A changing view of global health

By the time of graduation, 27% of medical students will have had international medical experience. That number probably doubles when you consider those who have informal medical experiences during or around medical school. Global health is a hot topic – for my school the number of students who participate in the global health pathway and certification program has been rising astronomically every year, and now represents about 25% of the class. For me personally, global health was one of the primary reasons I went to UW, as they have a fantastic global health department and are a member of a number of international programs. My first experience as a medical student in Madagascar left me reeling - the contrast between the environment of the University hospital and the small hospital in Antsirabe was beyond comprehension. We had one little boy who was in house for the entire 3 months I worked – he had been burned in a bush taxi accident from thigh to ankle, and also had a broken femur. Every day, we would hold him down and remove and replace the bandages stuck to his leg, helping the wound to stay clean of infection, but causing immense pain. The first time I participated in his care, I couldn’t understand why we weren’t providing pain medication. The reply? We have it, but if we give it to him every day we have to do this, we will run out. I walked away from my summer shaken to my core about what the right to health really means. A few years later, as I find myself again spending time in clinics in Africa, my understanding of these issues has again changed. Stories I used to tell about Madagascar, of the sharps containers made of soda bottles, or washing with only hand soap prior to surgery, now seem incredibly benign. Having now spent time in clinics where a sharps container of any kind seems like an alien concept, or where there is no hand soap to wash at all, you begin to wonder what you can even offer. When you have nothing to work with, what is the use of your fancy education or your ideals about improving a care system? You have to have the drugs in order to improve prescribing practices. You have to have the patients come to the clinic, rather than stay at home until they are too ill to walk and die of treatable, preventable diseases. You have to have providers who are motivated to improve the system and who want to learn, rather than disappearing the moment a potential extra pair of hands appears on the scene. I realize, through all of this, that these experiences will make me a better doctor. I am probably (no, certainly) benefiting more from my time in the clinic than the patients are. They say that medical students who return from global health experiences are more likely to work with underserved populations, have less reliance on expensive imaging, and have better physical exam skills. My original goal in medicine was to allow others to reach their potential, without the burden of disease. I know I will return to the First World more dedicated than ever to the concept of health, having seen vividly what this “burden of disease” can really mean. Still I can’t help but think about what effect I am having on these areas. As a student in Madagascar, I felt more like I was in the way and a drain on the valuable human resources than like I was contributing. Here, though the majority of the time I am not in the clinic, when I am, the best I hope for is to not to be a negative influence on the situation. My knowledge of vascular physiology is far less valuable than the ability to palpate a spleen. Because of this, I suspect I will leave Africa with my enthusiasm for global health intact, but my beliefs about how and where to apply that interest will be drastically changed.

Hallways that are usually teeming with patients in the morning clear out by mid-afternoon as patients are either seen, or told to come back tomorrow to wait again to see the provider.

An admission ward at a rural clinic

The clinic pharmacy

Cholera tents with a latrine trench, in preparation for the epidemics that start annually in the compounds of Lusaka

Luangwa, Visit Number Two

“That Baobab outside your hotel, that’s where they rounded up the slaves before going to the Indian Ocean. The weak ones they threw in the river.” These sentences are casually tossed out before dropping me off at the hotel in Luangwa. We are in the most remote of our three districts for work, and the distance from Lusaka spans more than geography. Here, the clinic is run by the maid (actually, technically she’s on leave until April, so it’s really run by a volunteer with even less clinical skill), there are annual floods that cut the small population off from the rest of the world, and the sand toilets for the village have collapsed so everyone has reverted to the river for all their needs (including water, bathing, laundry, and relieving themselves). If Lusaka feels like the African offspring of the American Midwest, Luangwa feels like… well, Africa-Africa. Thankfully, there is electricity during our visit (the last time I was here, not so much), but I am told that this is to curry favor for the upcoming election. The tap water in the sink is muddy brown (but again, this is an improvement over the last time).

Yep, tap water was really, really brown.

