Tuesday:
Nina and I spent all day working to get the machine ready to gather our arterial stiffness data for a project examining ARVs and their effects on blood flow. Stupid piece of crap...enough said.
After all day pulling out our hair at the clinic, I went home to cut 300 paper plates in half to make 600 masks for Day of the African Child and cut 600 nose notches. Thrilling.
Wednesday:
Nina and I worked all day at the clinic running the first round of testing with the women. We didn't have a translator, which made for an interesting revelation/confirmation. We have to place electrodes for an EKG on the women and measure the distance between the two pulse point we're using and the top EKG lead, then place a tonometer that gives us a reading of blood flow (velocity) at each point. Very Frankenstienish feeling. We were stuck in a tiny office with dim lighting that reminded me of horror film portrayals of mental institution...essentially, we were only missing the weird smells and the dripping water you see in every scene. My interactions with the women were completely different from what I had experienced every other day I was here. Medical sterilization at its best. I had to fight to keep the humanity I'm fond of in the room. At one point I was taking blood pressure measurements and Nina whipped out the tape measure and began taking the pulse point distance measurements. Immediately I felt uneasy, pulled my stethoscope out of my ears, took the cuff off and stood there staring into the eyes of the woman we were prodding. Instantly, I realized the uncomfortable feeling in the room...how very Tuskegee Institute. My mind flashed to the racist scientific experiments that measured head circumference, nose size and made bold, degrading, and downright ignorant statements to oppress those of African decent in our own country.
What bothered me the most, was that Nina didn't seem to notice. She continued measuring, continued rushing around both of us without lifting her head to really see the woman, without noticing the feeling of the room. I cannot conduct any work this way. I simply refuse. But in reestablishing that human connection with the woman, the tension was relieved with a smile and a touch--this is the importance of hand holding, of human contact.
It was in this instant that I understood a piece of Rwanda, and it's people, that I made a significant connection. The genocide started with systematic measurements that were used to divide people in to ethnic groups based on physical characteristics, many years before the 94 genocide. The Hutus and Tutsis were divided up long before the world turned its eyes to this tiny country (I still find it sad that my first education on Rwanda was through a mainstream movie, ten years after the devastation). Our behavior in the clinic that day was a parallel to that. Something that, clearly, I never intended, but seen too commonly in medicine and science in general. I strongly believe that this is not the inevitable fate of medicine. Not every interaction needs to be this way, so sterile, so mechanical, and I was happy to find that today I confirmed this idea in a smile. Again, it comes down to De Mello and his life changing idea of truly seeing people.
So, how do I do that in this experiment situation? I don't care if I look like the biggest nut alive, I talk to every patient. I use all the Kinyarwanda words I know. I'm awesome at miming. I show the women on myself where I will place leads. I show them every step on myself. I touch the tonometer to my skin and I watch their faces. I may be slower in getting done with each woman, but I will gladly sacrifice my time for maintaining the humanity and respect that these people have a right to. I am glad that I have figured out a way to connect again, in such a difficult setting. I extra glad I'm not a culturally incompetent moron, which was definitely the road I was heading down with this project.
Moose
Sunday, June 17, 2007
Last Monday Cont'd
I've finally recovered from the week and ready to blog again...
So continuing with the rural clinic work...
I attended a meeting for two hours with Mardge, Nina, Dr. JMV, the clinic director, and a woman named Aren who does something...she doesn't speak much english and Mardge was a little too busy for some explanations. Anyway, our meeting was to address the HIV+ pregnant population of Nycungu (spelling?) and their breast feeding practice. (Vertical) Transmission can occur at birth when mom and baby's blood can mix, but there are prophylactic pills that can be given to the mother and baby to reduce the risk a great deal. The other method of transmission is through breast feeding, which harbors a 10% risk for the first 6 months. All risk for all modes depends on viral count of the infected person--the more copies of the virus, the more chance of transmitting HIV. Here's the problem: the women don't have clean water for formula and dysentery is, I believe, the top cause of mortality in children under the age of 5 in most African countries. Mothers know that dirty water = death. The other problem is that the babies won't be getting mom's antibodies for certain diseases, which translates to generally weaker immune systems and poorer health. Bottom line is kids will be sick one way or another here. There have also been new studies out of South Africa that show mixing breast feeding and formula for the first 6 months increases not only the incidence of poverty related disease: malaria, TB, dysentery, but also the risk of HIV transmission.
