24 April 2010

Friends,

I'm sorry I've taken so long to write again. In the last few weeks, I've learned that living at the equator is physically exhausting, and I'm often too tired at the end of the day to write. The metabolic demand is higher, the nutritional quality of the food poorer, the economic availability of food crappier. It's hard even to keep up with my fluid balance, since I sweat so much everyday and getting clean water is a mild rigamarole. And I am a person of relative means. It is remarkable that people continue to exist here under conditions of poverty.

Which is not to say I haven't had a good couple of weeks. My first full week here was about adjusting physically to a new place and lifestyle (and temperature). I learned how the cell phones work (pre-paid cards, pretty good coverage, shitty battery life in my case); how to hail a motorcycle (“You riding?”); and that the best thing to eat is beans in bread from the lady who sells them outside the hospital and homemade guacamole.

My second full week has been about starting to get to know the people in the organization. I've met Philip, a patient in the HIV accompanier program who was resurrected from near death, social isolation, and suicidality from AIDS, when given HIV medicines, and is now Tiyatien's livelihoods officer. He is employed by the organization to counsel other patients on how to improve their social conditions and means. He is a visionary: with his new lease on life, he started a support group for people living with HIV/AIDS and a farm for them to work on because he believes that they must have a way to support themselves. I've met Agatha, a tall, part-Malian woman who is starting a center for local women where they can come and meet and learn the skills they want to learn. She has the land picked out already. And I've met Alphonso, who works nights as a nurse aide in the hospital and days running the accompanier program for Tiyatien. He supports eight family members, yet has an incredibly sweet and optimistic disposition. I'm not sure I would be so optimistic myself were I working under such demands. I've been interviewing some of these people for TH's website, and hopefully I'll be able to get those interviews online, whether in audio or transcribed format, soon. They'll give you a taste of Liberian English, which at first I had a hard time understanding, but now seem to have an ear for, at least some of the time.

It's been an eventful couple of weeks, too. Two Mondays ago, soon after I last wrote to you, the entire non-physician hospital staff went on strike. The physician assistants, nurses, nurse aides, pharmacists, cooks, security guards, housekeepers, everyone. So the doctors, Kerry and four others, went to the hospital, discharged the patients who could be discharged, and ran the rest of the show themselves, to preserve patient care. From placing IVs, to finding and dispensing medications, to taking vitals, and nearly to cleaning up vomit in the hallway. Not to say that they, and we, didn't sympathize with and support the strike. We did entirely. One of the docs sometimes works for months without receiving pay because he's on government payroll, and he served as a negotiator for the striking staff. An unreliable paycheck is one of the main issues underlying the state of the healthcare system here, and the strike helped get the government in Monrovia to pay (some) attention.

Hospital strikes here are unusual. Raj says he's never seen one in the 4 years he's been coming to Zwedru, although they came close to striking a few years ago. Their demands were pretty straightforward: they wanted year-long contracts and to be paid and paid on time. Currently, they work without a contract, which means they have no job security and no proof of the terms of their employment. Many have gone many months, even up to a year, without receiving pay, which is kind of mind-boggling. One of the nurses explained to me that almost all the professional staff are very young, recently out of school, and from Monrovia (remember, a 10-12 hour bumpy drive away), because they are the only ones who have the flexibility to be able to work under these conditions, so far from home. It seems like the staff don't get paid largely because the Ministry of Health bureaucracy is slow and corrupt, and because Zwedru is so far from the capital that decision-makers never feel the impact of their work (or lack thereof).

The strike was very well organized and peaceful. The workers all showed up to work on Monday morning, stayed for an hour, and then left. Tuesday, they all came to the hospital, but had meetings under a tree outside all day. Eventually they concluded to go back to work on Wednesday, and reassess the situation after two weeks. Kerry invited one of us medical students up to the hospital to help out with patient care while the staff was out, so I went up to take vitals, which is a simple but necessary part of patient care, especially here, where vitals provide nearly half of the quantitative data that clinicians use to practice medicine. Vital signs are the body's most basic properties: temperature, pulse, respiratory rate, blood pressure, and oxygen saturation in blood. They are, well, vital. Here, I couldn't measure oxygen saturation because the hospital only has one machine, reserved for the operating room. In addition to vitals, they can spin down a hematocrit, or red blood cell count, do a blood smear looking for malaria, order a Widal test, which helps assess typhoid, and I think that's about it. We can't even order a basic metabolic panel here, i.e. levels of fundamental electrolytes like sodium, potassium, and chloride, to assess how a patient is doing. Raj said they used to be able to order these tests, and a few other basics, like liver function tests, a few years ago, but the machine broke, so they can't anymore. And no, there's no CD4 counter, so HIV patients are assessed clinically, by the WHO's standards, which is a pretty rough guide for care. In the US, these tests are, again, basic. We don't think twice about ordering them, and in fact have such a huge amount of hard data available to us that it can be overwhelming to sort through as a medical student.

