News from Bolivia via Emily Moody (MP4)

Posted on behalf of Emily Moody, Medicine Pediatrics 4th Year Resident

Saludos desde Bolivia! I’ve been here two weeks, and it feels very familiar; even though it’s been 16 years since I lived in Santa Cruz (when I was a Rotary Youth Exchange student in high school).

The clinic here in Chilimarca was started about 30 years ago under the support of MAP, an international Christian health aid organization.  Jose Miguel deAngulo is the MD who came to run it in the mid-1980s (not sure exactly when). He and his wife Stella (who is a psychologist and program director) are Colombian, but moved here from the US where he studied public health at Johns Hopkins.  They raised their 5 children here at the clinic site, and home schooled them here.  The clinic is a primary care/urgent care clinic that provides basic vaccines, health visits, and has a basic pharmacy.

The scope of their work has changed over time. MAP initially supported a lot of outreach programs, including health promoter education for rural communities in addition to the functions of the clinic itself.  They had a very robust program educating “promotores de salud”, that reached many people. Initially it was 100% men from rural communities who participated in the program, but they ran into some problems with the men becoming very respected in the communities that some of them took advantage of their power and took advantage of young women in the communities (you will see the violence, machismo, and sexual violence themes return). So they started educating couples together, and also increased recruitment of women.  It took time for the communities to be willing to send women (they thought they were not able to learn the material, as women generally only completed a couple of years of school, and men completed a few years more), but it was very successful. In the last years of that program, they had 50% or greater participation of women.  They recently had to stop the program, because MAP re-organized priorities and was no longer able to support anything except the clinic itself.  In all, there are still >1500 rural health promoters in the surrounding communities that were trained here.

The women's group in Patamorochata in front of two houses: the white one was recently improved with plaster and cement as part of the Chagas control program, and the adobe one is how the house was previously.  On the far right is Stella Losada, the program director (and wife of Jose Miguel de Angulo, the local physician at the Chilimarca clinic)

Under MAP, they also started multiple other public health programs. One focused on increasing knowledge and community promotion to take care of children (also adults, but mainly children) with disabilities. It included some rehab, OT and PT some education on making and providing appropriate support devices, and a lot about education about differences. This was around 2000-2012, and this program has also been cut back by MAP.  It does still run, but is smaller.

They also have a Chagas program, for which they contract with the government to do Chagas screening.  The state program relies on people to come in to a clinic (in a city) to get tested, which is very unrealistic for a number of reasons. There is not a culture of primary care or well-checkups, so that is not an opportunity to do it. Many people from the rural communities believe that if you take somebody’s blood, then you have power over them to do witchery, so they will not make the trek to the city to give their blood – it would be ridiculous. So this program does outreach to rural communities. They do on-site education about Chagas, show what the vicuña bug looks like and how to repair holes in the walls to prevent them from living, and over time they establish trust to do the blood tests.  In a recent campaign in one rural community they had 14 positives. Those who screen positive then are referred to the central laboratory for confirmatory testing.  This program now has independent funding for the next three years.

The MAP clinic is still running. They have an 8am-10pm urgent care clinic run by nurses, 7 days a week. In the afternoon weekdays a general medical officer (MD from Bolivia, no residency) staffs a clinic also. They see anyone who comes through the door, with no charge.  They also have a dentist who works weekdays and a pharmacy on site with a well-stocked formulary.  Through the clinic they also do vaccines for children, as well as rabies vaccines for dogs.  Rabies is definitely here, in dogs and bats mainly. In Cochabamba last year, one nurse tells me they had >30 cases in people from dog bites.

The other large programs they run (sexual violence against children and infant mental health promotion and education) are entirely independent of MAP. Over the years of living in this community, they have come to see that there is a lot of violence inherent in society and specifically against women and children.  Within families and schools, children are hit regularly.  Sexual violence against women and children is also very common. Corruption within the police and courts is terrible, making it nearly impossible for victims of violence or sexual violence to seek justice.  The family (Jose Miguel and Stella) at this time are working to narrow their energies and focus their efforts on these two programs, because they feel that there are such deeply rooted societal problems that end up holding back children from developing their full potential, and that keep women from advocating for themselves and their children, that the other health projects don’t make the difference that they see can be made through their sexual violence and infant mental health work.