The debate now becomes, how do we keep them safe from diseases and get these women milk/clean water for formula--for 6 months? This was the topic of the day. Two hours, six of us in a crowded office, Kinyarwanda and French with very little English translation. I am amazed by the ability to understand and communicate without speaking the language. This is what I took away from the meeting:
The rural clinic of Nycungu serves 28,000 people, most of whom travel a great distance through the mountains to make it for a visit. (One grandmother walks two hours through the mountains to pick up ARVs for her grandkids once a month.) We are dealing with an estimated 96 HIV+ pregnant women each year. Not only is there a need to increase efforts for bringing these women into clinics and hospitals to deliver (to receive prophylaxis as mentioned above), but fresh milk and water needs to find its way into their homes. The proposed idea is to raise two dairy cows at the clinic and each day boil fresh milk and water to mix for each woman to come and get 1-2 liters to replace their breast feeding. Problems: too far to travel each day...
So, give each village or neighborhood a cow. Problems: not enough milk to share with people who aren't pregnant and you know everyone will want some. Still have to boil milk and water--water's not commonly boiled now. Run the risk of dividing milk up and the women are so poor they might still breast feed to save the cow milk for other children who are typically getting one meal a day.
This debate was obviously not settled.
We left the meeting to tour the rest of the simple, yet elegant facilities. (True beauty in extreme simplicity.) Nina and I were waiting for Mardge when I saw a toddler in the waiting room. The room was extremely crowded and everyone was looking at the Mzungo's standing around. The toddler takes one look at me and starts balling. I generally don't have this reaction from children, so I was slightly surprised. Everyone in the waiting room was pointing and laughing at me...I imagine "Oh silly mzungo! Hahaha" Every time she saw me, crying. Not just quiet sobbing or clinging to mom, but down right horrendous screaming. I looked at the women, threw up my hands, shrugged, and we all laughed.
I am impressed by this aspect of human nature: the uncanny ability to share thoughts and feelings that overcome the language barrier. Every day I have these encounters, especially with the children, where I feel connected to others, who seemingly live in a totally different world, yet there is a strong, stunning something that links us all. I know this sounds like a Lion King song, but it is entirely true. It is humbling and awe-some, in the truest sense of the word, to be welcomed in this way and to feel a universal, innate bond, true love, I suppose. It always makes me wonder, How would these people be received in the US? Why have I never felt this connection with strangers I meet in my daily life back home? After all, we speak the same language. I think it's because language often colors our world and attitude in such a way as to distract us from this feeling. I often find myself losing my patience with those around me and thinking negative things after my interactions with many other people. This all comes back to the Anthony de Mello quote I posted earlier. I suppose, I am not truly seeing those around me at home. It is sad in many ways that it takes something as extreme as a trip to another continent to come to this realization. Better late than never. I am anxiously awaiting the search for this connection when I return.
So continuing with the rural clinic work...
I attended a meeting for two hours with Mardge, Nina, Dr. JMV, the clinic director, and a woman named Aren who does something...she doesn't speak much english and Mardge was a little too busy for some explanations. Anyway, our meeting was to address the HIV+ pregnant population of Nycungu (spelling?) and their breast feeding practice. (Vertical) Transmission can occur at birth when mom and baby's blood can mix, but there are prophylactic pills that can be given to the mother and baby to reduce the risk a great deal. The other method of transmission is through breast feeding, which harbors a 10% risk for the first 6 months. All risk for all modes depends on viral count of the infected person--the more copies of the virus, the more chance of transmitting HIV. Here's the problem: the women don't have clean water for formula and dysentery is, I believe, the top cause of mortality in children under the age of 5 in most African countries. Mothers know that dirty water = death. The other problem is that the babies won't be getting mom's antibodies for certain diseases, which translates to generally weaker immune systems and poorer health. Bottom line is kids will be sick one way or another here. There have also been new studies out of South Africa that show mixing breast feeding and formula for the first 6 months increases not only the incidence of poverty related disease: malaria, TB, dysentery, but also the risk of HIV transmission.
The debate now becomes, how do we keep them safe from diseases and get these women milk/clean water for formula--for 6 months? This was the topic of the day. Two hours, six of us in a crowded office, Kinyarwanda and French with very little English translation. I am amazed by the ability to understand and communicate without speaking the language. This is what I took away from the meeting:
The rural clinic of Nycungu serves 28,000 people, most of whom travel a great distance through the mountains to make it for a visit. (One grandmother walks two hours through the mountains to pick up ARVs for her grandkids once a month.) We are dealing with an estimated 96 HIV+ pregnant women each year. Not only is there a need to increase efforts for bringing these women into clinics and hospitals to deliver (to receive prophylaxis as mentioned above), but fresh milk and water needs to find its way into their homes. The proposed idea is to raise two dairy cows at the clinic and each day boil fresh milk and water to mix for each woman to come and get 1-2 liters to replace their breast feeding. Problems: too far to travel each day...
