Global Health Enhanced Skills Program – Gina 2017

I have not yet started my clinical work in Zimbabwe, but I’ve discussed the healthcare system with many now, and am beginning to grasp certain challenges I may encounter in the hospital.
During my first week, I already heard talk of several deaths that occurred in the last few weeks. I therefore wasn’t surprised to learn that many international doctors were shocked at the death rates seen in the hospitals of Zimbabwe. People die at a young age from conditions as benign as dehydration, apparently. Also, there is unfortunately no place for preventative medicine in a place where people are expected to pay for each medical visit, and are refused on subsequent visits if they still have pending bills. Even when in hospital, patients need their family members to provide their meals, clean them and sometimes even provide water (some have indeed died of dehydration in hospital). When every bandage is accounted for, it’s no wonder some just go to the hospital as a very last resort. It took quite some convincing to bring a young man with HIV and obvious signs of meningitis to the hospital, and once there he just wanted to leave rather than remain in an unclean bed. Even if well intended, I can imagine how frustrating it may be for healthcare workers to help due to lack of medication, clean equipment, or simply clean water. And of course hospitals are understaffed with professionals who practically volunteer their time, as the country has no money to pay hospital staff.
I look forward to meeting and learning from these workers who decided to stay and help their country.

In the meantime, I’ll be spending a few days enjoying Zimbabwe’s beautiful nature overlooking the “Smoke that Thunders”.

February 21st was a national holiday in Zimbabwe, in honour of the ousted former president Robert Mugabe’s birthday. It has been interesting to discuss how his politics affected all Zimbabweans.
Those who grew up in Rhodesia in the 60-70’s recall how lovely of a place this was to live. They frequently point out areas of the city polluted with trash where street vendors sell their few vegetables, describing how the area used to be a nice market, shopping center, restaurant, etc. And, when driving outside the city in the vast greenery, they discuss how the land used to be highly productive fields, or how abandoned buildings used to be working factories. It’s not often that the future generation has less than the previous one, but it is very much the case in Zimbabwe for the 20 somethings who grew up under Mugabe’s rule.
In shops, you can purchase 100 trillions dollar bills of the old currency, now worthless. As the value of currency dropped, first a few zeros were cut off from the bills (up to 24, eventually!). Then the whole currency system changed to American dollars. But through cutting off zeros countless times and changing from one currency to the other, what was deposited in the bank years ago was now meaningless. All savings went out the window as bank accounts were forcibly emptied. It was difficult for me to comprehend how a whole nation survives without any savings in the bank. Even if you attempted to start savings accounts for your children, for instance, all vanished overnight. A couple told me how the husband’s pension plan was worth an arbitrary 5$ after 36 years of saving when the currency changed. For a time, people could only barter with their neighbours and friends. Basic needs such as milk, eggs, oil and canned goods had to be bought in South Africa, as shops in Zimbabwe were bare. There was no electricity for weeks. This undoubtedly brought the people together, as no matter the family name, country of origin or ethnic background, all lost everything.
There was however still a tear in society in the early years of independence, as farm lands were confiscated from colonial families while the gouverning officials fed false beliefs that the white rulers had kept all the best lands for themselves. But as the years went by, and as Zimbabweans took over the “best “farms but failed to produce due to lack of experience and funds to purchase appropriate equipment, it became evident that the propaganda tactics were false. And as the country’s economy plummeted as a consequence of corruption and poor decision-making, it wasn’t surprising that no one regretted the departure of Mugabe. It made no sense how such a rich and educated country could have no economy. Tactfully announced as a stepping down and not a coup, the event was followed by days of celebrations throughout the country. Despite heavy celebrating, not a single brawl occurred, not even a shop looted. All are now hoping things will change. Many are skeptical that a proper change will occur with the strong possibility that the ruling party, Zanu PF, will win the elections. The second largest funeral in the region occurred in late February as the leader of the opposition party, the hope of Zimbabwe passed away from cancer.
A big change has occurred since last year already apparently. Indeed, there used to be police blockades at most intersections of the country where the officers were ordered to find a reason to fine every single drivers. With so little cash in the country, the government was trying to collect everything they could. And so officers would measure stickers with a ruler and fine over millimeters, or ask drivers to leave the car then fine them for leaving a running car, and many other absurdities. If you had no cash or refused to pay, you were brought to jail. Many would go through immense detours to avoid the blockades, while others just never left their homes as they got too frustrated.
Now, the blockades are gone. There is still very little cash in the country, and American Dollars are the preferred currency. There are Zimbabwean bond notes, but no one trusts this currency to last, so they are exchanged whenever possible. The country is however innovating and developing its digital transaction infrastructure.
It’s an interesting time to be in Zimbabwe, and I will definitely be following the elections and upcoming years closely.