There are usually some farm animals involved in our car rides – squawking emanating from a cardboard box quickly was revealed to be co-worker’s new chickens as we drove along. I’m just thankful that no one has strapped part or all of a goat to our Land Rover, but we still have a day to go before we head home.  What amazes me, more than the fowl stow-a-ways or stories of the past, are the people. One patient I saw this morning had been to the clinic five times in the past five months. Each for the same complaint – chest and back pain. What was different about the five months, I asked her.  Ah, she replied, with a fond gaze at her young son. My son is going to a new school. We parents have to build it, though, to contribute, so I have been making and stacking the bricks for the past five months.

What else would you bring on a work trip?!

As cliché as it may seem, there is nothing that reaffirms my love for Africa more than these moments – the grateful dzekomo from a patient, play-racing with children during my afternoon run, the extra few minutes that a kindly stranger takes to walk me to the right place, the laughter and a few extra mangos from the woman at the market. The sweetness and grace of these times balances out the frustrations that threaten to drown us in our work and our lives here. As usual, trading the posh civilization of Lusaka for a few days in the rural village of Luangwa reminds me what is really of value.

Whiskey and Shake-shake

I spent last evening at a Caledonian society ball. It was an evening of tartans, dances with names like Strip the Willow, and a whiskey bar. And no, I didn’t just move to Scotland. Evidently there is enough of a Scottish community here to throw these types of balls several times a year. Bagpipes, piper, and two kinds of haggis flown direct from the motherland (fatherland? What gender is Scotland, anyways?). Besides tripping over my feet trying to do the Military Two Step, I spent a good portion of the night wondering about culture.
The contrast between Zambia and Scotland is pretty stark. I heard some “amusing anecdotes” of trying to teach a Zambian chef to make cock-a-leekie soup, or what a bungle the staff made of the chocolate mousse. The toasts to the Lassies involved the same worn laughs - man’s inability to understand women, communicate worth a damn, and apparently function without the support of a good female. The riffs and compliments were familiar to me – apparently American humor about the sexes really hasn’t been influenced by two hundred years away from the British isles.

A few days before, I had spent another evening at a play put on by a Zambian acting group. Essentially, the play made a farce of the infidelity that is rife throughout Zambia, by illustrating the battle between married women and the single girls who poach their husbands. There were such winning jokes as, “the wife is better than the girlfriend, because you can beat her and she won’t leave you,” or the father of a character advising his distraught daughter to go back to her husband because “even I had girlfriends! Go back or I’ll kill you!” There were jokes about Indians, rural traditions, alcoholism, murder, and materialistic women. The Zambians were in stitches. I alternated between being appalled and laughing from sheer disbelief. Women are apparently equally guilty as a bad wife for the inability to keep their husbands “on a leash,” and for being the “sluts” that tempt away the men. 

Yep, Toto, we’re not in Kansas anymore. You can bring your culture, your oatcakes, and your kilts to Lusaka, but it just reinforces how many miles away your countries really are.

Zanzibari Christmas

Zanzibar. The very name sounds exotic. The streets are narrow, jetting off at odd angles, strung with tattered flags. Men wear the robes and caps of the Muslim faith. Women wear full burkas, with only their kohl rimmed eyes showing. We are in Stone Town for 3 days, over Christmas Eve. The mosques are far more abundant than churches, and the call to prayer reverberates throughout sunlit alleys far more often than occasional carols heard from open shop windows. Everywhere is the smell of cloves, sweet and spicy and blending with the stink of meat left in the sun and the underlying odor of fish. The market itself is a riot of items, far more variety than we see in Zambia. There is dorean, a spiny fruit which smells of sulfur, has flesh the texture of (as one woman put it, unfortunately) “fat on meat,” and tastes like nothing so much as garlic bananas. Jackfruits piled high, as large as watermelon, drip sticky white sap. There are bags of vanilla beans, cumin, and chili powder next to tables with dried octopus (octopi?), stacked like pancakes. 