So, give each village or neighborhood a cow. Problems: not enough milk to share with people who aren't pregnant and you know everyone will want some. Still have to boil milk and water--water's not commonly boiled now. Run the risk of dividing milk up and the women are so poor they might still breast feed to save the cow milk for other children who are typically getting one meal a day.
This debate was obviously not settled.
We left the meeting to tour the rest of the simple, yet elegant facilities. (True beauty in extreme simplicity.) Nina and I were waiting for Mardge when I saw a toddler in the waiting room. The room was extremely crowded and everyone was looking at the Mzungo's standing around. The toddler takes one look at me and starts balling. I generally don't have this reaction from children, so I was slightly surprised. Everyone in the waiting room was pointing and laughing at me...I imagine "Oh silly mzungo! Hahaha" Every time she saw me, crying. Not just quiet sobbing or clinging to mom, but down right horrendous screaming. I looked at the women, threw up my hands, shrugged, and we all laughed.
I am impressed by this aspect of human nature: the uncanny ability to share thoughts and feelings that overcome the language barrier. Every day I have these encounters, especially with the children, where I feel connected to others, who seemingly live in a totally different world, yet there is a strong, stunning something that links us all. I know this sounds like a Lion King song, but it is entirely true. It is humbling and awe-some, in the truest sense of the word, to be welcomed in this way and to feel a universal, innate bond, true love, I suppose. It always makes me wonder, How would these people be received in the US? Why have I never felt this connection with strangers I meet in my daily life back home? After all, we speak the same language. I think it's because language often colors our world and attitude in such a way as to distract us from this feeling. I often find myself losing my patience with those around me and thinking negative things after my interactions with many other people. This all comes back to the Anthony de Mello quote I posted earlier. I suppose, I am not truly seeing those around me at home. It is sad in many ways that it takes something as extreme as a trip to another continent to come to this realization. Better late than never. I am anxiously awaiting the search for this connection when I return.
Tuesday, June 12, 2007
The Rural Clinic
Today (Monday, honestly you should probably assume I'm writing a day behind) I spent the day with Nina, Mardge, and Dr. JMV at the Nycungu clinic, not sure how to spell that one. The drive was interesting and beautiful. We drove through the east end of Kigali and around a bunch of hills to the south. Personally, I was shocked I didn't have to get out and push the car. At one point the car rocked back and forth as we teetered on the verge of rolling back down the dirt road we came up on. The clinic is halfway up a hill and the roads are far from paved. I loved being able to look out the window on the way there and see the houses and the roadside change as the trip progressed. The homes reflected a much poorer community as did the far more ragged clothes. The houses were made in a lean-to style with large sheets of crimped metal for the roof. The entire way to the clinic we saw people selling things like fresh fruit, lone pairs of pants, and water. Young boys have cardboard boxes filled with candy and travel packages of kleenex. Very strange combinations of goods are being sold here. The roadside is incredibly interesting. When I say 'lone pair of pants' I mean one person holding up a pair of pants and trying to sell it to everyone walking by.
So I'm temporarily suspending the blog until Sunday. Sat. is day of the African Child! and so, I'm super busy after work getting everything ready for tomorrow. What are you doing, you might ask? Well, I'll tell you. I cut 300 paper plates in half to make 600 paper plate masks, then cut 600 nose notches, and 1200 eye holes, then tied a string on each mask...they're finally done, but tonight I have a pre-celebration meeting...so hang in there 'til Sunday!
So I'm temporarily suspending the blog until Sunday. Sat. is day of the African Child! and so, I'm super busy after work getting everything ready for tomorrow. What are you doing, you might ask? Well, I'll tell you. I cut 300 paper plates in half to make 600 paper plate masks, then cut 600 nose notches, and 1200 eye holes, then tied a string on each mask...they're finally done, but tonight I have a pre-celebration meeting...so hang in there 'til Sunday!
Monday, June 11, 2007
Grrr...Blogging is hard
So once again please use your imagination and pretend today is Sunday. I'm already getting bad
with updates...
