Family Feuds and Cancer Survivors

I make no claim to have battled the Emperor of All Maladies, I have merely doggedly walked under the feet of the insurgents who attempt to stand in the way of the Emperor's tank as it rolls into the square. I loved and resented the experience, captured by their vision and passion, I may even make a career of anti-tank mines myself.

Its a fascinating family dynamic. At its head is the Matriarch, simultaneously commanding, inspiring and terrifying, all the while deeply proud of her brood and how far they've come. The fatherly and jovial Uncle at the height of his career, confident in his inside knowledge of how the whole machinery works, with only occasional sexually inappropriate jokes. Then there's Diva, the sometimes moody and generally demanding teenager. The Adopted Child, sweetly cerebral but easily the brunt of the family's jokes. The Distracted Godfather, now moved on to faster moving races, still an efficient and skilled surgeon but detached from family functions. Last comes the Runt, once dotted upon but now pressured to prove that she can play with the big kids. As a family they can be inspiring, compassionate, blood-thirsty, passionate, and heartless all at once. If you succeed they applaud you loudly, taking credit for having painstakingly formed your skill. If you fail, they step back disgusted at your weakness, sure it is no fault of theirs.

It is one of those rotations in residency that seems like an initiation, a gauntlet designed to prove your worth at every turn. Having survived you now breath easier, knowing comrades have fallen before you, switched to other specialties, left without mental health intact.

Despite the incredibly melodramatic picture I've painted, I'm grateful to the Emperor and the Insurgents for lessons learned...I can say that from the other side.

Good news! You have lymphoma!

Well, I have some good news and some bad news... The bad news: you cancer, but the good news is that its lymphoma!

I recall standing next to my attending at the gyne oncology clinic as an elective medical student in complete disbelief at the words that had just come out of her mouth. The poor patient dissolved into tears. She had been pacing back and forth with too much back pain to sit in the chair next to her husband, a result of massive lymph nodes pressing on her psoas muscles.

A hideously awkward discussion ensued where the attending (sickeningly upbeat and logically) explained that lymphoma had a drastically better prognosis than ovarian cancer, so it was a better cancer to have really. The whole time the poor patient's husband tried to refrain himself from punching said attending in the face. Or maybe that's just the fly-on-the-wall little medical student's interpretation of what happened. My attending then did a smooth punt and turf to medical oncology despite the sobbing patients request for answers.

I remember feelings of helplessness washing over me, overcome with empathy for this hurting woman and anger towards a frankly ridiculous attending. It was in the midst of a frigidly cold elective in Ontario during which I was supposed to be impressing people but felt achingly lonely and completely incompetent for the entirety of the rotation.

Last night I had a vivid flashback on call at the Death Star. The emergency physician called me to see a woman with "new onset metastatic ovarian cancer" who had recent growth of parotid (jaw), neck and axillary lymph nodes (and of course, a mass in her pelvis). It felt like a case of: "patient has vagina, please see in consult." She was young, and as I spoke with her and her husband the fear was palpable. A single tear slipped down her cheek as she answered my questions. The truth was, the chance of her having ovarian cancer was slim to none as further investigations confirmed, gyne oncology was not the service that could help her. Unfortunately Dr. DoucheBag McEgo was the internal medicine Sr resident and it took three heated discussion, four hours and a (useless) consult with hematology for him to admit the patient. My blood was boiling with Dr. McEgo's passion and determination to turf this lovely patient to anyone but his team.

Hours passed, internal med finally saw her but as I walked by to see another patient, her husband grabbed my arm, looking for answers. What's going on? Does she have cancer? Is she going to die?

Leaving the post-partum lady with a fever and the palliative patient with metastatic uterine cancer who now had a lung full of fluid, I sat on her stretcher and laid it all out for them. Yes, right now it looks like lymphoma, but there's treatment for this. The husband curled up in fetal position crying. My heart broke a little...maybe a lot, but it felt like I was actually doing something useful. Not turfing, not fighting to get rid of patients, but being present in the pain, messy as it is. I'm not scared of tears anymore and I'm no longer just a witness to it all.

Full Circle

February 14th, 2008 Vancouver was enveloped in its standard winter cloak of gray clouds and cold rain. Although, even that I was only aware of cycling in the drizzle to work in the dark mornings for 6:30am rounds, leaving as light left the sky in the evenings. Exhausted and drained from another day at the Death Star. There was a haze in my eyes and my head ached, I was on call that night and groaned inwardly when the oncology fellow paged me to go to Emergency to see a patient.

She was a woman in her early 50s, who after a long post-operative recovery from ovarian cancer debulking surgery had now developed an abscess. She was febrile and in significant pain, accompanied by her husband. She was also a physician, as was her husband a fact I knew from her lengthy admission to the service.

The most amazing thing happened that night. Though her own pain and fear, she focused on me as a person. How is residency going? What type of practice are you considering? What are you struggling with? What do you love about the specialty? I stood next to her stretcher in the emergency department, examining her, explaining the CT scan she would get and the antibiotics she would be on, all the while completely floored. Here was my patient, a physician no less, taking the time to recognize my humanity, something no one else had taken the time to do that whole year. I remember the night vividly.

September, 2010 Why don't you see the next patient? She's a doc so make sure she's okay seeing residents first. And there she is as I walk in the room. A warm smile on her face, her arms tanned from the sun, positively glowing despite a recent recurrence and chemotherapy. Hey! I know you, February 14th. Were her first words to me. You saw me on the night I was readmitted to hospital!

I couldn't help but recount to her how she had recognized the person-hood of a junior resident in the middle of the night in the emergency department and in doing so had renewed my faith in a healing vocation. We can't cure her cancer, but nothing about her suggests a dying woman, she is living and vibrant, full of hope and laughter. And so I come full circle.

Doctor in Denial

There comes a time in every kid's life when they realize something about themselves that has become too obvious to deny. This has happened on many levels for me, and now, there's no denying it, its been four years, lets face it, I'm a doctor. No more denial.

The challenge comes when trying to find a new blog title though, something that portrays a journeyer, some humility, faith, a learner, open-mindedness, and yes, something related to obstetrics and gynecology. A list of hilarity ensued:

Hippocratic Acrobatics

Chicken Soup for the Vagina [lets get all spiritual]

Vaginal Soup for the Soul [that's going too far]

Vaginal Surrender: Gynecology on its Knees [an attempt at the humble part gone oh so wrong...]

