Gay Men and African Women

"Come on, don't be scared, just say it! FAGGOTS. That's the highest risk group in Vancouver." My preceptor spat out the words as he egged me on with a grin. He is a tall, ridiculously good looking, tanned and muscular gay man with salt and pepper stubble on his ever smiling face.

"I won't say it, so don't even try." Was my determined response.

For someone who sees herself as fairly open-minded and worldly my assumptions and stereotypes have been given a good beating this week, which is fantastic! I'm working at a clinic that functions as a family practice but focuses on the HIV+ population and specifically gay men. There have been both funny anecdotes and serious ethical questions that I've stumbled across which at week's end I find hard to process coherently.

There was the diagnosis I nearly missed because I didn't ask about nipple bitting . . . of course, silly me. Next I had a young businessman who skipped all pleasantries as he rushed into the room. "I have a rash." In a second, shirt and tie were off and he dropped his pants to show me the distribution. On the bright side, my choice of obstetrics has been confirmed. Although I love the HIV medicine, seriously folks, scrotal rashes are gross. I was also recruited to do a pap smear on a transgender young man who was going through gender reassignment but still had his uterus. So many fascinating and complex medical issues. Heck, not just medical issues.

A well-educated man in his 70s divulged to me just as he went out the door that he wouldn't even shake hands with 'them', he hadn't realized that the majority of the patients here were gay. He had even ignored the hand the doctor I was working with offered him. "You never know how you might catch it." Before retirement he had worked in a microbiology research lab. I was shocked by his views and told him that he should know better . . . with my usual undertone of humour of course.

The fashionista-shop-a-holic-I'm-in-love-with-Justin-Timberlake nurse shared his frustration with me after meeting with someone who had just found out they were HIV+. The patient is in his early thirties, as is the nurse. "There's just no excuse, I don't understand it. In this day and age we know about the disease, we know how prevalent it is and we know how to prevent it. I don't want to judge, but I just don't get how people go ahead and do what they do." My reaction was a bit of surprise I suppose. I thought that this nurse, having worked in the area for several years, with first hand experience would have some insight into why people are still getting infected. Even though HIV is no longer a death sentence and is treatable, it still turns lives upside down.

Perhaps it was similar to the shock I felt when on returning to Tanzania I ran into the husband of the head nurse I had worked with in Uha. We were waiting for transport out to the village. He was returning from her funeral, having died of the unspeakable disease and leaving two young sons. She knew all there was to know about the disease. We led HIV/AIDS seminars together for women, she counseled people to get tested and tell their partners, she delivered the babies of women we knew were infected and saw their fear and pain. But still, with all her education and experience she could not completely control her own health. Was her husband sleeping around? Had she been cheating on him? It doesn't matter, does it? Disease doesn't take a moral stand.

That's the conclusion I've come to. Several people asked me this week that it must be so different working with HIV populations here compared to Africa. More resources? Yes. But the loneliness is the same. Sickness and suffering unite us in our humanity. To look in the eyes of a middle-aged white professional man or to hold the calloused hand of a young mother from Uha I feel the same heaviness is my chest. That this world is not as it should be, and in the depth of our suffering there is inexplicable hope when we realize we suffer together.

Life is Beautiful

Life was not beautiful at 2pm when I was still at the hospital on Thursday afternoon after being up most of the night. Its the tightness you get in your temples, the blurry vision and incomplete sentences that are frustrating to no end. The ultimate problem is that you stop caring. I swear I dosed off while peeing then jerked awake and later found myself 'resting my eyes' when walking down long corridors (just for efficiency's sake of course). Not that the night was uneventful, we extracted a bottle of Dove shampoo from an unnamed body orifice (take a wild guess which one). It brought a whole new approach to the Dove campaign for real beauty. As the story goes he had been "watching a documentary on the male G-spot", which is surprising, because normally the story is "I was doing my laundry naked and I just fell on the flashlight" or "I slipped in the shower and . . ." Nice to have an honest answer I guess. But ANYWAY, I digress . . .

Eventually I got home, collapsed for an hour nap, dragged my pathetic self out of bed for a shower and headed to the airport to pick up a friend visiting from Calgary. And so began my lovely long weekend. There were three friends from various locations crashing at our house Thursday night. Friday was a deliciously relaxing day involving warm gooey cinnamon buns for breakfast, an exquisite foot spa (apparently that means pedicure with benefits), a run through the endowment lands and along the beach in the rain culminating with yoga by the ocean. This was directly followed by hot tea and the whole day was peppered with endless discussions about love, poverty, economics, and toe nail polish.