Today was by far the most fun I've had in a very long time. It was children's support group day!! I sat in a group for men 18-25 and we talked about what happens when they isolate themselves from the community. I suggested journal writing and role models who could come speak at the support group and the guys wanted to try writing. We had lunch and a treat, orange Fanta, and then off to the children's group.
The group is held at a mosque in Nyamirambo and we took a very crowded minibus to get there. All of us from the morning support group got out and walked to the playground and soccer fields in the back...you could hear the voices of tons of kids...Then, when we stepped into view about 200 kids shared a collective moment of silence before the stampede.
I didn't even get to put my bag down before I had children swarming me from four years old to ten. Boys and girls. Two little girls one about seven and another about four ran up to me and held my hands. This is a reaction kids give mazungo's a lot here and they're incredibly desperate for some sort of contact. The kids were fighting over who got to hold my hand. There was pushing. There was shoving. We were one step from complete and utter chaos. (Hear that Brandon, some people enjoy holding my hand in public...) anyways these kids were adorable.
When I finally made my way to the picnic shelter area, a group of girls were dancing. I walked over to see them and they taught me to dance. Not too bad, dancing in less than five minutes. Then we played relay games. There were two lines of kids and each sent one runner with a stick starting from opposite ends to run around in a big circle and they tried to touch the other runner with the stick. When you got back to where you started, you passed the stick. The kids were slightly losing interest and the other adult facilitators were trying to keep them playing so I kicked off my shoes, hiked up my skirt and hauled some major ass. I could just hear laughing and the occasional shouts of "mazungo" (I imagine there was some pointing as well...) The kids were cheering me on and I was trying not to trip or get caught by the seven year old behind me. My team lost, but the important thing is that I did not lose my dignity to a first grader. Almost, but not quite.
After playtime we sat under the picnic area. We finally wrangled 200 kids and then I busted out the camera...I have a new found appreciation for the professional photographers that take the class photos in elementary school...Eventually the group shots were done, but I made the mistake of trying to take pictures of smaller groups and more natural shots of the kids which turned into an act of mob violence eliciting an exhibition of major police force. Well, 200 screaming kids crowding me reaching for my camera, pulling on my clothes and yelling at me is just as serious. They were great though. It was truly an enjoyable day and I'll let my pictures tell the rest of the story. All of these kids are HIV+.
with updates...
Today was by far the most fun I've had in a very long time. It was children's support group day!! I sat in a group for men 18-25 and we talked about what happens when they isolate themselves from the community. I suggested journal writing and role models who could come speak at the support group and the guys wanted to try writing. We had lunch and a treat, orange Fanta, and then off to the children's group.
The group is held at a mosque in Nyamirambo and we took a very crowded minibus to get there. All of us from the morning support group got out and walked to the playground and soccer fields in the back...you could hear the voices of tons of kids...Then, when we stepped into view about 200 kids shared a collective moment of silence before the stampede.
I didn't even get to put my bag down before I had children swarming me from four years old to ten. Boys and girls. Two little girls one about seven and another about four ran up to me and held my hands. This is a reaction kids give mazungo's a lot here and they're incredibly desperate for some sort of contact. The kids were fighting over who got to hold my hand. There was pushing. There was shoving. We were one step from complete and utter chaos. (Hear that Brandon, some people enjoy holding my hand in public...) anyways these kids were adorable.
When I finally made my way to the picnic shelter area, a group of girls were dancing. I walked over to see them and they taught me to dance. Not too bad, dancing in less than five minutes. Then we played relay games. There were two lines of kids and each sent one runner with a stick starting from opposite ends to run around in a big circle and they tried to touch the other runner with the stick. When you got back to where you started, you passed the stick. The kids were slightly losing interest and the other adult facilitators were trying to keep them playing so I kicked off my shoes, hiked up my skirt and hauled some major ass. I could just hear laughing and the occasional shouts of "mazungo" (I imagine there was some pointing as well...) The kids were cheering me on and I was trying not to trip or get caught by the seven year old behind me. My team lost, but the important thing is that I did not lose my dignity to a first grader. Almost, but not quite.
After playtime we sat under the picnic area. We finally wrangled 200 kids and then I busted out the camera...I have a new found appreciation for the professional photographers that take the class photos in elementary school...Eventually the group shots were done, but I made the mistake of trying to take pictures of smaller groups and more natural shots of the kids which turned into an act of mob violence eliciting an exhibition of major police force. Well, 200 screaming kids crowding me reaching for my camera, pulling on my clothes and yelling at me is just as serious. They were great though. It was truly an enjoyable day and I'll let my pictures tell the rest of the story. All of these kids are HIV+.