Vagina Smagina [not quite profound enough]

Confessions of a Passionate Nomad [sounds like a travel blog, although a friend once told me she could see me 'saving the world, one vagina at a time'...]

Confessions of an Aspiring Mid-wife [might get doula-wacked, better watch out]

Dr. Mister the Gynecologist [insert inside joke here]

God, Boob-juice and Hysterectomies [stop while you were ahead]

Eventually, after several episodes of gut wrenching, eye-watering laughter, here's the new title, comments welcome.

Informed Consent, the Lion King and Cholestasis

So...what you're saying is that there's a risk of stillbirth so that's why you recommend getting labour started now?

This was after a thirty minute discussion on cholestasis of pregnancy which is associated with a 1-3% risk of stillbirth at term. The poor woman came in as itchy as a bed bug infested child, going a bit nuts scratching her skin off. There's no need for an urgent induction, but we do tend to recommend proceeding with a birthday party if the baby is already fully cooked in there.

Well, this is a miracle baby you know, it was an IVF pregnancy and we're really quite nervous about it...but...its just...well...

Understanding where people are coming from is crucial, we get taught to ask how people feel about treatments, what their perceptions are yada yada yada, but I couldn't quite get inside this woman's head.

We had tickets for the Lion King this weekend, couldn't we have the baby next week instead?

Then it all made sense. We're not in Uganda any more kid, there's more important things than life and death you know, there's the Lion King. [Insert irony here.]

Off to Amsterdam Again

My time is drawing to a close. I’m going to miss things. I’ll miss the carpenters saying good morning and greeting the chapatti lady as I wind through the neighborhood, past plantain trees, scattered maize and jack fruit trees on the way to catch the matatu every morning (I live behind a petrol station you see). I’ll miss the milky chai, fresh pineapple and mango breakfasts. I’ll miss my chats with Veronica every morning in Kisenyi before we start our surveys as we sit in her somewhat derelict hair salon, the world passing us by on the dusty street outside. She loves reading, and although she has no books, she budgets to gets the local Luganda paper every morning and as she sips her chai she translates the stories for me.

She this man! Ah! He was to marry this woman, but then at the wedding day, this woman here came into the church and said that he was already married to HER and had three children! These people…

The last page of the paper always has an update on the soaps. Most are dubbed Brazilian soap operas (not quite sure why), sheer cheesy hilarity to watch. Apparently everyone says I look like the character ‘Ina’. Veronica points at the pictures as she explains:

Shona, have to seen it yet? On TV? Well you see this man, he is in love with Ina but they forced him to marry this woman, see? Can you see even the tears in his eyes? Oh it is so good this show.

She’s an amazing woman, she’s 55 and has had seven kids, four of whom are alive. In addition to being village chairperson, it sounds like she helps support about 10 grandchildren. Two of her children are working in Iraq and she wants to send her other daughter as well, the money is good she says. It blows my mind. They mostly work in security and when they are there everything is provided, their salary goes directly into a Ugandan bank account. Perfect scenario, no? Except for the getting blown up part I suppose.

I’ll miss the vitality of life, the gratefulness for each day that people have. The vivid colours of clothing, the smiles in response to my attempts at Luganda, the very grittiness of life. As my mom says of life in the developing world, the colours are brighter and the pools are deeper. It strikes me also that heartache is closer to the surface, each moment of life is more precious, it can come and go so quickly after all.

I’ll miss my Ugandan family, the sometimes profound, sometimes hilarious dinnertime conversations. They are middle class Ugandans who are deeply generous, taking in all sorts of strays in need (mzungu and Ugandan alike!) I’ll miss groundnut sauce…but I suspect I won’t miss the matoke (steamed and mashed plantains) for every meal. After some deliberation, I don’t think I’ll miss the Lugandan gospel music piped through the household sound system at 7am every single morning. I vaguely recall initially finding it a lovely part of the whole Ugandan experience… naive rookie!

I may even miss the tachycardia-inducing bodaboda rides. The first day I was sure I would not die, instead I would be smeared on the road between a matatu, a large truck and a bicycle overloaded with plantains, maimed for life. After that it turned out to be a fun part of the daily routine.

I’ll definitely miss not being on call…two months with no call has been soul restoring. Although my soul has been restored by much more than that. I’ve found passion for my vocation again, or it has found me. Instead of pulling myself out of bed each morning to do something interesting that I feel privileged to do, the work itself pulls me out of bed and drives me through the day. I feel empathy again, compassion, my jaded attitude has dissolved in the mud of Kisenyi and in the eyes of the women who have shared their stories with me. I’ve lost the sense of overwhelming helplessness in the face of human need and again am ready to hurl myself indignantly at injustice.

I’m reminded of a quote that a physician read out to our class on the first day of medical school, as we sat packed into our seats in Libin theatre, naively full of apprehension, dreams and ready to take on the world.

Do justice,
Love mercy,
Walk humbly.

Of course, these were familiar words, as I was raised on them.

A Love Affair

I’ve been having a love affair with Jinja.

Who’s Jinja you say? Fine, I’ll admit it, not a person but a place. The source of the Nile. It was the third weekend I had been up there, the first time for rafting, the rest to kayak.

The kayak skirt tucked tightly around me, my red Spice playboat responding to every movement of my hips as we paddled along. I feel a bit guilty, you know, with the water shortages in this part of the world, that I should be inhaling so much of the Nile into my sinuses…so wasteful.

My teacher David and I had spent hours working on my rolling, you know, the second 180 degrees that gets your head OUT of the water. As I feel I have a gift for easily accomplishing the first 180.

We now paddled down the river to approaching rapids. The sky was bright above us, the sun beating down, but ahead huge dark clouds loomed. Like a prairie thunderstorm on a steaming summer day, we could see a sheet of rain approaching in the distance. The clouds flashed like fluorescent bulbs, trying to flicker to life and I heard deep grumbling in the distance. I cursed myself for not having invested in a waterproof digital camera as the light show was breathtaking.

It was exhilarating. The pounding waves, spray and foam of the rapids, David convinced I was capable of turning my kayak backwards and surfing the wave. Of course I was, but it took few runs to maximize the percentage of time my head was out of the water.

Then the storm hit us, pelting down, the rain seemed to have the force of a waterfall. Powerful, overwhelmed equally by beauty and adrenaline.

An affair I won’t easily forget.

Sorry, No Cervix, No Survey

But what about the men? What about us? We are important also! He was about the fifth Somali man who had interrupted us with the same question.