In Morochata with Dona Berta (the president of the local women's group and a health promoter) with
her 1 yo son Yoel and 9 yo daughter Sarah, and with Jenny, a lawyer who works in the rural communities as an advocate
for children and women who suffer sexual violence

As I mentioned earlier, Stella and Jose Miguel raised their family here. The kids were homeschooled here and enjoyed school and learning. The children’s friends from the community talked about the rote memorization and punishment that they suffered at school, and the kids were appalled – and one of the daughters made it her mission to start a school where other kids could enjoy learning as much as she did. They did it, and have a school for 6 mo to about 7 yr right next to the clinic.  It is a great place – they employ a lot of Montessori philosophy and have a garden and chickens, and do a lot of different kinds of hands-on learning. The school is also focused very much on involving parents, and providing a classes and instruction on child development and mental health – emphasizing attachment and security within the family.

With Daimar, a 4 yo with CP who receives services through the outreach programs for children with disabilities. 

One of the children in the family was then the victim of sexual violence. After she was able to tell her family, a long series of very difficult events followed that included trying to prosecute the perpetrator. They found that the society and judicial system are entirely set up (from mothers at home all the way to the courts) to blame the victim. Unequivocally. They struggled for a long time to get a lawyer who would actually advocate for them, and to get judges to hear the case. There were no resources available for the victim or family. So they started FUBE (Fundacion Una Brisa Esperanza) that advocates for victims of sexual violence. They have a building in central Cochabamba (Centro Una Brisa Eseperanza, or CUBE) where their activities are centered. They provide counseling services (they have 4 psychologists), legal services (4 lawyers), provide community and support for victims (who are ostracized by their communities after revealing the abuse), they do research, a lot of community education (to general public, police, judges, lawyers), they work for judicial reform.  They do a lot. The daughter who started this went to grad school for psychology and she and her husband went to law school, so they have part-time professorships at the Rutgers Law School and live half of the year here working for FUBE and half of the year in Philadelphia to teach, write grants, etc. They also do courses for US students to come here and learn about human rights law and judicial advocacy (for law students) and the health system (for nursing students). They currently do about 3 trips per year with 15-25 students (either law, nursing, or an interdisciplinary group) for 1-3 weeks each.

As I said, the main passion of Jose Miguel at this time is infant mental health. Between the machista culture, the violence, etc he sees that few babies establish secure attachment with parents from an early age. They focus on the first 1000 days (including gestation) as the most critical time for brain development and allowing the child to develop its full potential. They are planning to start programs including home visits, community education, and education within the schools.

For my clinical time, I have been working with Freddy (the clinic doc) to see patients together and do some pediatrics teaching. I’ve ordered a Harriet Lane in Spanish for them. I will also spend some time with the nurses in the urgent care when the clinic is closed.


The public health part of all of this is the most exciting to me. Since my area of public health experience is in environmental health, I’m working on developing a home safety checklist as well as a longer guide for home visits surrounding environmental health.  It has been fun, because the housing, city organization, and potential risks are quite different from those at home.  By the end of my time here, I also hope to have a presentation put together to do a sort of training or short course about environmental health.  I’m excited about the possibility that this will fit into and support the work they have already started.  Their model for the 5 main determinants of infant mental health include: physical development, socio-emotional development, cognitive development, development of auto agency, and safe and enriching environments.  My work will all be focused on that 5th determinant.

A final Asante from Ryan as he finishes his rotation in Tanzania

Posted on behalf of Ryan Fabrizius from March 6

 

Jambo from Arusha (actually waiting in Dar es Salaam airport at the moment)! 

