d be pressing on a neck in a sterile field for a total of 45 minutes. What a waste of time.
The first case was an elderly African American lady wearing a grey sweatsuit and shiny crocodile shoes. After completing all the preoperative paperwork, I positioned, cleaned and draped her neck to make sure the field was sterile, and called my attending before injecting the lidocaine and starting the dissection. The catheter came out easily. The attending left swiftly, and I was left sweating in my mask under the bright lights, holding pressure. Five minutes went by in silence. The OR nurse, Jean, asked me what dressings I wanted. They were retrieved. The patient lay quietly, patiently awaiting her reprieve. The fifteen minutes finally ended and I checked for hemostasis, placing a neat pressure dressing on her wrinkly neck. Jean and I transferred her from the table to a wheelchair while she muttered about wanting tea and pancakes. Then I ran off to complete other tasks before the next case.
The next patient was another elderly man with a heavy Caribbean accent. He was with his wife, who was sleeping next to him in the holding room. He had a good-natured disposition and a long grey beard that ended in a sharp point. I did his paperwork and interrogated him at rapid pace to make sure his blood pressure was controlled (it wasn’t), that he was not on a blood thinner (he was), and that if he was on a blood thinner that he knew why (he didn’t) and his most recent INR (ditto). I wanted to get this done as soon as possible. The attending didn’t answer my phone so I called another attending on service, who agreed to supervise. We waited ten minutes. The attending finally showed up. The case went the same, with the exception of the patient needing extra lidocaine for the pain.
When the catheter came out, I braced myself for another fifteen minutes of emptiness. I wanted to take my mask and sterile gloves off and pull my phone out for entertainment, but that would violate our sterile field. To my surprise, the patient broke the silence. “Ah, what I wouldn’t give for some fish and grits right now,” he said. My eyes, previously glued to the clock, turned to the wispy tufts of hair on his chin. I didn’t like grits at all. The OR tech laughed and chimed in, “It’s always a good time for fish and grits!” They shared a slow and hearty chuckle. “Ya, it is,” my patient said. “I got a granddaughter who live across the street. I make her fish and grits every day and she call me Papi and don’t let no one else call me that.” I asked him how he makes fish. “Well, I had one of the dialysis nurses at me house the other day. She said she never had such good fish. You got to steam it in lemon juice with some dry onion and cumin and butter. If you do it right, ain’t nothing better.” We all shook our heads, imagining a perfectly steamed fish. Our time was up and I put the dressing on. We helped Papi up from the table. “I want a hot coppa tea,” he sighed.
I signed his paperwork and walked back to the floors, back to checking boxes off my to-do list. It was a slower walk and I felt more human. I had been transported into my patient’s world for a few moments, a world that was abstract and foreign to me, but real and wonderful to him. Holding pressure was the perfect time to step into his life outside his disease, with no responsibilities other than mechanically achieving hemostasis. Hard to remember in a field where you are always under pressure, but so worth remembering.
My dad always taught me that there are many ways of seeing the same thing, and it’s up to each person to see what’s in front of them in the correct way—the correct way being the way that is most beneficial to you and everyone around you. Residency is tough: there are rude people, unfair hierarchies, rough hours and inequalities. But medicine is a privilege: we are privy to everything in a person’s life for a critical slice of time. To isolate the body and ignore the human in front of us would not only do a disservice to the patient, but cheat us of the best part of this profession: its humanity.
As the intern, lowest of the low and even more so because it’s surgery residency, for me to be in the operating room is no small feat. Even if all I’m doing is removing a catheter (the procedure takes five minutes tops), I’ll take it. The other day, we had three such cases scheduled. Having become nonchalant about these “surgeries”, I was somewhat annoyed—after you yank the catheter out, you have to hold tight pressure at the neck so the punctured vessel can clot off. For fifteen minutes. In fifteen minutes, I could complete 5 other necessary tasks! Instead, I’d be pressing on a neck in a sterile field for a total of 45 minutes. What a waste of time.
The first case was an elderly African American lady wearing a grey sweatsuit and shiny crocodile shoes. After completing all the preoperative paperwork, I positioned, cleaned and draped her neck to make sure the field was sterile, and called my attending before injecting the lidocaine and starting the dissection. The catheter came out easily. The attending left swiftly, and I was left sweating in my mask under the bright lights, holding pressure. Five minutes went by in silence. The OR nurse, Jean, asked me what dressings I wanted. They were retrieved. The patient lay quietly, patiently awaiting her reprieve. The fifteen minutes finally ended and I checked for hemostasis, placing a neat pressure dressing on her wrinkly neck. Jean and I transferred her from the table to a wheelchair while she muttered about wanting tea and pancakes. Then I ran off to complete other tasks before the next case.