I paused as I tilted my head to the side and studied him thoughtfully from the rickety stool I sat on, my brow furrowed. Tall and lean, loose black curls on his head his skin nearly golden brown.

Do you have a uterus?

A what?

A uterus. A womb. Have you given birth to any children?

He laughed and shook his head. What was this crazy mzungu all about anyway talking only to women and not to men?

Surveying Somali women has been a challenge for us all along. Not only are we limited by our abysmal Somali language skills, but they are a relatively closed community. As refugees living in a poor neighborhood, they are as suspicious of Ugandans as Ugandans are of them and speak no Luganda. Unlike Ugandans, who approach with friendly greetings, Somalis have a direct, blunt approach. What is happening here? Who are you?

We had occasionally struggled through some surveys in Kiswahili, as a few of them have learned a bit along the way. A survival skill on their tragic pilgrimage across East Africa. But today we hunkered down at a fruit stand, owned by a Somali woman we had interviewed last week, who invited us back. At first, things were a bit rough. What?!? All I get is a piece of soap? Give me another one! But slowly women gathered, curious as to what was going on. All covered in various colours of flowing veils, a circle of cloth framing their faces, others with only their eyes visible. Rarely you catch a glimpse of an ankle, or a toe through a worn through sock.

We had a young Somali woman helping to translate. Her English was good and she reported being an avid BBC World News fan. As a diaperless 14 month-old crawled around a huge basket of papayas under the fruit stand and with flies buzzing around, we heard the now familiar stories. Married at 14 years old. Of course they had never had sex with anyone but their husband, they indignantly reassured us.

You don’t understand, we are Somali women! No boyfriends, only our husbands. We are clean down there! If not… She made a gesture with her finger across her neck. Doreen asked, but what about the men?

Ech, the men, they do what they want. Who knows about the men, you cannot control them! What I did know, is that the men found it was miserably unfair that we only wanted to talk to the women.

The women were confused by some questions. Yes, of course I go to the hospital when I am sick, yes, I am Somali, I must go. Always statements with pride in who they are. But the idea of going for screening, of checking something when you had no symptoms, no pain, no bleeding. No. You go when you are sick. Silly mzungu with the crazy questions.

A cheeky Oxfam gender adviser (my sister) I know added her two bits, "as a gender adviser, i would like to advise you about the issue of gender equality. I am concerned that your research is not addressing the issue in a balanced fashion and seem to prioritize one gender over the other. Concerning to say the least, especially in this day and age."

Money Can Buy Bliss

Knock off pink Speedo swim goggles: 8,000 Shillings

Matatu fare: 200 Shillings

Bodaboda (motorcycle) ride: 2500 Shillings

Munyonyo resort admission: 20,000 Shillings

Swimming in an Olympic-size pool surrounded by palm trees: Priceless

How much does sex cost?

Well that depends. On the time of day. Whose asking. What the ‘guest’ is after. If your kids school fees are due. That turns into between 50 and 1000 Ugandan shillings they tell me (a few cents up to fifty cents), that is, if you’re not looking to spend too much time there. The councilman turned to me and said, you know these women get very rich, see they are fat and healthy.

Hmm. It was the only answer I could muster. The calculations cranked slowly in my head, from the surveys we’d done these women have sex with between 10 and 40 men per week. My math skills have never been spectacular, but that’s not much above extreme poverty as an income.

We had slipped through narrow muddy alleys that morning, the stench of chicken manure permeated everything, apparently this is where you get all things ‘chicken’ in Kampala. Crouching through a low door jam, down a muddy hallway, puddle hopping across a tiny courtyard surrounded by doors. Women in various outfits, most quite simple. All of them with different hairstyles, the diversity of hair extensions in Kampala is truly spectacular. In general most of the women had slightly lighter skin, many had scars across their arms and legs. We were at three different ‘houses’ during the day and the women warmly welcomed us. It took some getting used to. Of course we’re used to pausing the survey when a woman has to go grab some tomatoes to cut into her sizzling pot of onions, or sometimes serve a customer some cassava, or a chapatti. But instead we paused so the women could slip off into a room to do their work. They were generally quite jocular and at the second place we visited, after doing three surveys and teasing each other back and forth they planned a joke on the next client that came in about how much the mzungu would cost. I just had to laugh along with them, the alternative was crying I suppose.

All their stories were different, some had finished secondary school, others could not read. The majority of them had children, a few were married still. Several of them had received screening for cervical cancer, something the majority of the women we’ve talked to had never had. And all these women used condoms every time. No question.

They were hard working women. The only time I glimpsed apology in one of their eyes was when we asked about religion. She said she was a Muslim. Veronica, the research assistant paused. Muslim? But your name isn’t Muslim.

She looked down, embarrassed. Well, I’m actually Pentacostal but you see… her voice trailed off. Veronica just picked up where she left off, putting a hand on her arm. You are what you are, and that’s just fine. It seemed a profoundly affirming statement.

There are many things in our world that are heartbreaking and unjust. But we live our lives everyday, able to live in our broken world without it crossing our minds. We sterilize our lives, separate our daily living from the realities of so many. Whether in Vancouver or Kampala. But when it is thrown in your face, when it happens as you look into a woman’s eyes, you can’t just turn around and pretend you never saw it.

God Lives in Africa

Doreen, is that man crazy or does he just really love Jesus?

She laughed. Maybe both, but I think he's just a Christian Sheona.

The street preachers in Kampala are phenomenal. Seriously. They spend hours and hours eveyday in the scorching sun and pouring rain. There’s the skinny guy who brings his own pulpit and megaphone. He stands on the side of the bustling Entebbe Road going into Kampala yelling at passersby and matatus then intermittently staring intently at the bible on his wooden pulpit, recenlty I think he's run out of batteries for his megaphone. Then there’s the lady with shoulder-length braids who was next to the Nakasero market yesterday when I was buying a pineapple. Her brow furrowed with intensity, she appeared furious as she preached, suddenly whomping her bible against the tailgate of the little Toyota pick-up truck next to her with a loud metallic clank. They just seem so angry, I don’t understand what story they’re telling. Where's all the peace and love folks? I hope they’re describing Jesus getting angry in the Temple about injustice and the rich ripping off the poor…I’m not convinced.

My all-time favourite Kampala street preacher has got to be the guy who strolls around by Shoprite [a South African grocery store]. The same angry, passionate preaching, waving bible in hand. But this guy has a follower…so to speak. He’s a tall Ugandan wearing the long white Muslim dress with the traditional embroidered cap. His face is equally intense but he looks like he has some kind of transcending knowledge. He raises his right hand, his elbow bent at a right angle with each movement and he repeats again and again, “Allah akbar….Allah akbar….Allah akbar….” Whether it’s in response or in harmony with Shoprite man I don’t know. I wonder what God thinks, all these folks fighting for his attention.