 The food is delicious; curries thick with coconut milk and fresh spices, prawns, grilled octopus, fish of all kinds, ice tea flavored with limes and honey, coffee brewed Arabic-style with real milk, coconut rice, spicy ginger gelato, Tusker and Sarangeti beer. Bellies full and bags heavy with scarves and spice packets, we head to Jambiani, on the east of the island. Our van blows a tire halfway there, and we wait by the side of the road for an hour or two while cars stop and men pile out to help our beleaguered driver. Finally, we arrive in the village, which consists of a number of houses (all, it seems, have crumbled on at least one side; apparently repairs become less urgent when the climate is balmy), around 5 restaurants, and a collection of beach bungalows for the mzungus. 

We have rented out the entire bottom floor of a large guesthouse, run by a cheerful, small Zanzibari man named Dude (doo-day) who sports Hawaiian print board shorts and Von Dutch tees, and pads around like a helpful house gnome delivering fresh bread and instant coffee. He takes us sailing after a few days in his mango tree boat (apparently, the wood lasts longer). It’s a catamaran with a sail sown of hand stitched tarps and rice sacks, and is constructed by deceptively simple engineering – lines and twine and random sticks all serve in place of the usual pulleys and cables.  He takes us toward the reef, and we weigh anchor long enough to snorkel. There are giant starfish and sea urchins the size of softballs, and hundreds of multicolored fish. In the evenings, we eat religiously at Coco Beach, a restaurant with amazing food and a sharp-tongued manager who at least once a meal manages to offend us. 

I spend most of our three days at the beach lying on the bench outside the house, with a fever and cough. It’s the most beautiful place to be sick, ever. By New Year’s, I’m back up, though I go to bed at a shameful 9 PM after eating dinner by candlelight on the beach. The next day, we catch a ferry to Dar es Salaam. The line to the ferry reminds me of a cattle drive, with everyone pushing to board the boat and secure a seat. Kate (who is about 5’ tall) says her feet didn’t touch the ground as she was borne along. The ferry makes us all slightly nauseous with the rolling, but they show Jackie Chan movies, which helps somewhat. When we arrive in Dar, we are amazed at the amenities. Chamomile tea! Gummy bears! Tabasco sauce! We stock our suitcases. Annie, Kate and I share a hostel room with Hank, an older man who works in the mining industry and comes to Dar monthly on business. He makes sweet, but awkward attempts at jokes, though clearly has lost the knack of talking to twenty-something females. He keeps a bow in a pair of cowboy boots in the corner, a plate of fresh chilies on the nightstand, and has four cell phones. After a blissfully air conditioned night, we head back to Lusaka. It’s been a good trip.

 

Getting in touch with your inner Neanderthal

Alright, digression to my undergrad years as a psych major... There’s a pretty well-known phenomenon in psychology about our ability to consciously express preferences. That is, people are capable of coming up with an explanation about why they like something, but that very act alters their preference. For instance, if you ask someone to pick their favorite book, they really love Harry Potter. But if you ask them to pick their favorite book and tell you WHY, they will probably realize that Harry doesn’t make them sound sophisticated or cool (unless, like me, you think Harry Potter transcends such paltry things as coolness), so they say that their favorite book is actually Zen and the Art of Motorcycle Maintenance. Then they can give a nice, clean explanation about why they love it. But they’re deluding themselves AND you, because admit it, they really, really love Hogwarts, and they’d be way happier reading Harry Potter over and over if stuck on a desert island. So, pretty much, if you want to get in touch with who you really are, you can’t think through your opinions too much, because then the rationalizing of just why you get all googly-eyed at Daniel Radcliffe ruins it. 

Interesting.

Now, for me, I’ll admit I’m a naval-gazer. Hence, the blog. Unfortunately, the above phenomenon guarantees somewhat that all my carefully thought-out opinions about what I think about the world, including thoughts on medicine, social justice, hobbies, relationships, and the like, are probably an attempt to make me into a person that sounds good to myself.  And that means that I could (and not even be consciously aware that I was) actually be someone who would prefer to watch Jersey Shore reruns and eat marshmallow peeps all day. Scary, no? So maybe I should go with my gut more, and stop thinking about all this life stuff, and I’d be way, way happier. Hmmmm.  Well, if you need me, I’ll be in my room listening to the Postal Service and reading the Chamber of Secrets.