Monday, April 30, 2012

Ethics


Today I saw my first live C-section. I don’t ever want one. Ever.

Before I launch into the details, I need to take a moment to flesh out some of thoughts I have on ethical dilemmas one can encounter when working in developing countries. The truth of the matter is, you have many more opportunities for research, medicine etc. in developing countries, but just because you have the opportunity does not mean you should seize it. Just because you’re in a country where patient rights are not as salient does not mean you should breach them.

When I was in Haiti I had the chance to see a vaginal birth, and it was one of the most amazing experiences I’ve ever been a part of. But, it raised a lot of questions for me. The Haitian midwives knew I wanted to see a birth, but they didn’t call me until the woman was 10 cm and ready to push, probably thinking that I wouldn’t want to wait hours and hours in the birthing room. However, that meant I first entered the room when the woman was clearly distressed and not in a place to consent to me being there. I asked her if it was okay if I was present for the birth, but I was uneasy about the situation under which this “consent” occurred. Moreover, I was completely uncomfortable just sitting and watching. It felt voyeuristic, impersonal, and just plain wrong. As the pushing became more intense I got up to help hold the woman’s legs. By doing so, I was part of the birthing team. I helped encourage the mom to breath or push in my pseudo-Creole. At one moment I took my hand off of her foot and she screamed at me to put it back so she could have something to push against. Suddenly I felt like this birth was personal. I was invested in her and her baby. With each surge of contraction I became more and more connected to her. When it was all over she thanked me for helping her, and I thanked her for letting me be a part of the birth. I wanted to hold her little one so badly, but she hadn’t held him yet and I did not want to be the first person in this world to do so.

Here I’ve also had some ethical questions arise in relation to my research. First of all, I chose to ask older adolescents about sexual behavior retrospectively because of the sensitive nature of the topic. Anecdotally I’ve heard plenty of stories of 13 and 14 year olds giving birth here, but just because they’re mothers does not mean they are emotionally or mentally mature enough to consent to research. Second of all, several people have asked me why I am doing this research in a school setting. Why don’t you ask the village women? They are more likely to have children younger because they’re not in school. I chose a school setting for two principal reasons: 1.) Research points to the fact that school-based interventions are efficacious when implemented correctly 2.) I need a venue through which I can act on the research. I’m not going to do research for research sake. I’m not going to ask village woman about their sexual behaviors if I can’t do anything tangible to help their situation, or attempt to help their situation. Coming up with an intervention for women in the village is an endeavor that is bigger than me, and I’m not going to do something if I can’t do it well or if it won’t carry any potential benefits for the participants. Sometimes you have to know your limits.

And so now we arrive at the c-section. I’ve become close with two of the surgeons here. One is a Gabonese guy doing his residency in surgery here. He’s in his early thirties and he lovingly refers to us fellows as “les jeunes” (the young ones), even though one of the fellows is also 30. The second is a young Swiss doctor who is here for about two months and is training to be an OBGyn. One night at dinner, surrounding by two other doctors, I asked if they thought it would be okay if I observed a c-section. All of the doctors responded: “not a problem, we’ll call you the next time we have one.”

Again I though to myself: just because this is so easy to do, should I really do it? I have no idea what sort of hoops I’d have to jump through in the states in order to observe surgery, but I imagine there would be quite a few. And there was no possibility for me to help in this case; I would literally just be a fly on the wall.

In the end I decided to do it. I can’t say I have a good reason other than curiosity and the fact that one day I may find myself in the position where I need a cesarean and TLC “A Baby Story” is rather poor preparation. This is admittedly selfish, but I decided that if the surgeons didn’t find my presence objectionable, it was okay to be there.

The woman initially needed a c-section because they baby was transverse. The baby did end up moving but the midwife saw meconium (a.k.a the baby was in distress) so they needed to get her out ASAP. The mom was wheeled into the operating room and visibly distressed herself. It was her third baby, but first c-section. She opted for general anesthesia because she was so nervous. I’m sure if I were in her position I would be terrified, but it’s equally bizarre to wake up and have missed the birth of your child and suddenly have sutures in you. I would have stayed awake.

The baby was out in about four minutes, though it felt longer than that. It was so strange how they place the blue sterile draping around everything but the belly, as if it were totally disconnected from the human body on the table. I watched them cut through layers and layers and finally the baby! She was actually in a breech position at that point. The midwives and pediatrician took the baby to the other room and thankfully she was just fine. I watched the surgeons close up, which took about half an hour. The layers upon layers they have to suture….oh my. The uterus was basically out of the body cavity and it needed two rounds of sutures. This is an awkward comparison, but it was so large and round it looked like a Thanksgiving turkey. The final layer of skin was stitched from the inside so you could barely see a thing, but man was it hiding a mess of stitches underneath.