I was chatting with my Ugandan family about it, who have been described as ‘serious Christians.’ They likewise think its hilarious and shared a story of a preacher waving his bible chasing a naked man around the central clock tower one day shrieking as he cast out demons from the naked running man.

Faith is everywhere around here.

Sticky Fingers

There are children everywhere in Kisenyi, but usually they’re scared of me and hesitantly curious, never wanting to get too close. But today, in a rather dodgy area of Kisenyi II, a 2 year old little guy spotted me in a store where we were doing a survey. He yelled out, “Mama! Mama, mzungu!!!” And from then on I was his property. He would let no other kid touch me, screaming at them when they got close. Under the beating sun, his sticky, sandy hand grasped tightly onto mine. He laid his sweaty cheek against my hand, his face covered in varying degrees of dried snot. My heart melted, I couldn’t help it. I guess its not made out of stone after all.

Tears

I was with Dr. C today for colpo, one of the gyne oncologists. She’s tall and slim with flowing braids always arranged elegantly. Her belly is unmistakably swollen with pregnancy. She a bit more gentle than some of the other straight-to-business gyne oncs. However, as it is with doctors across the planet, everyone is always rushed and has an important meeting they need to rush off to. All the patients today were HIV positive, not uncommon as cervical cancer is much more prevalent in these women. The first woman was a 32 year-old, here for cryotherapy for her CIN II. It was my first cryo experience and I know they say one of the benefits is that you don’t need any anesthetic, but dang that looked uncomfortable! Tears rolled silently down her cheeks, then weakly she asked us to stop. She lay there dazed afterwards. It must seem rather barbaric. Someone putting a gun shaped instrument in your vagina, which is attached by a tube to a huge CO2 cylinder with a massive monkey wrench on the top to turn it on and off. I knew exactly what was going on and I couldn’t help but envision a medieval torture chamber with a few modern gadgets.

The second woman was slight, her bright turquoise dress flowed to the floor and her hair was combed up into an Afro twice the size of her head. As we broke the news that the biopsy had shown no cancer she clapped her hands together twice and hooted with joy. Her wide smile transformed her face. Her tears were not silent, she thanked us and thanked us and thanked us again. Dancing as she left.

The next came in shimmering in a dress of gold rimmed yellow, black and white. Her news was not as good. Infiltrative carcinoma. We admitted her for a work-up and to set her up for the OR if she was an operative case or for palliative care if not. She just sat in shock. Then tears came with anger as she was shuffled out of the room. I asked about radiation and chemotherapy, Dr. C explained that those were treatments you had to pay for so they were rarely an option.

The next three women played out the same scene, almost exactly the same story. There were no more tears of joy today.

I plodded out of the hospital in the afternoon, turned up the hill and along the dusty road under the sweltering sun. A bit defeated. Sometimes you have the emotional energy to process it all. To fight overwhelming despair. Other days, you can’t. So you just escape.

I had a beautiful cappuccino. Sitting at a café in the shade with a warm breeze, watching the world go by. Overcome by gratefulness. For espresso. For shade. For such resilient, brave women. For the privilege I have to witness their stories. For the hope that I have.

Tomorrow I’ll yell indignantly at injustice again.

Dancing Pea Pods

Yesterday we came upon a group of four women shelling peas outside their home. We stopped to interview one of them as she continued her work. There were a few toddlers around laughing, screaming and occasionally throwing pea pods at each other.

As we stepped closer I noticed the large sac from where the bright green un-shelled peas were being pulled appeared to be gently undulating. Must be the heat I though. A wave of nostalgic memories washed over me, of shelling peas at my grandparents farm with my cousins...our payment for getting to watch Mr. Dress-up.

I looked into one of the pots and realized these were long peas...and they were wiggling. My 'peas' were grasshoppers. Its grasshopper season! The women pull off the legs, wings and antennae before throwing them in the pot and frying them to be sold as a snack. Just like peanuts, they explained.

When I told my Ugandan family of my learning for the day they insisted I have to try them. Now, they're best fresh, we'll get Annette to buy some tomorrow morning and prepare them for you.

Yum.

Laughing Sisters

The breeze blew into the room, gently shifting the lace curtain covering the doorway to reveal the two cow knees roasting on the charcoal jiko. A toddler sat naked next to the smoking stove, using charcoal bits as building blocks and giggling to himself, as if there was nothing in the world more fantastic than his architectural plans. Our laughter from within made him look towards us. I was in a tiny living room sitting on a sagging sofa with Veronica (one of the research assistants) and two sisters. The older sister sat on the floor while we did the survey, she had insisted there was nothing to hide from her sister and she wanted her to stay. She sat on a woven mat, leaning against the wall with her legs folded beneath her and thought our survey was fantastic entertainment.

One of the questions we ask is whether they’ve had sexual intercourse, the research assistants hate asking this one, preferring just to tick off the ‘yes’ box. She smiled as she answered: “Well…you know...I am Catholic, but I’m not the virgin Mary! Where do you think my four children came from? The Holy Spirit?” When asked if she’d be up for doing self-collection for HPV with a swab in her vagina, she said sputtering with laughter, “why not? There’s much bigger things than that been in there!” My favourite answer however, when asked if she would need her partner’s approval to do the self-collection. Veronica pausing for breath attempting to translate for me, “You’re joking! What do men know about vaginas anyway? What he doesn’t know hasn’t hurt him so far!” The sisters shot jokes back and forth the whole time, it may have been the most entertaining interview so far. They were both intelligent, well-spoken, hilarious women. The laughter in their eyes and bursting out every pore lightened the sometimes intense days we’d been having. It was refreshing. Joy in the slum.

At some point that afternoon Doreen the program coordinator caught sight of my feet. “Sheona!” What?!? I assumed I had just made some kind of terrible cultural faux pas. “Your feet!” A bit of relief, she was just appalled at the state of what Kisenyi had done to my feet and declared that Friday afternoon she was taking me for a pedicure. We laughed some more. It was a good day.

April Fools

Written from one doctor to another on their Facebook Wall:

"We have oxygen in the hospital now!"