By 8pm Friday I was on the ferry with another set of friends heading to Galiano island. Saturday morning brought with it a brilliant blue sky and calm waters as we crammed our camping gear into the kayaks and battened down the hatches. Of course Bertha (my camera) was strapped to the deck of my kayak in her fancy Pelican box. We paddled along the coast, past intricate sandstone carvings molded by the ocean, turkey vultures circling overhead, cormorants skimmed the water as we came upon their nesting site and dozens of seals sunned themselves on rocks. A pair of otters crawled out of the water and playfully rubbed water from their eyes as they scurried around the rocks. The whole time our chatter was nearly with pressured speech about all the challenges and experiences that residency has brought interspersed with silence in awe of the beauty around us. We crossed the straight to Wallace island, camping on the northern tip. Uncontrollable laughter accompanied our racoon-safe food hang before our pitas, hummus and wine appetizer. The sun sank slowly behind Saltspring island to the West sending shimmering gold across the water to our feet. A day of perfection, surreal in its beauty and a lifetime away from anything mildly related to medicine.

Sunday morning the sun greeted us again, unheard of on a random weekend in September on the West coast! The wind had picked up but we had a 'following sea' which pushed as back along the coast. Out of sheer necessity I actually started paddling with good technique, figuring out how to isolate those back muscles (fortunately my roomie is a professional!) Soggy, chilled, and blissfully exhausted we glided back into the Montague marina.

Life is beautiful. I am profoundly privileged and blessed to be who I am where I am right now. This situation is helped by the fact that I'm now working in a clinic that doesn't start until 9am! Can you believe it?!? 9 to 5, its novel, and no call! In the mornings I curl up in a chair sipping tea and listen to morning meditations courtesy of the world-wide-web and the Jesuits. The outlook is good!

Nostalgia

The sky was bright but the rain fell steadily, pattering softly on the roof and I sat inside insulated from the cold dampness. Slippers on, cozy in my hoodie. Something about today made me want to be back in Tanzania. Maybe it was reading about flooding in Africa on the BBC news, or the frustration of running around doing nothing at work today, who knows. Maybe its the rain.

The memories so vivid. Breeze blowing through tall grass on the plains, clouds rolling across the hills. Bright green maize sprouting in rows of dark brown earth. Women in the fields, weeding, children on their backs. Visitors, always visitors. Children holding my hand, doing homework on the cool cement floor of my living room/kitchen, kicking the soccer ball out in front of my house. Surrounded by people. Walking down dusty paths to visit people, flip flops reassuringly slapping my heels with each step. Shared chai, scalding my mouth, ginger warming my throat. When it rained I couldn't hear my roommate Atu over the thundering on the metal roof. Water seeped under the door and earwigs fell from the roof. No insulation from life. Every moment was about being, not doing. I learned how to fully appreciate the present, not regretting the past or worrying about the future. "Time is not passing, it is coming."

The rain petered out as the sun set and transformed the low-lying clouds over Vancouver into delicious golden peaches and oranges. We slurped noodles on the front porch watching bikers whiz by and dogs pull their humans out for evening strolls. The long long distance from Tanzania isn't just geographical but living in the present seemed like it was infinitely possible in the moment as the moon rose and the light faded. So tomorrow I'll got back to the same hospital with the same people, but I'll try to be instead of do.

Voldemort and Sierra Leone

Blurp-blurp. Blurp-blurp. The submarine sonar sound of my pager swims in my ears through the thick darkness. I page the number.

"Trauma team activation. Multiple stabbings."

Then I'm in the trauma room, everything is happening through a fog. Nurses, paremedics and the emergency doctor are there but no one is doing anything. Blood everywhere. Then somehow its me, gasping for breath, blood coming from the side of my chest, standing there bent over.