The next patient was another elderly man with a heavy Caribbean accent. He was with his wife, who was sleeping next to him in the holding room. He had a good-natured disposition and a long grey beard that ended in a sharp point. I did his paperwork and interrogated him at rapid pace to make sure his blood pressure was controlled (it wasn’t), that he was not on a blood thinner (he was), and that if he was on a blood thinner that he knew why (he didn’t) and his most recent INR (ditto). I wanted to get this done as soon as possible. The attending didn’t answer my phone so I called another attending on service, who agreed to supervise. We waited ten minutes. The attending finally showed up. The case went the same, with the exception of the patient needing extra lidocaine for the pain.
When the catheter came out, I braced myself for another fifteen minutes of emptiness. I wanted to take my mask and sterile gloves off and pull my phone out for entertainment, but that would violate our sterile field. To my surprise, the patient broke the silence. “Ah, what I wouldn’t give for some fish and grits right now,” he said. My eyes, previously glued to the clock, turned to the wispy tufts of hair on his chin. I didn’t like grits at all. The OR tech laughed and chimed in, “It’s always a good time for fish and grits!” They shared a slow and hearty chuckle. “Ya, it is,” my patient said. “I got a granddaughter who live across the street. I make her fish and grits every day and she call me Papi and don’t let no one else call me that.” I asked him how he makes fish. “Well, I had one of the dialysis nurses at me house the other day. She said she never had such good fish. You got to steam it in lemon juice with some dry onion and cumin and butter. If you do it right, ain’t nothing better.” We all shook our heads, imagining a perfectly steamed fish. Our time was up and I put the dressing on. We helped Papi up from the table. “I want a hot coppa tea,” he sighed.
I signed his paperwork and walked back to the floors, back to checking boxes off my to-do list. It was a slower walk and I felt more human. I had been transported into my patient’s world for a few moments, a world that was abstract and foreign to me, but real and wonderful to him. Holding pressure was the perfect time to step into his life outside his disease, with no responsibilities other than mechanically achieving hemostasis. Hard to remember in a field where you are always under pressure, but so worth remembering.
My dad always taught me that there are many ways of seeing the same thing, and it’s up to each person to see what’s in front of them in the correct way—the correct way being the way that is most beneficial to you and everyone around you. Residency is tough: there are rude people, unfair hierarchies, rough hours and inequalities. But medicine is a privilege: we are privy to everything in a person’s life for a critical slice of time. To isolate the body and ignore the human in front of us would not only do a disservice to the patient, but cheat us of the best part of this profession: its humanity.
Sunday, October 16, 2011
Truth Unfolding
When I was a medical student, I loved surgery because it stood for truth in my mind. There was no lying or covering up or giving 50% or even what you thought was 100%. Whatever you did had to be exactly precisely accurately 110% correct.
Now I am realizing that demand on a whole new and sometimes frustrating level. As a resident, I am not just pretending to care about patients while I try to pass exams. I am actually responsible for their care. There are times when I'm the only surgeon scrubbed on a case (simple ones, of course) or the only one writing and reviewing admission orders on a patient, or seeing them on discharge when they leave the hospital. Am I giving 110%?
Surgery is truth. You can't cover up a bleeder--you have to fix it right then and there before you move on to any other step of the operation. Your sutures have to be exact--if they aren't, the fascia will dehisce and the patient will wind up at your door with a complication. Or if your skin sutures aren't good, the skin will bunch up and heal with an ugly scar--your fault. There's no hiding, there's no room for error, your mistakes are like a mirror staring back at you.
So how does one go about being perfect if there's no room for error? No one is perfect but God. I have been frustrated with this thought recently, wanting to do the very most excellent best for my patients in the OR and on the floor, but my ignorance and lack of experience make that feel nearly impossible. I haven't seen or done or practiced or been taught enough. I am reading with a renewed vigor; for the first time I truly believe that my studying pancreatic cancer will make a real difference in someone's life. I never felt that way as a student--it was much more nebulous.
The answer is always the same of course, it's just my mind that runs in circles back to the same conclusion after running the mill of my silly human emotions. The only thing to do is work as hard as I possibly can to learn whatever I can, squashing ego and laziness.
The beauty of this formula is that it's good for my soul as well as my profession.