 

Today marks the beginning of my journey back home. The past two months have so quickly passed, and this week has been a one of good byes and thank yous. I had the chance this week to do some home visits with the Hospice team. Unlike American Hospice care, the hospice team at Selian visits home-bound patients regardless of their life expectancy. For example, most of the patients that we saw have HIV infection as their primary debilitating illness, which, we hope, will not be life limiting if they are able to receive their medicines and routine HIV care regularly. The particular patients were selected because of their poor overall condition and lack of family support and resources. It was a wonderful chance to see a broader picture of the daily experience of these patients, seeing their homes, families, and neighborhoods. In health care, we life to think that the clinic appointments, hospital visits, and medicines prescribed make a big difference in someone's overall health, but seeing the patient's living conditions and imagining their daily life, I can see how far downstream we are from the roots of their problems. 

 

The last word in this series is actually one I have mentioned before, but it is so nice I'll use it twice. "Asante", as I have mentioned, means thank you. I have so much to be thankful for at the end of this two month experience. It has been a great joy to work alongside the Tanzanian medical staff at Selian, to experience their hardships, the challenges to caring for patients in this environment, and the camaraderie of sharing our knowledge, experiences, and goals. To let me follow along on their hospital and clinic rounds, my Tanzanian colleagues gave up their time and departed from their routine. But on top of that, I feel more than just a collegiality was fostered, that it was a lasting friendship. For that, I am thankful. Asante does not seem to explain this gratitude deep enough, but it is the best that I had to offer in return. Asante has been offered so many times during my stay here, both from me and to me. It is often for ordinary services, such as at a store or restaurant. It has been offered from our patients, often the most fervent "asante" coming from the patient and family for whom we have no good option to left. However, when I consider how much I have received during my time here, I wish I had more than just one word. I wish I had the power to help my friends accomplish their goals. I wish I could take the stories that I have seen and strike the problems at their roots. I wish we could all have equal opportunity to quality health care and the basic needs that would sustain that health. But for now, I offer thank you, and resolve myself to not forget what I have seen and the people I have shared life with here in Tanzania.

News from Laos and an U/S Project with Patricia & Junaid

Posted on behalf of Patricia Hickey (PL3) and Junaid Niazi (MP3)

Sabaidee from Laos!

Junaid and I are halfway through our rotation working with local Pediatric residents. Our role is to discuss patients with the residents and teach, as well as learn. These residents are completing 3-year residency programs developed by Health Frontiers, a group based out of the US. The residents are supervised on the wards by excellent Lao “teachers,” as they call attendings, and are also supported in their education by the Health Frontiers coordinator, currently a congenial Australian pediatrician. Visitors like us come from countries all over the world to contribute and learn. The Lao teachers are more patient with random foreigners coming to teach than I think we might be in the US. They trained at a time when resources were even more limited and the country was much more isolated from the rest of the global medical community but they are very competent and experienced. The mob of white coats on rounds is even more impressive here than at St. Paul Children’s as there are more trainees per team here. So there is plenty of teaching to go around...for the most part. This week it turns out most of the residents are attending seminars given by German Neonatologists so there is less for us to do. We can’t participate in patient care directly because we don’t speak Lao and don’t have Lao medical licenses.

Rounding

We arrive at the hospital in the morning after the residents have completed their morning report (in Lao) and most of their rounding. They are usually busy filling out fairly extensive paper charts and writing paper orders, which parents take to the pharmacy/radiology/etc to pay for each item of care ahead of time, be it an X-ray or antibiotic. The residents take turns presenting “interesting cases” to us - which as far as we are concerned is all of the cases. Even if it’s something we've typically seen, such as gastroenteritis, there are always discussions to be had about different management in areas with different epidemiology and different resources. Many of the cases have been especially interesting because they represent very late manifestations and advanced disease. There tends to be an additional element of mystery because of the frequent lack of diagnostic tools available. I think sometimes we have had the benefit of correlating history and physical more closely with diagnoses because of the extensive workups our patients have in the US. For example, here they may never know that a patient has Tetrology of Fallot because there is no Pediatric Cardiologist in the hospital and if the patient is too sick to be transported to radiology she won’t get an echo. There is a 6 month old baby here who I suspect has TOF but his last echocardiogram (performed by an adult Radiologist) months ago was read as large ASD which would not explain why he is in heart failure and has a palpable thrill.