A Poverty Spectrum

Pouring rain again today. Kisenyi was a bog, we slipped around for the first several hours. Red mud caked in inches on my flip flops and splattered up the back of my legs. The first house we went to was the poorest I’ve seen yet. We approached the wooden shack hearing voices within. The inside room was pitch black save for a single candle, next to the empty chai cups left from breakfast. Two single beds lined the walls and the uneven dirt floor was covered with thin, ragged mattresses. The walls black from smoke from the charcoal jiko. We interviewed a 65 year old woman who thanked us profusely for visiting. She was endlessly apologetic for the pungent smell of urine emanating from the mattresses on the floor where one of her young grandsons had an accident overnight. She’s had 16 pregnancies, six children and eight grandchildren. Seven people live in this room, smaller than my own bedroom.

Yesterday we had approached a similarly crowded part of Kisenyi, simple brick buildings, the open sewers trickling by. Kisenyi has sporadic patchy electricity but no in-house plumbing. Water is collected from taps spread throughout the community at a cost of 50 Ugandan shillings per 20 liter Gerri can. As we ducked in the short doorway between curtains I stopped, confused. From dirt to a carpeted floor. A couch lined one wall, directly across from the large TV, with DVD and VHS sitting below it next to a huge speaker. In the corner was a flat screen computer monitor, keyboard and computer. But the thing that I couldn’t take my eyes off, was the massive fish tank bubbling away, spanning half the length of the room with tropical little fishies shooting back and forth. As we started the interview a stark naked 3 year-old shot screaming into the room, soaking wet from her bath she ran around oblivious to us. Finally noticing me she burst into tears and buried herself next to her mother’s pregnant belly. We all had a good laugh.

Last weekend I took off to Jinja, just north of Kampala to go whitewater rafting on the Nile with some other folks working at the hospital. It was unbelievable. Spectacular scenery and exhilarating rapids (obviously). I felt refreshed and renewed after the weekend, ready for another week of witnessing human stories. I had a mildly profound conversation with an internal medicine resident from Yale, as we sat sipping tea, and looking out across the Nile. We were discussing how we, as residents, are abysmally trained on how to be present for patients in the midst of suffering and death. We neither have the vocabulary, or the emotional and spiritual skills to respond to a suffering human being in the face of no treatment options we can offer them. And that is exactly the situation we find ourselves in everyday at the hospital here. There are no ICU beds for the gasping patient with agonal breathing, so we either go home for supper and return to an empty bed the next morning, or watch him die. Similarly in obstetrics, a woman in hemorrhagic shock, despite the medication and resucitation that are available to give her, but there is no anesthetist available to take her to the operating room. We can stay and be present, or leave. Either way the woman has passed away by morning. Helplessness in the face of suffering and death is the most uncomfortable place I've ever been.

Perspective

I crawled out of bed feeling achy this morning, my throat was parched and sore. There are these ridiculously vicious guard dogs that yowl miserably all night and I hadn’t slept well. Grumpy, tired and sick…oh and it was cloudy outside. I felt down-right sorry for myself, this was not going to be a good day. I fought myself into the crowded minivan, then onto the bodaboda swerving taxis, bumping through muddy potholes to get to Kisenyi to start the surveys with the research assistants.

It was an ‘outreach’ day, free HIV testing for kids today so folks came from all over. Instead of going to women’s homes, we talked to those who were attending the clinic. The first interview of the day was with a 39 year-old woman. Her outfit was swirls of peach, yellow and green with an elegant matching headdress. She walked slowly and appeared weary. Her voice was soft as she eagerly agreed to complete the survey with us, despite the fact that it would slow her down in getting to see the nurse. As the story unfurled, she described her painful two-hour journey on swollen tender feet. She was HIV positive and here to get her children tested for HIV. When we were finished, she gently took my hand and thanked me in her soft voice, not letting go. She said it was so good we were starting this program, because she definitely needed to be screened for cervical cancer since she was HIV positive… when our program got started, and if she was still alive, like in a year or two, she would do the screening she said. Her sincere, dark eyes spoke volumes of hope.

Perspective. My throat suddenly felt better and my heart was humbled. This was thanks I did not deserve.

As my wise slum-dwelling little sister says, "I am glad that you are having a back to the basics time in Uganda (oops, I mean, the country of Africa). I find spending some time acompañando a mujeres [walking with women] in a slum is good for the soul. Brings you back to what the world is about, to why you do what you do and helps realign priorities.

Plantains, Mud and Cervical Cancer

We started down a muddy alley where several women ran a row of cooking stalls, little shacks made from old planks and recycled car parts. Huge pots on charcoal jikos with piles of plantains steaming covered in banana leaves, beans boiling and peanut sauce simmering. Once we started doing a few surveys word spread among women, cervical cancer is all too common yet women know little about it. Confidentiality turned out to be challenging as women and men endlessly sauntered close wanting to know what the muzungu was at, could they do it too? One woman was persistent, popping back to see if we were done so she could go next. She started reeling off questions, what if she had a lot of pain, what if things didn’t smell right, what if there was this chunky foul discharge? Her symptoms could mean a dozen different things, from benign to well, terminal I suppose. Had she been to a doctor? No, there was no time, she had to work to feed her kids. Her eyes were worried and sincere. We went through the survey and found she was HIV positive. She was 38 and had never had a pelvic examination, an incredibly common situation in most of the world.

There we stood, next to an old converted container that smelled faintly of urine, mud and broken glass at our feet, in an alleyway buzzing with people, the sweet smell of steamed plantains mixing with the human odours of sweat and engine oil. She looked into my eyes, asking for help. I stared back humbled. Completely helpless, overwhelmed by my knowledge and unable to convert my skills and training into the real help that she needed. Yes, the project we’re doing will eventually provide proper screening but we’re just getting started.

I urged her to see a doctor, told her where she could go, and gave her some names of medications she could try (for the benign options, obviously).

Last week at rounds we had discussed a woman who had cervical cancer and was HIV positive. Initially her cancer was treated successfully but it soon returned, metastasized and took her life last Thursday. A combination of underlying cancer allowed to rampage through her body in the setting of an immune system ravaged by AIDS.

This isn’t fair. But this is life, in all its grittiness, that’s what I asked for, wasn’t it?

It feels like such a privilege to be able to see people in their environment. Whether it was the chai/chapatti stall girl who took a break and sat in the alley with us, the mama lishe who sorted the rice for lunch which searching our faces inquisitively wondering about this ‘HPV’ thing we were talking about, or the 60year old woman who is currently having post-menopausal bleeding fumbling nervously and with fear as she asked questions about whether she had cancer…the tethered goat in the background gently chewing on her 2 year-old grandson’s shirt in the shade of a tree. The suvey is going well, it gives me hope in the midst of such raw human need.