Now I am realizing that demand on a whole new and sometimes frustrating level. As a resident, I am not just pretending to care about patients while I try to pass exams. I am actually responsible for their care. There are times when I'm the only surgeon scrubbed on a case (simple ones, of course) or the only one writing and reviewing admission orders on a patient, or seeing them on discharge when they leave the hospital. Am I giving 110%?
Surgery is truth. You can't cover up a bleeder--you have to fix it right then and there before you move on to any other step of the operation. Your sutures have to be exact--if they aren't, the fascia will dehisce and the patient will wind up at your door with a complication. Or if your skin sutures aren't good, the skin will bunch up and heal with an ugly scar--your fault. There's no hiding, there's no room for error, your mistakes are like a mirror staring back at you.
So how does one go about being perfect if there's no room for error? No one is perfect but God. I have been frustrated with this thought recently, wanting to do the very most excellent best for my patients in the OR and on the floor, but my ignorance and lack of experience make that feel nearly impossible. I haven't seen or done or practiced or been taught enough. I am reading with a renewed vigor; for the first time I truly believe that my studying pancreatic cancer will make a real difference in someone's life. I never felt that way as a student--it was much more nebulous.
The answer is always the same of course, it's just my mind that runs in circles back to the same conclusion after running the mill of my silly human emotions. The only thing to do is work as hard as I possibly can to learn whatever I can, squashing ego and laziness.
The beauty of this formula is that it's good for my soul as well as my profession.
Thursday, August 18, 2011
New Moves
Five months ago I was sitting on a couch in the dean’s office of my medical school in Irvine, California, five miles away from my favorite beach. It feels like a couple weeks ago. It was about an hour after every fourth year medical student received an email from the central body that matches students to residency positions. That Monday match email is succinct: either “congratulations. You matched.” Or “you did not match”. I received the first, my husband the latter. Hence the couch.
“Well, you matched in Philadelphia,” my dean said, looking straight at me. He probably knew it would blow me away. Worse things have happened. To me, even. Much worse. But somehow this felt really big. In that moment, I saw my gracious dad lose a few pounds of muscle, a few hairs, and another couple of inches. I saw my beautiful mother gain a few curves, muscle aches, and fine lines. I saw my sister struggle with her post-stroke husband without my help. I saw her two beautiful little boys growing up without Farah Aunty there to do the airplane and a million other little things they’ll probably never remember but mean the world to me. My world would go on without me.
Two months into residency in Philadephia, that will all probably come true. All of it except the part about my world going on without me. Initially, I focused too much on what I was leaving behind, and not enough on what I was going to. I have a wonderful marriage I’m only beginning to discover, new friends and old ones to connect with and keep in touch with, and the job of my dreams to pursue. There’s a whole new city to explore, a whole new body of homeless people to serve, so many new opportunities to be at peace with God.
More senior residents at my hospital and others are weathered and weary. I don’t know what it feels like to be a resident for several years (or even several months!) but I pray that I wake up every day feeling like I’m living the dream. I hope I always think drawing an arterial blood gas is a cool procedure, and prepare for it with similar attention (but not trepidation!) years into my career, carefully positioning the patient and examining the operative site. I hope I am soft around the edges, turn around to make sure I didn’t miss something someone said, and remember to smile. It took a long time to come to where I am, a lot of blessings strung in a long row. Philadelphia might have been a blow, initially, but in the end, I can’t help but feel that much more motivated to be the best person and surgeon I can be here—it is literally the singular reason I find myself on this side of the country. Naïve and idealistic? Sure, let that be me.
I’m on my way back home to California just 6 weeks into residency; my assigned two-week vacation happened to fall in August. My nephews will no doubt have learned all kinds of new things and I can’t wait to see them and all my family and friends. But I’m also at peace with life in Philadelphia. The geography is ancillary; the real work of life is simply to constantly seek out ways to be better. And there are many.
“Well, you matched in Philadelphia,” my dean said, looking straight at me. He probably knew it would blow me away. Worse things have happened. To me, even. Much worse. But somehow this felt really big. In that moment, I saw my gracious dad lose a few pounds of muscle, a few hairs, and another couple of inches. I saw my beautiful mother gain a few curves, muscle aches, and fine lines. I saw my sister struggle with her post-stroke husband without my help. I saw her two beautiful little boys growing up without Farah Aunty there to do the airplane and a million other little things they’ll probably never remember but mean the world to me. My world would go on without me.