The hospital

Resources here are changing frequently as Laos is a country in the midst of change. Construction surrounds us at every corner, from before dawn to well past sunset. We eat croissants for breakfast, walk to work dodging streams of shiny cars, and blend in with crowds of backpackers on our way to the hospital where there is minimal air-conditioning. Where you can be intubated but cannot obtain blood gases or portable chest X-rays. Where you can get a head CT but not an albuterol inhaler. Where we found a brand new ultrasound machine in the PICU untouched because no one was taught to use it. We have discussed the basics of bedside ultrasound with some of the residents and are working on a developing a “how to” guide, as well as planning several practice sessions. I am sure adoption of this technique will require much more reinforcement by people more qualified and more consistently present than we are but hopefully we have at least introduced the idea. This has the potential to be an incredibly valuable tool where portable imaging is not available and imaging in the Radiology department is not always affordable or attainable. We are grateful that we literally stumbled across this project and excited that several residents seem eager to learn bedside ultrasound. Before we leave Laos, we want to ensure that a procurement system is in place for ultrasound supplies—the gel, photo paper for printing images, etc. If we can accomplish this, then we will have given back a tiny fraction of what we have gained from this experience. Until next time!

Patricia & Junaid

Junaid Niazi, MP3 & Patrica Hickey, PL3

Pole - Swahili lessons from Ryan Fabrizius, MP4 in Tanzania

Posted on behalf of Ryan Fabrizius, Medicine Pediatrics Resident in Tanzania

Jambo from Arusha. 

Since last writing, I have been rounding on the medicine ward, which has been quite a different experience compared with pediatrics. While malnutrition and respiratory infections malign the infants and children, HIV devastates the adult population. Surprisingly, non-communicable diseases are just as common, if not more so, than HIV and its complications. Diabetes, hypertension, and chronic obstructive lung disease (emphysema) are much more common than I expected, and unfortunately, with the transition of local populations to urban lifestyles, will likely become the major burden of disease in developing countries like Tanzania. Just as it is in the US, chronic disease is difficult for patients to understand and providers to feel like they can make a difference, but I have been impressed by the knowledge and compassion of the local doctors to not just treat but to educate their patients on how to manage chronic diseases. For example, in outpatient clinic this week, I sat with Christopher, the internal medicine registrar, as he took about 30 minutes of a busy clinic day to explain diabetes type 2 to a patient. The concept of disease occurring without symptoms and not having a onetime solution is a difficult one to grasp, but Christopher patiently reached for common ground in understanding. Despite the myth that doctors in developing countries are "paternalistic", I have found that in this case and many others, doctors like Christopher strive to educate and empower patients and families to understand their condition and proactively participate in their own care.

For today's Swahili lesson, I wanted to introduce the word "pole". Just like "karibu", pole is a common and versatile word that enters into interaction several times per day. It is usually used here for "sorry", like when you bump into someone or walk on a clean floor with dirty shoes (I seem to leave a trail wherever I go). "Pole" also has some unique uses that we have observed. It is considerate to express "pole" when you see someone carrying a heavy load (we get a a lot of "pole"s when we carry groceries home up the hill). Many people will say "pole la kazi" when they see people at work, whether working at the hospital, harvesting roadside crops, constructing/digging, etc... It means, literally, sorry about the work. It feels similar to the feeling of sympathy medical residents give each other during a busy night shift or after a difficult series of events. To me, it seems to be expressing, "I have been there and I feel your struggle, hope you get to finish work and rest soon".