One of the patients I saw had been in a motorbike crash the previous night and his face was swollen and cut up. We also don't have an x-ray machine here or an xray technician, so when I asked one of the docs how they assess for fracture without one, he replied, “physical exam.” Which translates to, “press on his face to feel if anything moves.” In the US, trauma patients like this are given lots of head imaging, e.g. xrays to look at bony deformities and CT to look for brain injury. The finest of fractures is noted in the radiology report, even if nothing needs to be done about it.

Later in the day, I was invited to watch a Caesarian section. Unfortunately, I didn't know much about the patient's case before I went into the operating room, but I think she had had prolonged and obstructed labor. In the US in this situation, the fetal heart rate is monitored to track how distressed the baby is, and that helps determine what needs to be done. Here (I was noticing a pattern), they don't have this equipment, and instead use a fetoscope, an instrument that I thought only existed in museums and old paintings. It is a trumpet-shaped tube that you put to a pregnant woman's belly and to your ear to hear the fetal heart beat. I didn't get a chance to use it, so I can't say how well it works, but just as comparison, the equipment I was trained with is a handheld doppler ultrasound. A quick search on Ebay showed that the machine costs $40 to $150: http://stores.ebay.com/MWM-Medical

Anyway, the OT, as the operating theatre is called, is the only room in the hospital with air conditioning, though it didn't work too well. I changed into scrubs, stepped in, and watched the surgeon and scrub nurse pull an infant out of the patient's belly. The baby came out with low APGAR scores, i.e. limp muscle tone, no cry, poor color, no grimace to stimulation. She looked terrible. I watched the nurse and the nurse anesthetist try and fail to resuscitate the baby. She died as her mother was sewn up. I'm not even sure if she ever lived.

I tried to normalize it. You see a lot of sad and terrible things in any hospital, and part of the experience involves accepting it and moving onto focus on the next patient. But in reflecting, I realized that I had never seen a baby die in my six weeks of obstetrics in the US, except one who had mysteriously died while still in utero at full term and had to be delivered dead. I couldn't take this one c-section as representative of anything, but it reminded me that childbirth is still a life-threatening experience-—for mom and baby-—in a lot of the world.

Most of my time here has actually not been in the hospital. I've been helping out with various things, including trotting along with the accompaniers for the past few days. We've been going out to find the depression patients who haven't come back to clinic in a while, ask them what's been keeping them, and encourage them to come back or go to one of the support groups. It's been great to get to know some of the accompaniers, who do the day to day work of TH. They are patient and empathetic and work hard in this hot hot sun. And they seem to know everyone in town while still maintaining confidentiality.

I'm half-thinking about writing a book called, “Hot, Dusty, Sweaty, and Thirsty,” where I live the life of a community health worker for a year to document its hardships, in the style of Barbara Ehrenreich. Ehrenreich wrote a booked called “Nickled and Dimed,” in which she spent a year pretending to be working class and writing about it, and she argued that working Americans are working really hard and being screwed despite their efforts. I wouldn't actually do it because I find the gimmick fundamentally kind of offensive (she could have just asked a bunch of working people what they thought), but it might have brought some attention to the plight of community health workers. As I alluded to in my last post about the Pool Fund, there's a big ideological divide in the international health community about whether these workers should be called workers (CHW's) or volunteers (CHV's), i.e. whether they should be paid. It is ludicrous that this question even arises, especially since their work is, as Raj terms it, “truly heroic.” Heroism aside though, people should be paid when they work, especially when they are hot, dusty, sweaty, and thirsty, and when their jobs require them to be kind to sick people in addition. It's not rocket science, and I'm sure most policy-making doctorates would go home the day their paychecks stopped. The sad thing is that paying CHW's would be so cheap here. It's $1600 a month (total!) to pay 40 people for part-time work at the national minimum wage. You could even double their salaries, pay them well for skilled and valuable work, and still it would be peanuts.

One of the other things I've been doing is helping with computers. I installed my anti-virus software on the county health information officer's computers a few days ago. I found 8000 infected files on one computer; it was pretty satisfying to clean that out. Just as there's a disproportionately high burden of infectious disease in people here, there is also a disproportionately high burden of infections in computers here. The other med students and I have also been teaching basic computer skills to the Liberians a few times a week. There's a big old digital divide. Teaching is feel-good here, since even the smallest computer-related thing is new information and ever-so-much appreciated.

Okay, I'm pooped. The fruit update is that I've made my tastes known to the neighborhood, and kids come by now with plums and occasionally po-po to buy. There's 4 kinds of plums here, but I've only tasted one so far. It's sweet and makes me happy.

Good night from under the mosquito net, safe from equatorial insects,
Roona