Two months into residency in Philadephia, that will all probably come true. All of it except the part about my world going on without me. Initially, I focused too much on what I was leaving behind, and not enough on what I was going to. I have a wonderful marriage I’m only beginning to discover, new friends and old ones to connect with and keep in touch with, and the job of my dreams to pursue. There’s a whole new city to explore, a whole new body of homeless people to serve, so many new opportunities to be at peace with God.
More senior residents at my hospital and others are weathered and weary. I don’t know what it feels like to be a resident for several years (or even several months!) but I pray that I wake up every day feeling like I’m living the dream. I hope I always think drawing an arterial blood gas is a cool procedure, and prepare for it with similar attention (but not trepidation!) years into my career, carefully positioning the patient and examining the operative site. I hope I am soft around the edges, turn around to make sure I didn’t miss something someone said, and remember to smile. It took a long time to come to where I am, a lot of blessings strung in a long row. Philadelphia might have been a blow, initially, but in the end, I can’t help but feel that much more motivated to be the best person and surgeon I can be here—it is literally the singular reason I find myself on this side of the country. Naïve and idealistic? Sure, let that be me.
I’m on my way back home to California just 6 weeks into residency; my assigned two-week vacation happened to fall in August. My nephews will no doubt have learned all kinds of new things and I can’t wait to see them and all my family and friends. But I’m also at peace with life in Philadelphia. The geography is ancillary; the real work of life is simply to constantly seek out ways to be better. And there are many.
Tuesday, May 17, 2011
The Malek Diaries - 5/17/2011
California. :)
We're back in California, recovering from jet lag and finishing up some very important conversations with contacts in Juba. The trip was a very fulfilling experience despite the myriad challenges we faced and the many issues that are still unresolved with the clinic. To provide a service like medical care in such a needy community as Malek in a country so overrun by NGO's and international bodies is really tough. South Sudan has been in civil war for so much of the past 60 years, and has depended so heavily on outside aid for sustenance and decision-making, that the government itself is incapable of providing any essential services for its own people. To fit into a model like that is a challenge for any NGO, and even more so for a small, family-operated one like us.
Having said that, some real progress has been made. The building will God willing be complete in 30-45 days, and we have solid staff onsite to supervise and take ownership from the very beginning. The people of Malek and surrounding bomas (aka village areas) are on board. We have blessings from the county and state officials, and are in the process of partnering with the national government and other agencies that work with NGO's to ensure sustainability over time.
One of the most important things I learned in this process was how essential an exit strategy is to a project proposal. Our proposal was 15-20 pages long, depending on the version, and had many details in it. It did not, however, have an exit strategy, as Dr. Baba requested from us in his Juba office two days ago. He explained very patiently that many NGO's, including those working in Jonglei State building clinics, have failed because they want to be completely private, and run out of funding after awhile, or contact the government when they are running out of funding, by which time it is too late for the government to sustain the clinic because they have not provided for it in their budget. By this time, the community has become accustomed to receiving care, and is left with nothing. We have heard this story too many times. According to Dr. Baba, the best way to avoid this is to involve the government early on, which we are in the process of figuring out how to do. We all have one goal: to provide sustainable, high quality, affordable health care services to the people of Malek and surrounding villages.
We are nowhere near the end of this project, a fact that is intimidating but exciting. Even with government participation and ownership, our close involvement, especially in the first year of operation, will be crucial. We have many ideas, including setting up a rotation at the clinic for health care workers from home, expanding the clinic to include more services such as a maternity ward, an operating theater and more beds, and endless other possibilities. It is easy to build a building. It's keeping it going in a sustainable, functional way that's hard. God willing, we will keep learning along the way.
Thanks for reading, and thanks to my amazing mom for being the best part of the trip!
We're back in California, recovering from jet lag and finishing up some very important conversations with contacts in Juba. The trip was a very fulfilling experience despite the myriad challenges we faced and the many issues that are still unresolved with the clinic. To provide a service like medical care in such a needy community as Malek in a country so overrun by NGO's and international bodies is really tough. South Sudan has been in civil war for so much of the past 60 years, and has depended so heavily on outside aid for sustenance and decision-making, that the government itself is incapable of providing any essential services for its own people. To fit into a model like that is a challenge for any NGO, and even more so for a small, family-operated one like us.
Having said that, some real progress has been made. The building will God willing be complete in 30-45 days, and we have solid staff onsite to supervise and take ownership from the very beginning. The people of Malek and surrounding bomas (aka village areas) are on board. We have blessings from the county and state officials, and are in the process of partnering with the national government and other agencies that work with NGO's to ensure sustainability over time.