The scar on my forehead burns as I'm ordering two large bore IVs, bolus 2 litres, CBC, type and screen for the trauma patient. The image in my head (as pain sears through the scar on my forehead) is of a fetal heart rate tracing, plunging lower and lower, the sound of the doppler pounding out the heart rate getting slower and slower. Wawumph, wawumph . . . wawumph. Nobody is doing anything about it. I hear myself yelling at the shock of no one rushing the woman to the operating room as the baby's heart rate drops. And then I'm running as if through wet cement, the air thicker than molasses, trying to get to the labour and delivery ward in time to save the baby. The elevators are blocked by scrawny African teenage boys with AK-47s, their eyes dead, their voices threaten me as I'm yelling, desperate to get upstairs. I can't control my body's movements. Then my surrounding are no longer the hospital halls but a war zone in Sierra Leone. A young boy with his machine gun hanging down his back pushes a wheelbarrow through tall grass in front of him piled with dead bodies. Flies. Heat. Fear.

Blurp-blurp. Blurp-blurp.

I wake with a start, my heart racing, full of fear, clammy with sweat. The dim shapes of the call room come into focus.

"Mrs. K hasn't peed for 6 hours."

Clearly I'm going nuts. Surgery must be stressing me out. That and I'm reading too much Harry Potter. I'm also reading "A long way gone: memoirs of a boy soldier". Vivid and moving. Maybe too vivid for me these days.

P.S. I don't actually have a scar on my forehead the connects me directly to labour and delivery and the mind of Voldemort . . . I don't think.

Cutting

Its official. I'm addicted. I love cutting. I can't even explain the exhilaration of it, probably some psychiatric problem I'm sure.

Mr. A is a divorced videographer in his 50s. We got a call from the ICU, it was one of the more, um, exuberant residents. This is how it went when we returned the page:

"F***, what's his name? What's the fat guys name? Anyway, we have a guy with alcoholic pancreatitis and he's going to f***ing die if you don't cut his belly open, we can't even ventilate him anymore."

Years and years of education to come up with such eloquent and concise vocabulary, that's quality.

The 'fat guy' had abdominal compartment syndrome. Pancreatitis is really quite nasty, your pancreas digests itself and then works on digesting the rest of your insides. The pressure in Mr. A's belly was so high it was pushing up against his chest and they were having difficulty getting air into his lungs. Unfortunately, his deaf mother in a nursing home was his next of kin (i.e. decision maker) so she signed things over to his ex-wife . . . who decided he didn't really need the said 'life-saving' surgery. So, we did what most patriarchal medical doctors do when the decision-maker doesn't agree with their treatment . . . two ICU physicians signed a form to make the decision for him, that is, the decision we wanted made.

Our part was the decompressive laparotomy. Quite barbaric really. Although the really barbaric part was when the chief resident handed me the scalpel. The belly before us distended and rock hard from the pressure.

Cut with the belly of the knife. 90 degrees to the skin. One smooth, continuous motion. And there I went. From just below his sternum, around the belly button, and down to his pubic bone. Then we cauterized through the thick layer of fat, through the muscle, fascia and then pink intestines just oozed out, worming their way out of the pressurized cavity. An image of a snake pit from an Indiana Jones movie crossed my mind. Dark brown fluid poured from the opening. Dirty yellow omental fat covered with what looked like white lichen, where its being digested by pancreatic enzymes. Quite the rush.

We didn't close him up, instead we put layer after layer of sticky saran wrap over the gapping belly, cut a whole in the middle and connect it to a vacuum. Back to the ICU he went, most likely to die.

I love cutting. I can't deny that I find surgery stimulating and fascinating, but its just not the same as obstetrics. The full words to describe my thoughts fail me, but the fact is, I'm a better person when I'm doing obstetrics and women's health. My heart felt cold as we wheeled Mr A back to the ICU. In my mind he was the 'fat guy'. I had no connection to him, and yes, compassion, but no empathy.

Three weeks ago there was a woman here on holiday from Spain. She was 17 week pregnant and having a miscarriage. I spend most of my day with her and her husband. I suppose it helped that I spoke Spanish but my soul resonated with their situation. First talking to her and explaining what to expect. Then assuring she had a private room in the emergency department (no small feat). Then fighting again as she was transferred up to the surgery ward to a four-person room as she laboured. Finally staying after I could have gone home to reassure both her and the nursing staff who had never had anything like this happen on their floor before. At days end I caught that tiny being cupped in my hand, wrapped him in a towel and placed him by the window for the priest to come and bless him. Neither of the parents wanted to see. After that, I examined him and slid his miniature body into the plastic pathology container to be sent off. I left them that night feeling not only like a real doctor but a deeply human one.