Being only able to obtain a medical license for 1 month, the clinical portion of my international placement has yet to begin. During my first month in Zimbabwe, I’ve been learning about certain social determinants of health through work with the Susan Janetti’s Gecko Society. After raising funds and collecting various donated items ranging from computers to carpentry equipment, medical supplies, clothing, and many other, a large metal container is filled and brought from Vancouver to Harare. Once in Zim, Susan goes to different predetermined areas to drop off the donations. One of these is the Center for Total Transformation, where I spent most of the month.

The CTT is a privately funded NGO caring for vulnerable children, most of who are orphans or come from abusive homes. At the center, the children receive 2 meals per day and attend class from 9 to 1pm.
These hours unfortunately cannot be extended, as some have to walk for 4 hours to reach the center. The education received is informal, as the school hasn’t obtained the needed credentials due to lack of funding. The children do however complete the needed 7 subjects and grades which could possibly allow them to pass the required exams on continue to higher education.
The center has a medical clinic, built by the Gecko Society, and a social worker is always present to advocate for the children. Unemployment being an important issue in Zimbabwe, with rates varying between 90-98% depending on the source, the center has also opted to teach children specific skills which would allow them to earn a living. A local artist teaches them to make beautiful cards which are then sold abroad, and the goal of Susan’s current visit was to build a carpentry and sewing workshop. Thanks to 2 Canadian carpenters and 3 Zimbabwean workers, these were built in 20 days and fully equipped with various tools, materials and 9 sewing machines.

I quickly realized the most important thing the center offers to the children is a safe haven for the day, where they can escape their rough reality.

I went with the carpenters to the CTT every morning and taught the children about various health topics. On my first day, I was asked to teach primary students the same day. I quickly thought of a talk on hygiene and nutrition in my mind while walking towards a large gazebo usually used as an assembly area. There, about 200 children were sitting calmly on the concrete floor. They remained attentive throughout the whole 1-hour course despite their limited knowledge in English (and my limited teaching experience), always eager to participate when prompted. These were children who visibly wanted to be in school and learn. During my talk, I met certain determined gazes that I simply won’t forget. I felt them latch to every notion I could teach.
During the following weeks, I taught High School students about reproductive health, women’s health, first aid and basic anatomy. I got to know a few students throughout the weeks and learned about their impressive resiliency through their personal stories.

Through my work at the CTT, I witnessed how poverty affects many children of Zimbabwe, stripping them from safe homes, proper education and even parents as many become ill at a young age and cannot afford to seek medical attention. I saw the effects of malnutrition, often surprised to learn the age of children who looked half their age due to stunting. Because some children didn’t have proper housing, many students were absent during rainy days of this wet season, as they didn’t have dry clothes to wear, or had to help repair their flooded home. We traveled to different villages throughout the month, listening to countless stories of misfortune due to the current economic situation in the country. The common theme is everyone’s speech however is hope. All have remarkable faith in the future. And I can easily say I’ve never seen so many smiles in one month.

It’s been over one month since I finished my refugee health rotation, and I have just started working at the BC CDC tuberculosis clinic.

Since leaving the clinic, I’ve been reading articles on refugees’ living situations in different countries for a research project on homelessness. I’ve read and re-read about the impressive challenges refugees face when leaving their country and resettling. Many remain unemployed and  live in precarious housing situations. Most experience discrimination.  All have difficulties going through acculturation.   When resettled, few manage to feel a sense of “belonging”. This brought me to constantly think about my patients at the refugee clinic, hoping their situation was different than in the literature. I’ve been wishing we’re better hosts than the ones in the articles, and that, unlike the cases read, our refugees found stability in their new home without having to face the hardships described.

Then, yesterday at the TB clinic,  I saw a child I had been following at the refugee clinic in the waiting room.

The boy was visibly happy to see a familiar face after consulting with different new doctors over the last month, and I was overly delighted to see him again as well. The feeling faded quickly though, as his father smiled sadly, and I remembered at which clinic I was now working.  The father looked exhausted.  I continued seeing patients, anxiously waiting to finally reach the boy’s chart, hoping his family could catch a break, for once. I knew the family’s story well. They had to flee their country. They had to stay in a refugee camp.  After living through impossibly difficult situations in their home-country, they’ve come to Canada only to worry over their boy’s health for 2 months now. The poem “Home” resonated in my head:

” you have to understand,
no one puts their children in a boat
unless the water is safer than the land”.