One of the most important things I learned in this process was how essential an exit strategy is to a project proposal. Our proposal was 15-20 pages long, depending on the version, and had many details in it. It did not, however, have an exit strategy, as Dr. Baba requested from us in his Juba office two days ago. He explained very patiently that many NGO's, including those working in Jonglei State building clinics, have failed because they want to be completely private, and run out of funding after awhile, or contact the government when they are running out of funding, by which time it is too late for the government to sustain the clinic because they have not provided for it in their budget. By this time, the community has become accustomed to receiving care, and is left with nothing. We have heard this story too many times. According to Dr. Baba, the best way to avoid this is to involve the government early on, which we are in the process of figuring out how to do. We all have one goal: to provide sustainable, high quality, affordable health care services to the people of Malek and surrounding villages.
We are nowhere near the end of this project, a fact that is intimidating but exciting. Even with government participation and ownership, our close involvement, especially in the first year of operation, will be crucial. We have many ideas, including setting up a rotation at the clinic for health care workers from home, expanding the clinic to include more services such as a maternity ward, an operating theater and more beds, and endless other possibilities. It is easy to build a building. It's keeping it going in a sustainable, functional way that's hard. God willing, we will keep learning along the way.
Thanks for reading, and thanks to my amazing mom for being the best part of the trip!
The Malek Diaries - 5/11/2011
Malek.
On Monday, we went to SCOM to buy the rest of the block for the dividing walls. SCOM's office is very near Malek; the company is using land formerly owned by an oil company that moved out when war broke out in 2008. SCOM is run by a group of unfriendly Maldovians producing block at $2 each and making a hefty profit.
After we got our block loaded onto a hired truck, we transported it to the clinic site and unloaded it as a community. This week, Anyuen and Alier will move to the clinic site as their living quarters are also in the process of being built.
Later in the day, Deng told us that the women in the community had some concerns they wanted to share with us. We had specifically wanted to meet with them, too, so we were excited about the opportunity. It has been difficult to meet with the community as a whole because they are at work planting maize and sorghum in preparation the rainy season. They were concerned about not having a woman employee at the clinic to confide in. There was also a traditional birth attendant at the meeting who was eager to learn more skills as she has no formal training. Their worries were real and helped us understand their needs. We are working on addressing them through a community elected female liaison and considering formal midwife training through a nurse contact we met in Bor. We assured them that primary health care can only be achieved with healthy women and children, so their active participation is crucial.
Talking about health opened other doors. One elder woman told us they are powerless in their culture--they have no say in important decisions and are beaten if they disobey the men in their families. Girls are married early in life because their marriage brings their family a dowry of 100 or so cows. Their fathers are eager to trade them for the cattle, attempting to regain what they lost in marriage (their family had to pay cows to marry the women who became their wives). If the women refuse, they can be killed by their own brother, father or uncle. A 17 year old girl was beaten to death by her father last month for deciding to marry a man with no cows. A similar story was later relayed.
The women said they confided in us because we came as two women with so much independence. It gave them hope. I asked them if they thought educating their daughters was important. They all agreed, but said school is too expensive and fathers want their daughters to marry as early as possible--after primary school if there's a suitor!
The burden of these cultural barriers is catastrophic. The only thing I can think of to lift these women up is an education for their girls. They agree. The majority of their daughters will not go to high school. They will be married/traded for cows,have a baby every year, and raise poor children who are also uneducated.
It also occurred to me that microfinance might empower the women of Malek. I asked them if any of them make anything to sell. Only one of them answered yes. But the market is so far away, several hours by foot. They have nothing to sell and no one to sell it to. I learned about microfinance in my MPH training but the sense of powerlessness of these Sudanese women made me understand their desperate need for financial independence in a much more immediate way. Microlending won't solve all the problems these women face, but maybe it will empower them, and cultural changes take time.
Today, we met with another physician at Bor Hospital, Dr Samuel, who answered a lot of our questions regarding some of the challenges of working in South Sudan and particularly in a rural area. It felt strange asking him questions like "what do you do for diarrhea?" and "what prenatal/perinatal care can be offered in a rural health care setting?" but the practice of medicine is so different here.
Next, we held a clinic for the community. It was clear that many problems were related to basic hygiene. The most heartbreaking cases were the babies with diarrhea. We did some counseling on basic hygiene, but the lack of sewage and running water make it so tough. We saw another patient with complications resulting from a combination of poor dental hygiene and dehydration (ill spare you the details). Public health interventions are definitely going to be crucial to the clinic's success.