Sunday, June 10, 2007
A day behind
Yesterday I went with Nina to the genocide memorial in Kigali. I bought a book from the exhibit because I truly have no words.
I did get a chance later to check out the craft market...
At night we all went to Republica to have a celebratory good bye tea for another intern Rebecca who's leaving tomorrow.
That was pretty much it, very depressing.
I did get a chance later to check out the craft market...
At night we all went to Republica to have a celebratory good bye tea for another intern Rebecca who's leaving tomorrow.
That was pretty much it, very depressing.
Friday, June 8, 2007
The big day, with relatively little activity
So I just finished yesterday's post and it still listed it as a Thursday post, so the first couple sentences about pretending it's still Thursday makes me look stupid. Whatever, such is life. (At least I don't look as dumb as mom in that turkey hat...hahaha, Just kidding mom, great hat.)
I say today was a big day because I had my project meeting with Mardge. Or Dr. Mardge as she's commonly called here. We've decided on two projects. One being an ARV non-compliance issue. We're going to ask the women, while we're gathering medical data for a project for something else, questions about what makes it hard to take their medication. Very light, very conversational, very relaxed. We, Nina and I will also be asking these questions at the Icyuzuzo clinic and the more rural clinic we will be traveling to on Mondays. Our other project is a little bit trickier and we're looking to address the issue of disclosure. Who do these women tell about their positive status? Why do they disclose, why not? How do they feel afterwards? What reaction do they get? One teen girl reported that her grandmother found out her positive status, told her whole town, and then no one would play with her. I'm finding that many people don't tell anyone outside of their immediate family. It should be interesting to see what everyone says.
Nina and I also did a little shopping today and I discovered my hidden talent for haggling. Originally, the saleswoman wanted to sell me a pair of sandals for 8,000Francs which is $16US and I told her nope, walked away and ended up with them for 3,000F ($6). I truly have a shoe shopping gift. (Don't worry Grandma, I only bought one pair to replace the painful pair.) I came home and we had the second awesomest pizza ever (I heart Lou's!). Which is saying a lot, since I have high pizza standards being from Chicago and all...
Other than that, I spent the night writing two days worth of blogs, reflecting a lot on yesterday, and reading for fun. Tomorrow it's a sobering trip to the genocide memorial in Kigali and possibly the memorial at a rural church.
I say today was a big day because I had my project meeting with Mardge. Or Dr. Mardge as she's commonly called here. We've decided on two projects. One being an ARV non-compliance issue. We're going to ask the women, while we're gathering medical data for a project for something else, questions about what makes it hard to take their medication. Very light, very conversational, very relaxed. We, Nina and I will also be asking these questions at the Icyuzuzo clinic and the more rural clinic we will be traveling to on Mondays. Our other project is a little bit trickier and we're looking to address the issue of disclosure. Who do these women tell about their positive status? Why do they disclose, why not? How do they feel afterwards? What reaction do they get? One teen girl reported that her grandmother found out her positive status, told her whole town, and then no one would play with her. I'm finding that many people don't tell anyone outside of their immediate family. It should be interesting to see what everyone says.
Nina and I also did a little shopping today and I discovered my hidden talent for haggling. Originally, the saleswoman wanted to sell me a pair of sandals for 8,000Francs which is $16US and I told her nope, walked away and ended up with them for 3,000F ($6). I truly have a shoe shopping gift. (Don't worry Grandma, I only bought one pair to replace the painful pair.) I came home and we had the second awesomest pizza ever (I heart Lou's!). Which is saying a lot, since I have high pizza standards being from Chicago and all...
Other than that, I spent the night writing two days worth of blogs, reflecting a lot on yesterday, and reading for fun. Tomorrow it's a sobering trip to the genocide memorial in Kigali and possibly the memorial at a rural church.
Thursday, June 7, 2007
The True Thursday Events
Ok, so I started a whopping one sentence of Thursday's actual events and then fell asleep. So just pretend it's still Thursday. Also, I've heard that a few people have tried to post comments and were unable to do so. Good news! I changed the settings and you can feel free to comment, question, or critique as you like. Please let me know what you think and what you're wondering.