The Baby Mill's Got Nothing on This!

Mulago Hospital, Kampala, Uganda

Morning report this morning. Sixty or so residents, medical students, midwives and attendings cram onto benches as the suns rays begin to creep through the window raising the temperature by the minute. All the house staff in crisp white coats, the nurse-midwives equally crisp in their light dresses, knee-high socks and nursing caps pinned meticulously on their heads. An exhausted resident lists off the happenings on labour and delivery in the last 24 hours.

Total women in labour: 73, vaginal deliveries: 48, C-sections: 17, stillborn: 2. The special teaching case is a woman of 28 years old, gravida 4, plus 1 (apparently that means one kid), previous Ceasar. Presented in active labour for 34 hours. Became fully dilated and the fetal heart was 166 at this time. After 3 hours of pushing there was no fetal heart found and fetal parts were palpated abdominally. Uterine rupture was diagnosed and a c-section was arranged, this happened 3 hours later. The baby was stillborn and a hysterectomy was performed due to bleeding. She became anemic with a hemoglobin of 50 and was transfused two units. We are continuing to give her more fluid.

Wow. BC Women’s is a quiet country hospital compared to this. Our morning rounds include pedantic scientific details of preeclampsia for the most part. We ONLY have about 8000 deliveries a year. Of course, they ARE beating us with the c-section rate, 25% isn’t too bad…but then you have more dead babies and mothers losing a uterus they might have otherwise wanted to use again.

The discussion was stimulating and passionate. How could we not prioritize a woman who had a previous c-section and let her labour this long? We have condemened her to infection, she may get a fistula down the road, we took away her baby. What can we change for next time? They know what care they want to be giving, but are bound by the resources they have. I felt for the poor, haggard-looking resident presenting the case, having felt the wrath of attendings in a sleep-deprived state at morning rounds myself.

Next the NICU gives their 24 hour update. Eight neonatal deaths, 6 pre-term, and 2 at term. One may have had a congenital heart defect.

It all left me a little numb, and it was only 9am.

We were going to head out to Kisenyi, the community where the surveys are going to be done. As we were about to leave, Doreen, the project coordinator, got a call on her mobile. There was an emotional jabber of Luganda and she ran out of the room. She returned after a few minutes, with red eyes. “I’m sorry, it seems my brother is dead.”

WHAT?!?

There had been clashes between university students who opposed one of the candidates being proposed as the new president of Makerere University. Things escalated and a security guard shot two students. As it turned out her brother (cousin) had been shot in the neck and was now in ICU. I’m no trauma surgeon, but things didn’t sound good.

It was 11am… maybe it was just the jet-lagged, but it seemed like a disproportionate amount of death and suffering before lunch.

Sex is Complex

Her soft voice in an English accent floats across the room as I struggle to focus and keep my eyes open.

So are you firm in the morning? [pause] Well, how firm are you?

The husband shifts in his seat, about to answer but his young wife cuts him off. The steady stream of her pressured speech has been non-stop for most of the last hour. After several years, their marriage is still unconsummated, apparently a situation that is seen quite commonly at the sexual dysfunction clinic. A comment from the wife sets off another line of questioning.

Oh, well… does your penis have a bend? Some penises do you know?

At once trying to normalize all experiences and put people at ease but yet creating pathology where there sometimes was none. The truth was, the problem was not his penis.

As a clinician our mandatory sexual medicine clinic is drearily painful for me. While I appreciate the importance of the clinic and the issues at hand, I am no psychologist and would make a poor counselor. We spend hours probing the ins and outs of the couples’ sexual lives (no pun intended). Bringing up sensitive issues from their past, guilt, abuse, fear. Low desire, no orgasm, and pain. Its all a bit depressing, there are few ‘happily ever after’ tales here.

They tell me there is hope though, with patients who are motivated and committed to treatment. I’ll let you know what I think in two months at the end of the rotation. All I know right now, is that sex is complex.

A Stolen Passport, a Crack House, and a Bunch of Good People

***WARNING: This is a long read...but does have some funny points, best of all, its true!***

Dark and dingy, with the dust flying the police roughly drag eight of the nine men to standing position, throwing them against the wall in a line with arms above their heads. The ninth sits back in a chair, a large sore on his leg prevents him from standing. Most of them are chachexic, wasting away. About half seemed drugged up and drunk. The police empty a trash can across the floor, they are about a dozen of them, tearing things apart to search for any evidence. There's garbage everywhere, broken glass, dirty clothes strewn around. A few planks divide the small wooden shack on stilts into rooms. Its humid, adrenaline is pumping through every vessel of my body, and sweat drips off my chin as the dust settles around me. I no longer even notice the stench rising from the human waste and trash that pervades the muddy waters beneath the house.

"Who is it that did it? Point him out? Do you recognize him?"

There's a young guy that looks familiar and I weakly suggest it might have been him, but I can't be sure.

They grab him violently and start beating him with a baton, yelling insults,"fumones inutiles." Useless druggie. He curls up in pain. I put my hands on my head, in shock at what I am witnessing. Then my sister, who some erroneously think of as quiet and shy, reaches and firmly grabs the arm of the offending policeman. "Oye! SIN ABUSO!" Hey, no abuse! In no uncertain terms. She says it calmly and forcefully. The policeman stops and leads her to the back room where he explains that if we don't beat them they will never learn.

Rho in turn explains the a cycle of violence will solve nothing. My calm brave sister, who refuses to stand back and be a witness. And the beatings stop.

They are now searching the men from head to toe, most only wear tattered shorts. Two of the police turn to us, delicately holding up a pair of womens' underwear. "Is this yours?"

I can't help but laugh as I recognize my last remaining clean pair of knickers. They were in the guy's pocket. The look on my face must have revealed everything, as one of the on looking officers looked at me and made a scrubbing clothes motion with his hands. Saying with his expression, "yeah, you probably want to give that a really good wash!" Hilarious. It was in general a bit of a clown show, anyone would think it was a group of boys playing cops and robbers.

Now why you ask, were we in the middle of a crack house raid? A weird dream perhaps?



Well, it all started when after returning from a couple of days about 100km north of Iquitos in the jungle, we came back into town to find our hotel room not quite ready. No worries, we though we'd just pop out for lunch and come back later. Leaving a small backpack of clothes behind the desk, I took Bertha (The Camera) with the clothes that remained in a backpack with me. Our passport also happened to be in said backpack.