In the end I’m glad I was there. Thankfully it was a “normal” cesarean without complications, but it was far from the joyous, invigorating experience I had in Haiti. This was surgery, plain and simple. I have a feeling this is just the beginning of processing this situation.

Sunday, April 22, 2012

PMI en Brousse

Two times a week the PMI nurses do mobile clinics in various villages (I’ve gone with them a couple times now), and this past Thursday we went to Bellevue, which is only accessible by boat. It was a little over an hour along the Ogooue (I have a nasty sunburn to prove it). There were only around 7 moms/babies there because a lot of families leave during the rainy season. When we got there we walked around the village to announce our arrival. When we go to villages by car, we drive up and down the main road honking the horn so people know we’ve arrived. Once we rounded people up we got to work weighing babies…..except we realized we forgot the harness things to put the babies in for weighing. After brainstorming for alternatives we decided on scarves (see pictures below). The pink one is my scarf. I asked the mamans to leave the babies’ diapers on for weighing (normally the kids totally strip down).

After weighing we did the requisite education/awareness part, and for the first time the women verbalized the doubts I’ve had all along about this education/awareness bit. The topic depends on who is leading that day: sometimes it’s focused solely around HIV/AIDS, but when the Majeure (head nurse) leads, she talks about everything from breastfeeding to safe sex. Normally it ends up being lecture style. People rarely make comments or ask questions, but every once in a while we’re able to solicit a response. On this particular day when the Majeure started talking about needing to use condoms (we pass them out at PMI) because of all the different partners people have, one woman had a total backlash. She stood up in the middle of the talk, slung her baby around her back and tied the fabric around as if she were about to leave, and paced back and forth saying things like “it’s no use giving me condoms, my husband won’t use them. He comes back from the city where he’s been with other women but if I give him a condom he’ll say I don’t have to use that with you, you’re my wife. He’ll hit me if I try to push it. It’s not me who sleeps around so don’t tell me about this stuff.”

Every time we do these talks I wonder about this specific issue, and finally someone said it. I have only ever seen one man at PMI, and I think he was the older brother of the infant. And so these women come and we tell them about things that really do pertain specifically to them in this context, things like breastfeeding, malaria, infant malnutrition etc, but we also tell them about things like HIV and STIs which aren’t necessarily in their control. After this eruption the Majeure suggested telling the husbands things like “look at the children we already have, the ones we can’t even feed. We can’t afford another one. We can’t bring another child into this world that we can’t provide for.” That might work, or it might not. It’s also only on the individual level. Seems to me like we could direct our efforts elsewhere, or at least equally with both groups.







Boat ride to Bellvue.


How to collect palm wine

Baby elephant skull. Can you imagine chasing this guy out of your garden?

The village

Mamans headed to clinic, and a picture of how babies are carried.

Skeptical....

Weighing a one week-old in a scarf.

For those who couldn't fit in a scarf, we had them hang onto the scale.

New pants!

Thursday, April 19, 2012

Fish Out of Water

It is just a fact of life here that I frequently find myself in situations where I am incredibly far out of my comfort zone. I have traveled so far out of that zone that I cannot even see the boundaries. Somewhere during my flight from France to Gabon it was totally lost. The other day I found myself having to explain the word “awkward” to my Swiss friend here because I use it so frequently.


And so I tell you this story in the hopes that you learn something from my awkwardness. The moral of the story: be specific.


I presented school officials with a rudimentary proposal for my research last week, and today was to be the “class observation” day. (Actually, Tuesday was to be the first observation day, but Gabon up and decided to have a “Gabonese Women’s Day” this year on April 17. Most people, like myself, were unaware such a thing was occurring until 10 pm the night before, even though this is important information because it’s a national holiday and therefore not a workday. I showed up at the school anyway in the off chance classes were going on but of course they were not.) So Wednesday was the first class observation day. Remember this: class observation. The following are excerpts from my “field research” at the school.


7:30 AM—lead to 5e classroom. Censeur gives brief introduction to class just saying I am a “Schweitzer fellow” and I’m here observing. Another man comes into classroom and Censeur says something about him observing class as well. I assume this is like what happens in the states when teachers evaluate other teachers.

7:35-7:55 AM—observations of materials, resources, physical state of classroom and surroundings, student interaction etc.