So much happened at Icyuzuzo today that I may have to split this all up! I'll keep it brief, I promise...hahaha. I spent the day following Dr. JMV. Nina and I sat in his office and saw patients with him. Phenomenal experience! A car drove us to the clinic and we went immediately into Dr. JMV's office to wait for him. On the way to the WE-ACTx clinic in Santra-Ville, my shoes were bugging me and I ended up with a bunch of blisters on my feet. I asked for band-aids at both clinics and was informed that neither clinic had any. Let me repeat that, no band-aids. Ok, again for those of you struggling to fit your head around that one (much like my initial reaction, so you're not alone!) NO BAND-AIDS. A clinic that performs routine blood draws on HIV+ patients and sees people who end up with skin lesions...doesn't...have...band-aids...Insane? Yes. Shocking? Not so much. These clinics are lucky to be staffed with physicians and have supplies of ARVs so band-aids aren't really a priority. Close your eyes and imagine being that poor.
Nina and I sat all day with Dr. JMV from about 9am to 2:30pm. This experience was absolutely amazing and I'd like to split my thoughts into two areas: the physician-patient relationship and patient issues.
Dr. JMV saw about 15 patients with yesterday being a slow day. The nurses also handled a lot of routine, HIV negative patients while we were with him. My focus question going into this shadowing experience was: How does he maintain the physician-patient relationship while seeing so many patients? It didn't take long to see what made him special. He is sitting when the patient enters and shakes their hand, says hello, and gets down to business, but he is never rushed. His questioning style is one that is both deliberate and detailed, but also slow and intimate. He never wrote a word while the patients were speaking. He never interpreted or explained while the patients were talking to him. If a patient started talking again while he was writing his notes, he immediately put his pen down and sat back to face the patient. Each patient sat in the seat right next to his desk where the barriers were broken down. He never slouched, but leaned in to be closer and hear better. The Rwandan people are very stoic and quiet. They often talk without looking at you. The tone and volume of his voice matched that of each individual patient and he never forced eye contact. His focus was intense and it was clear that he was both physically and mentally present. For that time, as far as he was concerned, Nina and I were not in the room. After he wrote his notes, he explained the patient's complaints as well as the purpose of each medication. For every single patient.
The patient that I see when I close my eyes and think of that day was a young boy probably about nine or ten years old. Old white Nike gym shoes stained brown by the dry red dirt, long yellow shorts with the three familiar green stripes of ADIDAS running along the side, and a dirty gray t-shirt. He came to the clinic alone and I never asked where mom or dad were, there was really no need. This young boy spoke softly and looked down at his hands as he answered Dr. JMV's questions. This physician was patient and kind. He prodded the boy and leaned in to lock his eyes and ask his questions. This boy was going to begin ARV therapy and needed a few other medications for a cough. Dr. JMV wrote the script and then did something I've never seen a physician do for a child: he carefully, one by one, explained each medication by name. Directions and all and asked the boy questions to make sure he understood. I had to go to the doctor a few days before my trip and my mom still asks me if I need her to come along. I'm 23. He was about nine. Hmmm... I know that he is alone because of necessity, but this speaks to the ability of understanding treatment in pediatric patients. As a future physician specifically interested in children's Infectious Disease, I am greatly concerned with the doctor-patient relationship. Too often I see physicians talk over and around children directly to the parent while never truly acknowledging the actual patient. And we, as a medical community, are wanting to see children feel comfortable with trips to see the doctor to grow into adults who trust us and come to see physicians when necessary. Do we expect this relationship based on trust and understanding to happen via magic beans and fairy dust? This boy came in and was able to describe his symptoms in his own words, expressing himself in a very poised and eloquent way. Many people do not hold the expression of a child equal with that of an adult, but this is to do them a great injustice. This is not to say children are capable of the same maturity or level of understanding as an adult, but their voice and the words it speaks are important. Just as important as that of the parent. This is something I will encourage in my own patients. In fact, for the first five minutes, I would love to cover the parent's mouth with duct tape and only hear from the child. So many adults feel uncomfortable in the presence of the physician, enough so to deter them from going. I feel this is an attitude that must be changed, and even better, never developed. It comes from years of talking to the doctor, finding their voice and the right words to explain their problems. How can a mother or a father know if a child's pain is sharp or dull, pulsating or steady? They, themselves are not feeling it, they must be told. If parents are encouraging their children to speak to them about illness, why not encourage them to speak to the person responsible for treating them as well?