Thankfully, when I finally reviewed his chart, I saw that the news was good. I promptly called an Arabic interpreter, and when the father and his son walked in, I cut to the chase and announced the good news.  “Alhamdulillah”, the father sighed with relief. I spent another 20 minutes with them, going through all other concerns the father had, even those unrelated to the current appointment. I was trying my best to offer them as much comfort as I could, hoping they’d  sleep a bit easier for at least one night despite all they had gone through.  After all, In one of the articles read, it stated: “(…) participants talked about being cared for as a form of the help they received. Caring did not involve trying to solve their problems. Rather, caring involved individualised attention, unconditional acceptance, non-judgmental listening and emotional support ” (1).

Not knowing how else to help, I was thriving to at least be like the “caring” people I had read about.

 

(1) S. D’Addario, D. Hiebert and K. Sherrell, Restricted Access: The Role of Social Capital in Mitigating Absolute Homelessness among Immigrants and Refugees in the GVRD, Canada’s Journal on Refugees, Vol 24, No1 (2007)

 

 

“Fairouz, Fairouz!”

How many times have I heard this name when mentioning my Lebanese heritage. Through songs like “Behabak ya Lubnan” (I love you, Lebanon), she acted as a uniting force in a country tearing itself apart in a civil war.

Although referred to as the “soul of Lebanon”, her fame also extended throughout the Middle East, where her voice was the first one heard each morning on most radio stations for many years.

Even to this day, I can recall many mornings spent with Syrian, Lebanese and Moroccan friends where Fairouz had to be played in the background, as part of their morning ritual.

This is what went through my mind as a Syrian patient tried to explain why she had went to the hospital: “Fairouz, Fairouz!”. I smiled, understanding why she had mistakenly understood this familiar and comforting name rather than “virus”.

The solution seems simple enough. Just stay in hospital until the infection is under control, then  continue treatment at the CTCT, a clinic in the Downtown Eastside. If going to that area  causes too many triggers for someone fighting an addiction, then all they have to do is stay in hospital for 6 weeks to treat their infection.   So simple, but why do so many patients check themselves out of the hospital before the treatment is completed, only to return a few weeks later with a much worsened state?

Addictive behaviour can seem irrational, indeed, and it can be quite maddening at times.   There is one article related to addictions, Reflections on Treating Addictive Disorders: A psychodynamic Perspective published in the American Journal on Addictions, which broadened my understanding of addictions. I had read this in medical school, and decided to go through the article again when working on 10C and feeling discouraged by the failed treatments. The author reminds us of a very important fact: that addiction is not about “pleasure-seeking”. Rather, he summarizes that causes of addictions  are related to difficulties with feelings, self-esteem, relationships and self-care.  It’s an important distinction, as it’s much easier to get frustrated at patients who aren’t doing their part simply because they want to feel a “high”. His conclusion, after 40-50 years of experience in addictions medicine, is that, no matter the patient and his or her other comorbidities, there are a few essential elements health-care providers need to use in their work: kindness, comfort, empathy, avoiding confrontation, patience, instruction, self-awareness, climate of mutual respect and balance in listening/talking.

I believe that it’s this conclusion, so simple and humane, that had struck me when reading the article. It was oddly comforting. And so, when I rounded on a few patients  in the Urban Health Unit of St. Paul’s Hospital who had visibly used the same day and appeared very unwell, I remembered the complexity of what was driving them to use. The pleasure-seeking hypothesis made no sense in these patients who were in obvious distress after using. And I actually felt relief when watching the 10C team in action- every essential element for helping patients suffering form addictions in the list cited in the article were vividly present. Now if only other wards and environments could demonstrate the same kindness, comfort, empathy, patience and respect as seen on 10C…

 

The article: Khantzian, E. J. (2012), Reflections on Treating Addictive Disorders: A Psychodynamic Perspective. The American Journal on Addictions, 21: 274–279. doi:10.1111/j.1521-0391.2012.00234.x

“Vous êtes gentils, mais inutiles. Vous nous regardez, vous prenez des notes, vous faites des rapports, écrivez des articles. Je vous aime bien, mais vous n’avez pas l’impression, des fois, que vous vivez de notre mort?”