The reality is that you can't identify with everyone. My hope is that everyone can empathize with someone, being aware of feelings towards patients is probably the first step. Maybe cutting isn't everything, it makes my heart beat fast, but it doesn't make it sing.

Paradise Plagiarism

This is copied (with permission) from someone very dear to me. Her description makes my eyes well up with emotion and then smile at the next paragraph. It is both beautiful and tragic, reminding me of the world outside my everyday bubble. Heartbreaking, frustrating, and hopeful all at once. She has a gift, both in how she shares this story, and in the work that she does so passionately.

FRIDAY

You work with it most days. You’re trained to not let it affect your innards. You see it all the time all around you, but some days it just kicks you in the gut. You can feel it in your stomach and the discomfort is intense and doesn’t go away.

It was a Friday. You know, the usual, choose which house in the slum is the poorest to improve to create a better quality of life for a family this means going around to visit the “poor” families to see who has the greatest need, determine what is greatest need and who seriously contemplate who it was that decided that you had the capabilities to make that determination.

This is the part that kicked me in the gut. We visited three houses. All members of the Centro Mujer, women and their families. All living in deplorable conditions, a true violation of human rights. Accompanied by a 50 year old worker at the centre, who is known for her strong opinions and harsh words, we walk a few blocks up, through the now closed market with all the smells of the afternoon after a market. We come to the house of a grandmother who takes care of her three grandchildren, her whole extended family live in this house. It has brick walls on two sides, the front is of plywood. Outside it has a tree planted by a previous group of gringos, the tree is called Angel Guardian. The front room has a tin roof, we go back to see the bedroom, straw matting and a tarp for a roof, we peer into the room, trying to focus in the dimness even though it is mid day, we see the drizzle accumulating in puddles on the tarp and the drips slowly making their way to the bed and all the possessions below. We say we are just visiting to invite her to help with the event tomorrow, she says she will come and she will make some nice hot ponche for the tourists, so they don’t get too cold. She’s always very hospitable, she apologizes that she has nothing to feed us, as she didn’t know we were coming. She apologizes for the state of poverty she lives in.

We walk a few more blocks down some muddy alleys past an old rusted out car. There is a piece of plywood blocking the distance between the old car and a big rock, must be the door. We knock, a girl answers, she must be about 8, she is looking after her cousins and her mother isn’t home, we look past her to see another rusted out car and two little girls, the oldest no more than two years old, sticking their heads out of the windowless windows of the car, where they had just woke from their naps. Yes they were all sleeping in the old cars, she says, because that’s the only place the rain doesn’t come in at night, well except through the windows, but the roof keeps them a bit dry she says. This is how they live. The faces of those two little beautiful creations in that car will always be burned in my memory. The inequality and injustice of great poverty hit me so strongly in that moment that I truly felt winded and on the verge of tears and had to turn around and walk away. I am supposed to be a professional, I have seen great poverty all over the world, but sometimes, for some inexplicable reason it hits you with enough strength to knock you out. It gives you great pain, but it also reminds you why you do what you do. Because it is a failure of humanity, our personal failure, that those beautiful children have to grow up in extreme poverty with no option for escape, so few opportunities available to them. It is a travesty that we are all responsible to make right. That is why I do what I do, and every once in while, you just need a kick in the gut.