 

The most interesting use of "pole" for me has been with patients. When most local medical staff approach a patient on rounds or clinic, they usually begin with "pole bibi/babu/mama" (sorry grandma/grandpa/mother), which acknowledges the fact the patient is having a struggle. The usual response is "asante" (thank you), which feels like an expression of gratitude for recognizing the burden on the patient and family. As medical workers in the US, I think we do recognize the value of this sort of sympathy. Some useful expressions that I have learned from my teachers are "this seems like a difficult time for you" or "i'm sorry you have to go through this", but usually this comes up after a display of emotion from the patient or family that beckons validation. In clinical practice here, I find it most interesting that this validation and sympathy is the greeting, rather a phrase reserved for certain situations. It seems rooted in the community values here, that one person's burden is shared amongst others, not just friends and family, but all people that interact with them. Here in Tanzania, there are so many burdens that people carry, even in daily struggles for basic needs. It is frustrating for me, as someone that takes for granted that my daily needs are easily met, to see the barriers that people have to providing for themselves and their children. On top of that, the burden that HIV, chronic disease, and other medical conditions place on an already struggling people seem absolutely insurmountable. This, for me, stirs up feelings of injustice and unfairness, questions of why? and how?, and often results in frustration and fatalism. But for the people here, they bear with each other in these circumstances, supporting one another and carrying one another's burdens. Linguistically, I do not know if these words have a common root, but "pole pole" is another common expression that means "slowly" or "gradually". It is the unofficial mantra of climbing Mt. Kilimanjaro: gradually, one foot in front of the other. And such is seems with bearing one another's burdens. Sorry for your troubles, but slowly, together, we will carry it together.

Learning the nuances of the Tanzanian Greeting Hamna Sheda

Posted on behalf of MedPeds 4th Yr Resident, Ryan Fabrizius

Hamna Sheda Jambo from Arusha!

This week, I did my last week of pediatric wards with the all-star team led by Joseph (the registrar - a role like our senior residents) and Dr. Steve Swanson (a pediatrician from Hennepin County Medical Center, now serving at ALMC and Selian full time) and comprising Kahema (the intern), Sasita and Baraka (the two Assitant Medical Officer students- a role like physician assistant students). It has been a great experience working with this team, and I have been so impressed by their eagerness to learn, compassion for patients, and their cheerful attitudes.

Joesph, as I have mentioned earlier, is one of the best assets at Selian Hospital. The registrar is a position given to an MD upon finishing the one year rotating internship and can be an indefinite position, or often one taken while seeking out a residency spot in a specialty. Their role is to attend on the wards and to supervise the interns, though there are many duties they fulfill behind the scenes such as teaching the AMO students, participating in hospital administration, and seeing patients in OPD (outpatient clinic). There are 4 registrars currently at Selian, all of whom are excellent, but Joseph stands above the rest in his medical knowledge, enthusiasm, ambition, and compassion for the community he serves. He actively pursues solutions to "upstream" problems that lead to the sad conditions that we often see: malnutrition, difficulty with accessing care early in the disease course, and recurrent respiratory infections. He often purchases essential supplies with his own money and stays late awaiting tests that return hours and hours after they were requested. He hopes to gain a residency spot in pediatrics this next fall, though this is a difficult task in Tanzania, since there is not a steady source of funding for these positions. Either a trainee has to pay their own way, which is thousands of dollars per year, or they must obtain a sponsorship from the government, church, or pursue an international training program. It would be a loss for Selian when Joseph leaves, but we truly hope for his success as a pediatrician, a field that is greatly under-resourced in a country with greater than 50% of the population younger than 15 years old and two pediatric residency programs.

Though learning Swahili has been quite slow for me, certain phrases seem to be preferred by different people. I have already discussed "Karibu" and the greeting ritual, but we noticed fairly quickly the phrase most preferred by Joseph. "Hamna sheda" (no problem) is mentioned in almost every interaction with Joseph. For Lion King fans, this phrase is a close cousin to "Hakuna matata", though for some reason wasn't chosen for musical glory; perhaps because matata is more fun to say. Examples of it's uses include responses to: 

• "Joseph we don't have any oral rehydration solution and we don't think we'll be getting it anytime soon",
• "the family cannot afford the antibiotics you recommended", or 
• "all of the thermometers have disappeared". 