8:00 AM—look at watch and realize teacher still isn’t here. Class started a half hour ago! Notes about how time isn’t used effectively and kids are clearly bored while they wait. Some are doing work, others talk, others sleep/rest. Do teachers normally just not show up?

8:20 AM—bell rings and man and I leave classroom and walk to 4e where I am scheduled next. He asks me about myself along the way and I explain the project. When we arrive at 4e classroom he explains to class that I am “from Schweitzer and is doing very important research here.” So much for being subtle.

8:22 AM—I am so uncomfortable. This is a much smaller classroom and the kids are a lot older. I am sitting in the front of the room and have about 40 pairs of eyes staring at me. Lots of note passing and giggling.

8:30 AM—no teacher here either? What the heck is going on?

8:35 AM---that would be so bizarre if he thought I just wanted to observe students and not a class in session. That doesn’t make any sense though; he couldn’t possibly have thought that’s what I meant.

8:45 AM—oh my good Lord. That’s exactly what he thought I meant.

9:10 AM—bell rings and we go to next classroom where man now tells class “she is a fellow from Schweitzer doing important work here and she needs absolute silence! No funny business!” Get me out of here. This is all wrong.


I walked out of the third classroom, after 3 wasted hours of confusion and discomfort, and was utterly baffled. This was not a language barrier issue; this was just plain misunderstanding, cultural or otherwise. It is still so bizarre for me to think that they honestly thought I just wanted to stare at students, as if Gabonese students are that far out of the realm of understanding. Well I tell you what, I saw the same adolescent antics: note passing, flirting, intentional distracting, fabricated ailments and trips to the nurse, etc.


Maybe one of these days maybe I’ll recount this story to a classroom full of eager public health students and laugh, but I’m still stuck on bewilderment and embarrassment. This is it folks: the good, the bad, and the awkward. Back to the drawing board.

Wednesday, April 11, 2012

Le Projet (the project)

So you’re probably wondering what I’m actually doing with my days, besides terrifying unsuspecting toddlers. I’ve been putting off describing my project in detail because it changed so frequently in the first two weeks that I wanted to have a cohesive plan before attempting to describe it. However, in the middle of my third week here, I’m (fairly) certain I have a solid plan, and even better, I’m starting to make moves so that it comes to fruition.


First of all, I came here wanting to focus on sexual and reproductive health, as that is my main public health interest, and if I may be so bold, specialty. Luckily, the medical director was interested in exploring sexual and reproductive health as it pertains to adolescents (teen pregnancy is very common here, and I believe that’s what drove him to want this researched in depth). In the grand scheme of things I answer to the medical director; however, the truth of the matter is I am very much on my own here. I meet with him once a week to update him on my activities and progress, but other than that this is completely self-directed. Every morning I wake up and make a to-do list and diligently go about crossing things off until I’m satisfied I’ve contributed and completed a full-day’s work. It requires a delicate balance between being proactive and patient: I’m not the only one with things to do around here, and I frequently find myself waiting for meetings, responses, etc. The other public health fellow and I lovingly refer to this as “hurry up and wait.” I make sure I’m prepared, but I can’t physically make things go any faster.


So, the plan. I will be conducting (hopefully) two needs assessments of adolescent sexual and reproductive health (SRH), with the goal that this information will contribute to a comprehensive SRH curriculum (that I will create before I leave). The first one will be a needs assessment focused on a local high school, and preparation/partnership is well under way for this one. I’ve met with the Directrice and Censeur (head master of sorts) twice already and they are definitely on board. The second one will be focused on the hospital, which will take more finesse and politics (not necessarily the best PR move to come in as a foreigner and assess how the hospital is treating/responding to adolescents’ needs). However, I sincerely hope I can accomplish both because you have to work both sides of the system. You can’t arm adolescents with the tools and knowledge they need to take care of themselves and then not have anyone on the receiving end to help them out.


So what does this all mean in English? For approximately the next month I will be gathering data via surveys, focus groups, interviews, hospital/school records etc. to determine adolescents’ behavior, knowledge, and attitudes surrounding sexual health. With this information I will write a curriculum for the school that addresses these issues. Ideally, I will also gather data at the hospital level to determine how well equipped the hospital is to address adolescent SRH.


Now that you know the plan, get excited for all the hiccups that are bound to occur along the way!

Tuesday, April 10, 2012

La Paque au Gabon (Easter in Gabon)

While I didn't have an Easter egg/basket hunt this year, I managed to have a pretty eventful Sunday. As are most things here, Church was quite an adventure.