On the way home, we shared a matatu with one of Deng's cousins Aton who works with a microfinance company in Bor. It turns out they are already lending to groups of women in Malek. Surprisingly, the default rate is high, and when the clients don't pay, the company may take the money from Aton's salary. Then she is left to fight for her money with the women.
Today was our last day as a team in Malek. It was far too short and I can't wait to be back again, God willing. Tomorrow Mom, Mayen and I will go back to Juba and meet with the Ministry of Health for registration and licensing of the clinic under our nonprofit. Then it's back to Nairobi for me and Mom, and back to Bor for Mayen.
On Monday, we went to SCOM to buy the rest of the block for the dividing walls. SCOM's office is very near Malek; the company is using land formerly owned by an oil company that moved out when war broke out in 2008. SCOM is run by a group of unfriendly Maldovians producing block at $2 each and making a hefty profit.
After we got our block loaded onto a hired truck, we transported it to the clinic site and unloaded it as a community. This week, Anyuen and Alier will move to the clinic site as their living quarters are also in the process of being built.
Later in the day, Deng told us that the women in the community had some concerns they wanted to share with us. We had specifically wanted to meet with them, too, so we were excited about the opportunity. It has been difficult to meet with the community as a whole because they are at work planting maize and sorghum in preparation the rainy season. They were concerned about not having a woman employee at the clinic to confide in. There was also a traditional birth attendant at the meeting who was eager to learn more skills as she has no formal training. Their worries were real and helped us understand their needs. We are working on addressing them through a community elected female liaison and considering formal midwife training through a nurse contact we met in Bor. We assured them that primary health care can only be achieved with healthy women and children, so their active participation is crucial.
Talking about health opened other doors. One elder woman told us they are powerless in their culture--they have no say in important decisions and are beaten if they disobey the men in their families. Girls are married early in life because their marriage brings their family a dowry of 100 or so cows. Their fathers are eager to trade them for the cattle, attempting to regain what they lost in marriage (their family had to pay cows to marry the women who became their wives). If the women refuse, they can be killed by their own brother, father or uncle. A 17 year old girl was beaten to death by her father last month for deciding to marry a man with no cows. A similar story was later relayed.
The women said they confided in us because we came as two women with so much independence. It gave them hope. I asked them if they thought educating their daughters was important. They all agreed, but said school is too expensive and fathers want their daughters to marry as early as possible--after primary school if there's a suitor!
The burden of these cultural barriers is catastrophic. The only thing I can think of to lift these women up is an education for their girls. They agree. The majority of their daughters will not go to high school. They will be married/traded for cows,have a baby every year, and raise poor children who are also uneducated.
It also occurred to me that microfinance might empower the women of Malek. I asked them if any of them make anything to sell. Only one of them answered yes. But the market is so far away, several hours by foot. They have nothing to sell and no one to sell it to. I learned about microfinance in my MPH training but the sense of powerlessness of these Sudanese women made me understand their desperate need for financial independence in a much more immediate way. Microlending won't solve all the problems these women face, but maybe it will empower them, and cultural changes take time.
Today, we met with another physician at Bor Hospital, Dr Samuel, who answered a lot of our questions regarding some of the challenges of working in South Sudan and particularly in a rural area. It felt strange asking him questions like "what do you do for diarrhea?" and "what prenatal/perinatal care can be offered in a rural health care setting?" but the practice of medicine is so different here.
Next, we held a clinic for the community. It was clear that many problems were related to basic hygiene. The most heartbreaking cases were the babies with diarrhea. We did some counseling on basic hygiene, but the lack of sewage and running water make it so tough. We saw another patient with complications resulting from a combination of poor dental hygiene and dehydration (ill spare you the details). Public health interventions are definitely going to be crucial to the clinic's success.
On the way home, we shared a matatu with one of Deng's cousins Aton who works with a microfinance company in Bor. It turns out they are already lending to groups of women in Malek. Surprisingly, the default rate is high, and when the clients don't pay, the company may take the money from Aton's salary. Then she is left to fight for her money with the women.
Today was our last day as a team in Malek. It was far too short and I can't wait to be back again, God willing. Tomorrow Mom, Mayen and I will go back to Juba and meet with the Ministry of Health for registration and licensing of the clinic under our nonprofit. Then it's back to Nairobi for me and Mom, and back to Bor for Mayen.
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