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.