I left the house around 9:30 to get a taxi and found a mess of people waiting. Now, I'm not exactly proficient (yet) in the taxi rush and haggle business. Basically, when a taxi pulls up everyone runs to it and yells where they want to go and then the driver either agrees or does not agree to take you there. The taxis are shared, so the driver will take whichever combination of people get in as long as they're going to the same place. After several failed attempts (no one wanted to take me to church) I resolved to walk.....about 45 minutes.

As a result I showed up to church incredibly late, but I think the big guy will give me a bit of a pass for this one. Plus, mass is 2 hours so by the time I got there they were starting the things that normally occur in the hour-long mass. However, there was a wooden plank of sorts acting as a barrier to the entry way. I stood outside for a couple minutes, then decided there was plenty of standing room so why not go in? As I duck under the barrier this old lady pops out of the shadows and snarls "you see that barrier? it's the same as in France. When there is a barrier at the church entrance you do not cross it!!!" To which I responded: "mam, I'm not French." She didn't think this was funny and shooed me out. Well, I did NOT just walk 45 minutes in the African sun for Easter mass to give up that easily. I stood my ground outside, and finally when everyone got up she let me in. Not only did she let me in, but she lead me to a seat next to the only other White people in the place.

Side note for all the Catholics reading this: yes the responses/prayers have been changed even in French. We also say "and with your spirit," and it's still weird. Also, for peace you grab both hands at the same time, and then some people bring their hands to their chest afterward. To me that looks more like "peace be with me," but I'm probably missing out on something.

I wish I could have taken a video of everyone singing! It was such a beautiful, celebratory occasion. When I was little, the priest at my church once chastised the congregation for clapping after the choir performed. He would have had a coronary at this place. The singing, dancing, clapping...it was all so much fun!

I did manage to get a taxi back home. The rest of the day was spent attempting hand-washing laundry for the first time (another fail. It smelled moldy. I had to rewash everything), going to the market to get homemade peanut butter that tastes smokey for some reason, and eating a fried food feast my roommate made. Weirdest Easter I've ever had.

Monday, April 2, 2012

HAS

Views of HAS:






























Next to the cemetery there is a little menagerie with two enormous pelicans and deer of some kind. I have no idea why.....
















The former hospital:















View of the Ogooue/old hospital and of the Albert Schweitzer Museum:

















Picture of traditional Gabonese boats called piroques. Some village are only accessible via boat.















Refectoire (outside and inside):

















The main outpatient center called the Polyclinique.















Different views of my house.













First Weekend

Friday night I skipped dinner at the réfectoire and headed to a bar along the Oogue with my roommate and one of the Dutch researchers to sip coca cola and see the view. At home I only drink pop medicinally, but I tell you, the Coke here is mighty fine. It is REAL sugar so it has a delightful syrupiness to it. The Coke at home is all fizz and no flavor! Anyway, so there we are enjoying our Cokes on the porch of Carpe Diem when a storm hits. It rains probably every other day here, but this was my first serious Gabonese storm. And we were stuck on a detached porch. It was SO LOUD because the roofs are metal slabs, and the lighting was terrifying! Fortunately, there doesn’t appear to be much thunder involved so at least I’m not cowering in the corner.


After we made it back home completely soaked, we changed clothes and headed to another bar right outside the main entrance to the hospital. One of the midwives and one of the German researchers were celebrating a joint birthday and there was quite a feast! Honestly though, I’m wary of food here in general. None of my roommates have had issues with the food at réfectoire, but those who have eaten at restaurants etc. have encountered some…..problems. So I only chose things that were completely cooked and stayed away from all the rest. Also, in Gabon when there is a party like this with a buffet of food, the women always go first and the men sit and gloat and tell them to hurry up. I think I shall instate this next Christmas J. I did get to meet a lot of people, mostly researchers, which was really nice. HAS is definitely an international community and everyone here is doing something different so the conversation is always interesting.


Saturday was rather uneventful as I was incredibly tired (the heat here just completely immobilizes you at times), but I did read for a while in my hammock on the porch!


Sunday was my first trip to the market. I went to the “larger” market called Matériaux, but it really isn’t that big. The first stop was the fancy/expensive grocery store called Cecado. There you can buy such luxuries as Nutella and Oreos, but actually the store is sort of empty, at least by American standards. I once worked at a fancy grocery store that literally had an entire wall devoted to yogurt. Let’s just say you won’t find that in Gabon.