The patients feel so comfortable as children and adults seeing Dr. JMV that I was surprised at the ease with which shirts came flying off! A little boy came in with his mother had a very severe and painfully swollen case of shingles (think Brandon... sunburned...100 times worse). Truthfully, I've never seen a human being that shade of red before. And the whole area was covered with tiny, painful blister-like spots. Dr. JMV asked him what he was in for today and before I knew it, we were looking at a bare back and a little kid butt crack. Just like that. He never appeared embarrassed and he was never prompted to drop trow, but there he was, quite matter-of-factly. I see London, I see France...I saw a lot today.
While it's true that the Rwandan people are very serious in appearance, with little show of emotion this is not usually true at Dr. JMV's office nor at the WE-ACTx clinic. In these places pain is not hidden. Physical weakness is not covered. Concern is intensely expressed. Is this due to feeling relaxed in the physician's office? Partly. Dr. JMV is comforting, attentive. They let down their guard with him because he is respectful of their vulnerability. It has nothing to do with physical exposure. It has everything to do with emotional exposure. He moves and speaks slowly. He asks questions that can be difficult or stigmatizing to answer, but he does it in such a way, with such an emotional tenderness, that shows each patient he or she is loved. Unfortunately, this cannot be taught to medical students. Too often, this relationship is taken for granted or never cultivated to the level of trust and true partnership that it should be. When one has the opportunity to witness an encounter of such quality between a physician and a patient, it is truly both inspiring and humbling.
So, what's the other part? Simply stated, desire. Necessity. These people are very sick and very poor which makes for the most deadly combination. I love hearing people use the phrase, "Oh that's the worst. I hate that." Poverty and illness, whether it's malaria, dysentery, HIV, or TB, that's the worst; I hate that. No higher, I call. Patients know that, especially in resource poor settings, they have very limited time to spend with the doctor and that the waiting room is often overflowing with people just as sick as themselves, waiting to be seen. They are always waiting. To see the physician, to feel better, to find their next meal, to find work, to get their test results. Once inside the physician's office, Rwandans no longer wait. The second the doctor asks the first question, many patients speak with a fiery quickness, voices raised, emotional faces. They have come to see the doctor and there is no confusion about why they are there. Many patients don't acknowledge Nina and I. The ones who do, shake our hands, sit, and don't look at us until Dr. JMV begins to write. They are finished, and now, again have time to wait.
So much happened at Icyuzuzo today that I may have to split this all up! I'll keep it brief, I promise...hahaha. I spent the day following Dr. JMV. Nina and I sat in his office and saw patients with him. Phenomenal experience! A car drove us to the clinic and we went immediately into Dr. JMV's office to wait for him. On the way to the WE-ACTx clinic in Santra-Ville, my shoes were bugging me and I ended up with a bunch of blisters on my feet. I asked for band-aids at both clinics and was informed that neither clinic had any. Let me repeat that, no band-aids. Ok, again for those of you struggling to fit your head around that one (much like my initial reaction, so you're not alone!) NO BAND-AIDS. A clinic that performs routine blood draws on HIV+ patients and sees people who end up with skin lesions...doesn't...have...band-aids...Insane? Yes. Shocking? Not so much. These clinics are lucky to be staffed with physicians and have supplies of ARVs so band-aids aren't really a priority. Close your eyes and imagine being that poor.
Nina and I sat all day with Dr. JMV from about 9am to 2:30pm. This experience was absolutely amazing and I'd like to split my thoughts into two areas: the physician-patient relationship and patient issues.
Dr. JMV saw about 15 patients with yesterday being a slow day. The nurses also handled a lot of routine, HIV negative patients while we were with him. My focus question going into this shadowing experience was: How does he maintain the physician-patient relationship while seeing so many patients? It didn't take long to see what made him special. He is sitting when the patient enters and shakes their hand, says hello, and gets down to business, but he is never rushed. His questioning style is one that is both deliberate and detailed, but also slow and intimate. He never wrote a word while the patients were speaking. He never interpreted or explained while the patients were talking to him. If a patient started talking again while he was writing his notes, he immediately put his pen down and sat back to face the patient. Each patient sat in the seat right next to his desk where the barriers were broken down. He never slouched, but leaned in to be closer and hear better. The Rwandan people are very stoic and quiet. They often talk without looking at you. The tone and volume of his voice matched that of each individual patient and he never forced eye contact. His focus was intense and it was clear that he was both physically and mentally present. For that time, as far as he was concerned, Nina and I were not in the room. After he wrote his notes, he explained the patient's complaints as well as the purpose of each medication. For every single patient.