This quote from the book A Sunday at the Pool in Kigali describes how a wounded Rwandan views a foreign nurse volunteering during the genocide as kind, but useless.  She goes on to ask whether the nurse feels she is living from others’ sufferings. I read these lines 4 years ago when I was in Rwanda, completing an elective as a medical student.  Working in developing countries had been a dream of mine since day 1 of medical school,  but those lines reminded me of the complexity of the task. First, do no harm. My aim is be able to actually have something to offer before heading abroad- I don’t want to feel like an impostor.  I’ll study well, and avoid that dreaded feeling, I vowed.

3 years later, I find myself in an Inuit community in northern Quebec. I’m on call, and am asked to come in at 2am to settle down a patient.  When I arrive, the nurse promptly asks me to prescribe strong sedatives they can inject into the screaming patient so everyone can get some sleep.

I find a 14 year-old girl sitting with her head between her knees, crying her head off. On each side are strong, young, male, non-native police officers firmly holding her in place. The male, non-native social worker who’d just started that day as well as 2 non-native nurses were also present. The patient had fought with her  mother, and no other family wanted to take her in for the night, so they brought her to the hospital. She’s yelling in her native Inuktitut, adding: “(insults) whites, (insults) police, nobody likes me, nobody wants me!” in English. And the policemen, exhausted from touring the town looking for a shelter for the patient, stare impatiently at me. “Can you inject her?”

Sure, I knew she was a frightened and saddened young girl in need for a compassionate ear, and I tried speaking to her. I asked to police to let her go and leave the room, I asked the social worker to step out. I spoke calmly, I let her scream as much as she had to. But it was too late. We made her live through the same trauma that her parents and grandparents had to endure, at the mercy of “non-natives”. We had opened the wound, and there was no calming her down now.  I called my staff, also a new young doctor, and we both tried calming her for over 2 hours. Policemen sighing, nurses yawning. Fine, we’ll admit her and calm her…

My staff and I sat in silence as they brought the sedated patient to her room. And then came the crippling Impostor Syndrome.  We had resolved nothing, and felt we had no business meddling in a communal issue  in such an aggressive manner.

I remembered all this, in particular the unsettling feeling described, when visiting Native communities on Vancouver island. I was worried the same feeling would reemerge during the rotation. I’m happy to say it didn’t, and my experience was overall very positive.  I was with physicians who were visibly welcome and were making a difference.  They worked with closely with community members and were very respectful of their culture. Nonetheless, I vow to learn as much as I can in the upcoming few months to avoid re-living that overwhelming feeling of uselessness.

 

Fresh out of residency, feeling up-to-date & on top of things- I know my guidelines & my red flags, I can be efficient and compassionate, I can investigate & differentiate, I have all the right tools and reflexes to cruise along.

The first patient arrives. My classic opening line: “how can I help you?” is met with a blank stare. I never fully understood the complaint by the end.

Then comes the second patient. I improvise a new greeting: “how was your weekend?” Without adding a word, I learn about weekend plans, then medical worries, then impressively detailed tales of woe. Being one hour behind has never felt so productive.

I’m shadowing during another patient encounter. “Been fishing lately?” is the opening line (this is an experienced md,  I see). The patient recalls how he felt half his face go numb while fishing, and he couldn’t move his leg. He just managed to drive home. The sound of red flags rising resonates in my head. The casual conversation continues however despite alarm bells urging me to rule-out and diagnose. The encounter ends with some gentle teaching, follow-up planned in one week.

I’m a bit puzzled. I learned to modify my approach to get information, but am overwhelmed by the problems encountered and the slow management. My questions are answered the following week however.

I went to a Native Reserve with another physician where we visited patients in their home. Each encounter lasted at least 60 minutes, only 5 of which were medically-oriented. An active member of the community comments on this doctor’s approach: “never has a health-care worker integrated our community so quickly”.

She explained that the community doesn’t appreciate the “book approach”, as illustrated by an elder’s outrage  when interrupted by a health-care professional looking to obtain a complete history.  She explains that, as a sign of respect, elders are never to be interrupted. The physician working with the community summarizes: “There’s no rush, we have to build trust and relationships before we can treat. We need to calm our eager reflexes learned in medical school and sometimes lower our red flags”.

As I prepare to head to Duncan for my first rotation at an Indigenous Health clinic, the smoke over Vancouver skies finally begins to clear.

And here I am- a brand new graduate,  a newly licensed physician and  new Vancouverite, ready to start this journey towards becoming a dedicated family physician.