The third house still awaited us, but I had already made up my mind which family we would be building a house for tomorrow. That is, until I reached the third house. We walked up to the cemetery, we wanted to take a moto taxi but none of them go that far, they don’t like to go through the cemetery. So we walk through the cemetery, getting decidedly soggy and the bottoms of my pants and shoes covered in mud and goodness knows what else from the continuous foggy, dreary, drizzle that is Lima in winter. We arrive at Paraiso, or Paradise, on the other side of the cemetery, I have visited it many times and it always gives me a different concept of my definition of paradise. It is one of the poorer areas of the slum, an invasion, a squatter settlement, meaning the families that live here could be kicked off their land at any time. No running water or sewer, minimal electricity, most people here cook with kerosene as opposed to propane that is more economical but needs to be bought by the tank which requires more money at one time than most people living here in paradise can afford. We start climbing the cerros, and the mud squelches under my shoes, I slip and slide in some small river of unknown liquid that is trickling down the hill, almost wipe out but I cling to a rock jutting out of the side of the hill. We reach the house, a woman I have known for two years, her 8 year old daughter comes to greet me, the friendliest kid I know, always wanting a hug and wondering how I am. She often accompanies me on home visits that I do in this neighbourhood. I go into their house; its walls are built of straw matting and the roof as well. The three little pigs wouldn’t stand a chance in here. Normally if you have straw matting on your roof, because it is the cheapest construction material, you would also have some sort of plastic or tarp to keep the rain out. This family doesn’t, she tells me her three small children are always sick with respiratory problems from the constant damp and dust. They have all been in and out of hospital since they were born. We chat for a while; she works sewing beads onto t-shirts- you know like the ones you buy at Old Navy or the Gap? She gets paid 20 cents a shirt and each shirt takes her about 2 hours, it is painstaking work, tiny beads in exact formation, you often get discounted, she says she hasn’t been paid for her work for the last month and a half. I leave her to her work and discuss the three houses with my colleague. We decide on the last house we saw. I go back to the house and tell this woman that tomorrow we will build walls and a roof for her house, so that her children don’t have to be sick all the time. The look in her eyes I will never forget, she had no words to say to me but the tears started to fall down her face, I have never felt so blessed to be able to accompany her in that moment.

So continuing on with the Friday night, after determining who is the poorest of the poor your job is to: get building supplies, find someone to build it - that is, find someone who knows something about construction who wants to work with a few hours notice on the biggest holiday in Peru, 28 de Julio, Independence Day, an impossible task- tell the family to clear their stuff out, get building supplies through the cemetery and up the hill to the straw matting that was the existing house, figure out how to get four pre-used pre-built plywood walls off of the third floor of the Centro Mujer, which is currently undergoing construction so the brick walls are still wet with mortar- try not to knock them down—get these plywood walls down to the street, through the cemetery and up the hill- with only the help of five older women who aren’t really the wall moving types. All because a group of gringos is coming, with about half a day notice and want to build a house. While you are doing all of the above, also, teach one of the final sessions, on how to be a leader in the community to stop the endemic violence, to a group of volunteer domestic violence counselors, as there is no access to sufficient professional services in the slum that I call home, San Juan de Lurigancho.

BUT, that’s not all, one of the women who you are training has a epileptic seizure in the middle of the workshop, this then precipitates hysterical crying from one of the other women whose mother is dying in hospital and her husband has just left her and her two children after beating her so badly she was unconscious and is therefore triggered because of being seriously traumatized and under a lot of stress.

AND, or perhaps because of, all the excitement, you start to see stars, which might be exciting if you had just imbibed some sort of hallucinogenic plant found only in the deepest, darkest Peruvian Amazon jungle, however, having experienced this before, you know that you have not had access to such a plant and therefore it is in fact the beginning of a migraine…. soon the vomiting and possibly suicide inducing headache will begin…. but for now, you can’t see. As you are the only one in the centre and the group came all this way on the cold, drizzly day you must finish the session. So you give them a group activity to do while you slip away for a minute to run down the block to your house and pop some gravol and pain pills so at least you won’t vomit on the fabulous women while you finish the session, hoping that you remember the just of what you were planning on saying as you can’t read any of your notes, due to the flashing lights in your eyes.

So while you are feeling around your room to find your drugs, you hear what sounds distinctly like gunshots….but being in a poor slum, you once again thank God that the many gangs in the neighborhood can’t afford guns and usually just throw rocks and beat rival gangs with sticks. However, on your return to the Centro Mujer, you notice everyone picking themselves up off the floor and brushing themselves off. You ask, what’s going on, thinking perhaps it was some sort of icebreaker or other fun activity that they decided to try since you were not there temporarily to lead the group. ---Turns out that it was in fact gun shots that you heard and somehow one of the gangs was shooting at a rival gang member, right outside the centre, on the street corner you just walk past, where the women were helping to lower plywood walls moments earlier. Hmm, makes you think, this getting rid of the violence thing is tricky, these motivated women you’re training don’t really know what they signed themselves up for. Creating change in a community that has deeply ingrained inequality, poverty and violence, the possibilities are endless.

Just your run of the mill, average, boring Friday.