He uses this phrase so much that Hope and I have taken to calling him Daktari Hamna Sheda. To an observer, I think this phrase could be generalized to represent the people of Tanzania as laid back, care free, no worries. The slower pace of life, simplicity of material possessions, and emphasis on relationships here fit this mantra well, but one might easily interpret this as laziness compared to the frantic lifestyle we pursue in the Western world. I have seen, though, that there is a different usage for people like Joseph. I really do not see him and others like him, resigned to be worry free in the midst of a community suffering under the weight of poverty and it's ghastly burden. "Hamna sheda" is not permission to avoid reality, but I think it is one way to accept reality but not to let it frustrate or corrupt. Though I am clearly frustrated with the lack of resources that I take for granted in the practice of medicine in the US, Joseph is able to see what is lacking but to not give in to despair. For him, it seems, "hamna sheda" is a recognition of factors beyond control and a challenge to strive for the best for his patients with the resources available.

I truly hope that places like Tanzania will someday have the infrastructure and resources that all people deserve, but I am encouraged by people like Joseph who are able to overcome these circumstances and to make Tanzania better.

Ryan Fabrizius (MP4) relfects on community in Arusha

Posted on behalf of Ryan Fabrizius, 4th Year Medicine Pediatrics Resident currently in Arusha, Tanzania

 

Mambo Jambo from Arusha, Tanzania. I hope this update finds you all well, I appreciate all of your responses, thoughts, and prayers. This week has flown by and I have been blessed that it has been filled with great experiences, coworkers, and friends. I am becoming more accustomed to work at Selian Hospital, and continue to learn new things everyday.

 

This week I have been reflecting on community. As many of you have experienced, there is nothing quite like finding yourself in another culture to make you aware of your own. Though my experience of culture here in Tanzania is doubtlessly affected by my obvious "foreignness", I have been finding the community here particularly enchanting. It has been explained to me that Tanzania is made up of over 120 different tribes, each with their own history, beliefs, and sometimes language. This is thought to be a real positive for Tanzania, since there is no one tribe that can dominate the others, as has been the unfortunate reality of many other African nations. It seems, from my naive perspective, that several tribes have maintained their way of life in a way that is so obviously different from the typical city dwelling Tanzanian. An example of this is the well known Maasai tribe, prominently donning their red and blue patterned scarves, beaded ear adornments, and patterned scarification on their cheeks. As a pastoral people, they are often seen tending to large herds of cows and goats, even in relatively urban areas around Selian hospital. It is a regular occurrence for us to run into a traffic jam of livestock being tended by a young Maasai herdsman. This contrasts to some of the other urbanized Arusha residents, many from other tribes like Chaga, who have taken to city life, working as shop keepers, taxi drivers, and other urban jobs.

 

One particularly fascinating aspect of life here that I have seen in my limited exposure, is how these different groups interact with each other and with outsiders, like myself. A prominent display of these daily interactions occur in the greeting of one another. Each day, myself and Hope, take our scenic walk to Selian hospital and are pleasantly barraged with endless greetings. The most common greeting is "mambo", which is a sort of slang term, much like "what's up?". To this greeting, we have been learning new responses in unlimited combinations. So far, we have learned "poa" (cool), "safi" (clean), "mzuri" (good), "mcima" (well), "fresh" (fresh?), and my favorite "poa kuchezi cama ndezi indana ya fridji" (cool like a banana in the refrigerator). There is also "habari" (what's the news?) and shikamoo (I respect you), which are more formal. Then there are the many school children eager to use their English phrases, like "good morning teacher" and "how are you?". Though I can barely scratch the surface to communicate in Swahili, I can sense the rich feeling of community in people greeting each other. When I watch others great one another, it is almost never a short interaction. Honestly, I have no idea what is being communicated, but I can sense the sharing of their intertwined lives. They stop to share a cup of chai, to rest in the shade, to carry their produce from the field together. 

 

In the hospital, I have seen how families rally to collect money for medicines and to search the countless "dawas" (small pharmacies) for the right medicines. I have seen how patients in neighboring beds support each other, like when a Maasai family cannot speak Swahili well and the neighbor will help fill in the details of whether they have received their medicines as ordered or have been taking the recommended refeeding formula. I have seen how the local doctors here will often buy necessary supplies with their own money, such as Oral Rehydration Solution, extra food, and even clothing for their patients. There is a sense of cooperation and support for one another that extends beyond family, tribe, and language. The people here have been gracious to greet us everyday, but I see that below this surface greeting there is such a richness of community here that amazes me. It challenges me to consider how I relate to others and how we as Americans (or whichever subgroup we find ourselves in) can look beyond ourselves to build stronger community with one another.