WHAT?!?

I know, I know. We broke rule number one of international engagement. The rule that says your passport should be strapped to your body, or safe in your hotel. We're not idiots either, we've both lived and worked on several continents. What can I say, nobody's perfect.

So we saunter off in the mid-day heat to find some lunch. Rho tells me to pick the place. So I pick. We go in, sit down. Stand up, leave. It was too gringo for Rho. We stroll down to the Malecon, a boardwalk of sorts that looks out over the Amazon River. Its about 20 meters above the now receded waters, at certain points it has stairs that descend into Belen, a shanty town of floating houses, others stand on stilts. Its where the very poor live, who have no land to own, no money to rent. When the river is high, you must paddle around to get to different houses, but now during dry season, the houses rest on swampy mud-flats. Latrines draining straight below the houses make for an odourous, messy backyard that results in increasing sicknesses during this time of year.

Its a beautiful day, we buy chicha morada popsicles and sit looking out at the river. My bag is in front of me, one arm through the shoulder strap, the other trying to ensure my rapidly melting ice-cream reaches my mouth.

Then, in a second. Two boys pause in front of us, grab, and run. And there goes Bertha. Shocked for a split second I pause, realizing what just happened I leap up and run after them. Valiantly hurling my popsicle which lands squarely on his ankle. Waste of a good popsicle.

The two descend down the stairs heading into Belen and I fly after them. Skipping several uneven steps at a time, all I can think about it violently tackling them. And together we disappear into the slum. Its the scene from Slumdog Millionaire. Mud is flying, someone sitting on their porch sees me chasing them and tries to cut them off, to no avail. We weave back and forth, around corners, under houses, across planks. Mud flying. Heart pounding. I get a hold of one of their shirts as I turn a corner, but he wrenches away and now they've disappeared for good. Enveloped by the slum.

I bend forward, hands on my knees, sweating and exhausted. Alone, in the middle of the slum. My right foot ankle deep in refuse. And the reality kicks in.

The passports are gone.

I don't mind so much donating my camera to the working poor (there’s insurance for that), but passports...now that's annoying. Rhoda and I eventually find each other and dejectedly try to find our way out. We stop to chat with people on the way out, who say the boys weren't from here, they are druggie types. The families we pass are appalled by the theft and offer condolences. They suggest we head to the police station. (Ironically two blocks from where we were sitting eating our ice lollies).

As we ascend back to the malecon to head to the police station, a shirtless kid, maybe eight years old, ran to catch-up with us, sporting baggy red basketball shorts. “Senorita, senorita!” He said he new the two guys, not by name, but he knew their house. His name was Michael, it turns out he was our Archangel. Instantly energized, we took off down the stairs again, following him. A bloke at the bottom of the stairs gently stops us, “wait a sec now, what are two girls going to do in there? Go get some police officers and take them with you.” He seemed genuinely concerned for our safety. So we trooped off with The Angel to light some fire under the police.

Rho mumbled about how the police are useless and when they are called in Luringancho, where she lives in Lima, they come after several hours and do absolutely nothing. Amazingly on this sunny, humid Sunday afternoon, the station was swarming with cops and Rhoda had absolutely no problem at all mobilizing them quickly with her perfect Lima accented Spanish. We started out with two officers, somehow a few motorcycles were added and it was with about a dozen uniformed, fully armed officers that we now descended into Belen. Surreal. Children, women, and men ran to see what the excitement was about. Hundreds of them, following the action. One of the kids, his feet bare and dirty, clothes encrusted with dirt, had a mobile phone he was snapping pictures of us with. Oh how the tables turn.

They surrounded a house, the herd of police suddenly dispersed into the tall grass and garbage behind the houses, then they all stand around, slightly dejected. No trace of anything to be found. Then as if on some silent clue they flock to another shack, propped up on stilts above the boggy ground, surrounding it, three of them climb up and cling to the wall at the back. A heated discussion occurred between the officers and a slurred voice from inside the hut. He refused to open the trapdoor at the top of the ladder which lead inside. For some reason the police wanted us to be very close…like at the bottom of the ladder, as they were deciding to break-in and raid things…not my favourite, not gonna lie.

And that was how I was somewhat dramatically re-united with the last clean pair of underwear, my beloved Bertha, and yes, those highly valued Canadian passports.

Its different how things work in Peru, we descend from the house to cheers from the gathered crowds. No one wants a crack house in their neighborhood. Then ALL of us (i.e. all dozen cops, the nine ‘delinquentes’, Rho and I and a few straggling kids), troop back to the police station.

The police take our statements with most of the accused lounging in the hall, hearing every detail, my name, age, where we’re staying, my profession… it was weird. The young guy a thought I recognized is called Juan, he’s 22. He sat in the corner of the stagnantly humid room where Rhoda had to article every single thing in the bag that we now had in (almost) its entirety. It had been spread around in every nook, cranny and pocket of the drug house.

As I gave my statement, I clearly heard Rhoda’s voice in fluent Spanish wafting from the other room as she explained to the police thugs how the hegemonic conceptions of masculinity contribute to domestic violence. She later educated me on the incredibly high prevalence of domestic abuse in the homes of police officers. Her views on drug addiction and its impact on society were also made known to the [unsuspecting] officers who gazed at her in wonder. This tall, attractive gringa who had no fear and was definitely only a gringa on the outside. The officers decided that my Spanish was from Cuzco, whereas Rhoda’s was most definitely a Lima accent. One of the officers wanted Rhoda to have his phone number…you know, in case anything else happened and we needed assistance…or if she wanted to go on a date later that would also be fine.

Hilarious.

We stumbled away, hungry, tired, sweaty and completely entertained from the police station a full four hours after the incident. Relaxing in the hotel that evening we were disturbed by loud knocking on our door. My nerves were slightly on edge and I leapt up off the bed at the sound. (Part of my jumpiness possibly due to the fact that I was quite scantily clad, a result of all one’s clothes being rubbed around a crack house and preferring not to wear said clothing). The two of the Peruvian ‘FBI’ wanted to talk to us, they returned again later with concerns about dollars they had found on Juan (when he went to relieve himself…I’d rather not know where they had been). It was a long time before I was able to sleep that night, fan wirring, bugs chirping, motocarros zipping by.