The patient that I see when I close my eyes and think of that day was a young boy probably about nine or ten years old. Old white Nike gym shoes stained brown by the dry red dirt, long yellow shorts with the three familiar green stripes of ADIDAS running along the side, and a dirty gray t-shirt. He came to the clinic alone and I never asked where mom or dad were, there was really no need. This young boy spoke softly and looked down at his hands as he answered Dr. JMV's questions. This physician was patient and kind. He prodded the boy and leaned in to lock his eyes and ask his questions. This boy was going to begin ARV therapy and needed a few other medications for a cough. Dr. JMV wrote the script and then did something I've never seen a physician do for a child: he carefully, one by one, explained each medication by name. Directions and all and asked the boy questions to make sure he understood. I had to go to the doctor a few days before my trip and my mom still asks me if I need her to come along. I'm 23. He was about nine. Hmmm... I know that he is alone because of necessity, but this speaks to the ability of understanding treatment in pediatric patients. As a future physician specifically interested in children's Infectious Disease, I am greatly concerned with the doctor-patient relationship. Too often I see physicians talk over and around children directly to the parent while never truly acknowledging the actual patient. And we, as a medical community, are wanting to see children feel comfortable with trips to see the doctor to grow into adults who trust us and come to see physicians when necessary. Do we expect this relationship based on trust and understanding to happen via magic beans and fairy dust? This boy came in and was able to describe his symptoms in his own words, expressing himself in a very poised and eloquent way. Many people do not hold the expression of a child equal with that of an adult, but this is to do them a great injustice. This is not to say children are capable of the same maturity or level of understanding as an adult, but their voice and the words it speaks are important. Just as important as that of the parent. This is something I will encourage in my own patients. In fact, for the first five minutes, I would love to cover the parent's mouth with duct tape and only hear from the child. So many adults feel uncomfortable in the presence of the physician, enough so to deter them from going. I feel this is an attitude that must be changed, and even better, never developed. It comes from years of talking to the doctor, finding their voice and the right words to explain their problems. How can a mother or a father know if a child's pain is sharp or dull, pulsating or steady? They, themselves are not feeling it, they must be told. If parents are encouraging their children to speak to them about illness, why not encourage them to speak to the person responsible for treating them as well?
The patients feel so comfortable as children and adults seeing Dr. JMV that I was surprised at the ease with which shirts came flying off! A little boy came in with his mother had a very severe and painfully swollen case of shingles (think Brandon... sunburned...100 times worse). Truthfully, I've never seen a human being that shade of red before. And the whole area was covered with tiny, painful blister-like spots. Dr. JMV asked him what he was in for today and before I knew it, we were looking at a bare back and a little kid butt crack. Just like that. He never appeared embarrassed and he was never prompted to drop trow, but there he was, quite matter-of-factly. I see London, I see France...I saw a lot today.
While it's true that the Rwandan people are very serious in appearance, with little show of emotion this is not usually true at Dr. JMV's office nor at the WE-ACTx clinic. In these places pain is not hidden. Physical weakness is not covered. Concern is intensely expressed. Is this due to feeling relaxed in the physician's office? Partly. Dr. JMV is comforting, attentive. They let down their guard with him because he is respectful of their vulnerability. It has nothing to do with physical exposure. It has everything to do with emotional exposure. He moves and speaks slowly. He asks questions that can be difficult or stigmatizing to answer, but he does it in such a way, with such an emotional tenderness, that shows each patient he or she is loved. Unfortunately, this cannot be taught to medical students. Too often, this relationship is taken for granted or never cultivated to the level of trust and true partnership that it should be. When one has the opportunity to witness an encounter of such quality between a physician and a patient, it is truly both inspiring and humbling.
So, what's the other part? Simply stated, desire. Necessity. These people are very sick and very poor which makes for the most deadly combination. I love hearing people use the phrase, "Oh that's the worst. I hate that." Poverty and illness, whether it's malaria, dysentery, HIV, or TB, that's the worst; I hate that. No higher, I call. Patients know that, especially in resource poor settings, they have very limited time to spend with the doctor and that the waiting room is often overflowing with people just as sick as themselves, waiting to be seen. They are always waiting. To see the physician, to feel better, to find their next meal, to find work, to get their test results. Once inside the physician's office, Rwandans no longer wait. The second the doctor asks the first question, many patients speak with a fiery quickness, voices raised, emotional faces. They have come to see the doctor and there is no confusion about why they are there. Many patients don't acknowledge Nina and I. The ones who do, shake our hands, sit, and don't look at us until Dr. JMV begins to write. They are finished, and now, again have time to wait.
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