After Cecado we ventured into the actual market area where you have your typical food vendors/stalls. There is quite a variety of vegetables and grains, but fruit (besides plantains/bananas) is sort of hard to come by. Women also make/sell their own peanut butter, but again I was a little nervous to try it. We also stopped by the tailor and I picked out some fabric for a skirt and pants! Allegedly it will be ready next weekend, but we’ll see about that.


The réfectoire doesn’t serve dinner on Sunday, so one of my roommates treated us to a delicious traditional Haitian meal! Certainly the best food I’ve had in Gabon. We invited two of the doctors over for dinner and they stayed and chatted for hours. Dinner is definitely my favorite meal here because of the conversation. We typically have dinner with one of the Pediatricians (Gabonese), an Internist (French) who is here doing research, and a Gabonese guy who is finishing up his residency. Last night we covered everything from infectious disease and the Ebola outbreak in Libreville in the early 2000s to the Black community’s historical distrust of American medicine. Just a typical Sunday evening at HAS.

Au Travail

I spent my Friday morning/afternoon helping the ladies at the PMI (Protection Maternelle-Infantile). To be honest when I showed up I wasn’t entirely sure what I’d be doing. At first I sat off to the side in order to observe, but I was quickly called over to help take infant/toddler measurements. Here’s how it works: the Minister of Health gives out little “carnets” (notebooks), which are essentially the patient’s medical record. The mamans bring the babies’ carnets and put them in an enormous pile and you just go through one bye one calling out names and weighing/measuring the babies. After measurements there is a group education session, a little cornmeal porridge snack for the 4 months+ babies, and vaccinations. The scale for infants is your standard tabletop scale and you just lay the baby in it and take cranial, thoracic, and height measurements. For the toddlers however, there is a scale hung from the door and then you put the little one in a sling and hang them on the scale like a little monkey. It’s pretty adorable/terrifying because I kept thinking they would fall out!


A quick note on linguistics:

First of all, having to call out names I am most certainly mispronouncing in front of an enormous crowd is not exactly a dream of mine. There was many an awkward silence after I would say a name because people clearly had NO idea what I was saying. A lot of names start with Nd or Nb or something along those lines and those sounds are so unfamiliar to an English speaker. Added to this is the confusion over first and last name, or name and family name. Basically, just a lot of opportunity to mess up. At the same time, it takes a lot longer to introduce myself to people here, whether I’m meeting an African or a European. When I studied abroad in Paris I always introduced myself as “Moe-li” because that’s how a French speaker would say it. To be honest though, I detest that pronunciation. So this time I attempted to introduce myself the way I and other Americans (particularly from the Midwest) say my name: “Ma-li.” This could not have proved more confusing for people. Nearly everyone thinks I’m saying Marley! It’s actually kind of fascinating because I have no idea where they are getting this phantom “r” from! Then I say no “Ma-Li” like the country and it normally works out.


But back to the PMI…..the day was really great because I learned a lot both by observation and from hands on work. It really was a very organized and well-coordinated system. I’m hoping this is just the first of many PMI days! I also plan to do some health promotion projects with them, but I need to see how it all operates first. I can’t go adding projects until I experience their current workload first hand.

Thankfully most of the babies were very happy and healthy little ones, but there were a handful of malnourished babies that appeared to be mostly with teen moms. I’m thinking of doing a breastfeeding/infant nutrition project because there are a lot of misconceptions about formula feeding (a lot of moms over-dilute so it’s basically just water) and I’m not sure clinically how much support women have for breastfeeding (i.e. do midwives/doctors explain the mechanics of breastfeeding and what to do when problems occur?). However, culturally there is definitely support for breastfeeding. In the states people cringe when a mom breastfeeds in public but there is certainly no bodily shame or discomfort here surrounding breastfeeding.


I’ll leave you with one last visual from my PMI day:

A maman brought in her 13 month old for his check-up and he was being a little fussy. With difficulty, she was trying to wrangle him into the sling so he could be weighed. I leaned over to ooooo and ahhhh to see if I could calm him down and as I go to lightly stroke his arm he turns to look at me finally and FREAKS OUT. I will never forget the utter terror in this child’s eyes. If I may, he went bat-shit crazy. Why? Because he had clearly never seen a white person before. He looked at me like I was the devil incarnate. So here I am in a room full of Gabonese mamans and the ones closest to me burst out laughing at the ridiculousness of this situation. I seriously had to distance myself from the child because he was completely inconsolable. Evidently this has also happened to my med student roommate who is Pakistani and works in pediatrics. Mispronouncing names I can work on, but this one is beyond me.