Our crowning glory happened the next morning as I sipped a dreamy espresso (the first of my trip might I add!) and we breakfasted on papaya and yogurt. As we flipped through the local newspaper, who should appear on page 14? Yours truly. Next to a story about the heroism of a successful police raid after a Canadian-Peruvian tourist who had been taking pictures was attacked by eight men! Our laughter spilled out all over the breakfast table.

Although I must say, as we strolled around Iquitos that day we were deeply grateful that all white people look the same. Also…we may have [innocently] lied to the FBI about when exactly our flight was leaving.

After all was said and done we felt prfoundly grateful. Interestingly, more than anything else I came away with renewed faith that in general, people are good. The whole experience gave us a glimpse of a side of life in Belen that no other tour could have given us. And as for those eight ‘violent delinquents’? I don’t feel violated in any way. I feel that they have had a hard life, yes there are choices we can all make about what activities we choose to be involved in, and I make no excuses for them, but the truth is, they were born into deep poverty whereas I was born with a large silver spoon in my mouth. Life isn’t fair, but its funny.

The Dust Turns to Mud

Its January, the middle of summer, and supposed to be steaming hot. But strange weather has been availing this year. Is it El Nino or just global climate change. The locals are unsure. Either way, the pervasive dust has turned to mud in the overnight rain.

I'm visiting my sister who works for Oxfam-Quebec in one of Lima's barrios as the Gender Adviser for Peru. She's been called many things: Mother Rhoda, Rhodita, La Doctora... I think I'll stick with Rhodita.

I stroll with her from the Women's Center back to her house. As we walk down the road, flip flops reassuringly slapping my heels, a woman comes towards us, her furrowed brow brightens at the sight of Rhodita. She looks close to fifty but in reality is no more than 35. Greeting each other with the mandatory besito, a kiss on the cheek. I am introduced as the visiting sister.

Como has estado? How have you been? Rhodita looks at her with genuine concern.

Bueno, las cosas siguen...como sabes. Well, things are going... you know.

They talk of the lawyer that visit The Center on Saturdays to help people, and Jose, the psychologist, who is available for counseling.

No se si va a ayudar. I don't know if it will help. She shakes her head, every inch of her body announcing defeat.

Rhodita smiles gently, and with complete reassuring confidence says: Cosas van a mejorar, estoy completamente segura. Things will get better, I'm sure of it.

Espero que si. I hope so.

We kiss goodbye and she hurries down the road and up the hill back to her kids. She has five of them, the youngest has cerebral palsy, and a violently abusive husband. I naively ask who's taking care of the kids...uh, its the 12 year-old of course.

"You seem pretty sure things will get better, that's cool." I pipe-up.

Well, if you don't have hope you might as well just curl up and die. I don't know if things will change or not, but she needs hope.

If nothing else, Rhodita says it like it is.

As we continue walking down the street, a young girl sees us and throwing her arms open wide, cries "Rhoda!" and runs for a big hug with a twirl. Her older sister Melanie come for her hug as well, they are on their way back from the market. They've just started their summer vacation and Rhoda ask what they are up to, then pauses.

Hey, how's your foot?

Getting better, but it still hurts a bit. Melanie replies.

Show me. Rhodita hits my arm to get my attention, Look at it. What do you think?

And before I know it, I'm doing a consult on the street.


Moving on, Rhodita says, its just they couldn't afford to go to a doctor, so I thought, since I had a doctor I'd let you see it. She grins at me. Melanie had got a bad cut on her foot from a smashed beer bottle, as her father threw it against the wall. Also violent. There are six kids, one developmentally delayed and the oldest, Jonathan, was badly burned last year in a fire at work. He's still healing, but all extra cash goes to creams for his skin grafts.

Rhodita works until 7pm most nights as well as the majority of Saturdays. Despite her usual levels of fatigue she manages to take me out salsa dancing after the open-air rock concert we went to and crinkles her brow at me when I yawn at 2am. But reluctantly agrees to take me home anyway.

She lives simply but fully and intentionally. To me she seems happier and healthier than I've ever seen her. Her way of life and the knowledge of the huge challenges she has faced overwhelm me and inspire me to reassess how I live my everyday.

I've stolen her away for a few days, we're in Iquitos, only accessible by river and air. Only a few buildings stand between us and the Amazon river. As I write this the motocarros buzz past outside, cicadas occasionally chirp and the fan moves the humid air across the room. I can't help but be both grateful and humbled.


P.S. The next morning I was DEEPLY humbled... by having slept with about 200 of my closest ant friends in my bed... they tickle.

The Folly of Human Desire

Only early afternoon, yet I was instantly exhausted by the couple that sat in front of us. She cried quietly into a tissue. He put his arm around her, looking slightly bored and detached as he looked at us accusingly. They had gone through three miscarriages and were now pregnant again, being followed closely at the recurrent pregnancy loss clinic after being fully investigated. An ultrasound had just shown a normal fetal heart rate at 10 weeks, but also found a subchorionic hematoma, a blood clot next to the developing embryo. Although things were fine at this point, it gives her about a 25% chance of losing this pregnancy as well.

There was a strange dynamic in the room. Deep pain and defensiveness. This is a place they had been before, and with all the medical technology in the world we could not give them a child of their own. I had seen the same look in the eyes of couples who have spent thousand of dollars on fertility treatments and IVF (in-vitro fertilization) to face failed pregnancies, or none at all.

A woman I saw at one of the fertility clinics had separated from her husband last year and was now dating someone else. Someone who would have a child with her. “He’s good enough and my eggs aren’t getting any younger.”

It amazes me. The desire we have to bring a child into the world. Is it desperate signals from rotting ovaries that do it? Maybe its the evolutionary drive to have our genetic material continued in the world? Or perhaps an equally altruistic and selfish desire to have someone else to love, to care for, and to bring us laughter. Is there a divine calling of love that creates this desperate need within us?

I don’t know what it is, but the desire for a child drives people mad. It breaks their hearts, destroys their marriages and makes them feel like they have failed at this business of life.

That same morning, prior to going to the recurrent pregnancy loss clinic they schedule residents at the Comprehensive Abortion and Reproductive Education clinic. Where the other side of human desire comes in. Seemingly the polar opposite, yet on some levels the same. The desperate need not to be pregnant. Not to have a child. Not to let anyone know. A 15 year old in foster care. A mother of four. Some heartbroken and scared, others logically facing the facts of life.

The incongruity in my mind and heart at the end of the day is a feeling I am slowly getting used to. The stories I have the privilege to witness in this messiness of life are not always easy to digest. We so much want what we cannot have and desperately don’t want what we have. The folly of human desire.