Greetings from Gulu - Reflections on Soc Med Course from Aarti Bhatt (MP3)

Posted on behalf of Aarti Bhatt, MedPeds 3rd year resident

Greetings from Gulu, Uganda!

What is Social Medicine and how do I implement it into my practice and day to day life? How do I truly work for social justice and health equity? These are the questions that led me to Gulu.

I have the privilege and the opportunity to spend 4 weeks learning and teaching about the social determinants of health with medical and nursing students, physicians, anthropologists, sociologists, economists, allied health professionals, village health workers, and patients. The course is called Soc. Med, and is crafted by Amy Finnegan (Sociologist) & Mike Westerhaus (Physician/Anthropologist). This is the 5^th year of the course which is held here in Northern Uganda. The 27 medical and nursing students taking the course bring their perspectives from various regions of Uganda, as well as from Rwanda, Zimbabwe, Argentina, USA and Lebanon. 

The Soc. Med experience challenges my understanding of why injustice exists in our society and subsequently leads to health inequity. We dissect topics ranging from colonialism to neoliberalism to intellectual property and the WTO. It is emotional, exciting, confusing, eye opening, awe inspiring, and an exercise in humility. It is also really fun. 

  

I’m still processing a lot (which is part of the reason it has taken so long to write this post), but will briefly offer some reflection. Additionally, I invite the broader community of health professionals to engage in critical, reflective and constructive dialogue about health equity that goes beyond the biologic basis of disease.  

Students come together to “look upstream” at the structural and societal factors that influence biologic illness

The “3Ps”, and unofficial mantra of Soc Med.

Getting Personal

The Danger of a Single Story. (this is a link to an awesome TED talk)

Part of my role as a facilitator for this course is to help incorporate concepts of narrative medicine into the Soc. Med curriculum. Narrative medicine shakes up the traditional structure of the doctor-patient interaction by challenging (as well as complementing) the biomedical model. In an era where health professionals are busy, focused on diagnostics, and patients don’t feel listened to, this method of of history taking deserves some attention. It involves bearing witness to the patient’s story (referred to as an “illness narrative”) while at the same time pushing the provider to examine his/her own biases and assumptions which are inevitably carried into the encounter. Students are encouraged to make statements like “Tell me about your health” or “What worries you?” instead of the more traditional questions which focus on symptoms and reason for admission. In debriefing, many of the students bear witness to stories of suffering, poverty, living through war, and injustice in the health system. Equally as important, students learn who their patient’s are, what is most important to them, and what brings them joy. Narrative Medicine is intensely personal, and getting personal is part of social change.

Social Medicine students visit Paimol and take a walk through the community with local village leaders. They learn about the  economy, daily life, the effects of the war on the area, and some cultural health beliefs. We discuss the ways in which community members negotiate their health  by engaging with local healers as well as government health services.

You may or may not know that the place where I am right now sitting, as well as the place the students above are walking, was in the midst of a bloody civil war from 1989-2011. The war was between the Ugandan government and a rebel group called the Lord’s Resistance Army (LRA). Many women and children were displaced from their homes to IDP camps. Young boys were coerced into becoming child soldiers. Human rights atrocities were committed from both sides. I feel mildly ashamed that my only prior exposure to the conflict was a youtube video created by an organization called Invisible Children. But I think it is safe to say that the narrative about the war created by Invisible Children was the dominant narrative (and sometimes the only narrative) most Americans were exposed to. Now, I have seen the movies Uganda Rising and War Dance (highly recommended), and I have engaged in dialogue with historians. I have listened to the stories of student colleagues and friends in this class who lived through, navigated, and are personally affected by the conflict. I am beginning to really understand the danger of a single story.

I will end here for now, though expect more to come. 

Love from Gulu! 

Aarti