Off the beaten path… PNG

Written words march along the pages of reports in a procession, adhering to the same drumbeat that all reports do. They may talk about sexual violence against women, or human rights violations, or child prostitution, or war crimes. In most cases the words fail to convey the reality of the situation. But imagine if, as your eyes glance over the pages, the words peel off…first one, then ten, then hundreds of them. The black scribbles swarm around you, and you are about to gasp for air when they swish away and converge into a mass, morphing into the figure of a woman. Her eyes are shut swollen by punches, her lips bleeding, the skin on her back tattered by the gravel road she was dragged on. The words in the reports that I have read in the last few months took that form today. In flesh.

There she was, lying on the stretcher after being beaten up and tortured all night, accused by villagers of being the sorcerer responsible for the death of a child. The child, judging from the daily cases of meningitis and cerebral malaria, probably succumbed to the black magic of those illnesses. The only hex in the room, as my hands trace her bones feeling for fractures, was the animation of the written words that have stared back at me over the last few months.

Witchcraft. It is a dangerous phantom in PNG that conjures violence and kills at the hands of other human beings…not the hands of a witch. There are many taboos here. Misunderstandings. Old traditions mixing with new ones. Witchcraft living side by side with religion. Mostly Christianity.

Remember the woman from my previous entry..the one whose husband forced a stick inside her vagina to terminate an unwanted pregnancy? I’ve been thinking about her…and her husband. It’s hard for me to be angry with him. According to the woman, he had never hurt her before…never beaten her or raped her. Never. So what would drive him to do such a terrible act…what would lead him to hurt the woman he loves? Ignorance? Desperation? Four other children that he cannot afford to clothe, feed, or take to a healthcare provider until they have been devoured by the voodoo of disease? What is going through his mind now? Is he ashamed? Empty? Devastated? Festering with guilt?

Abortion is illegal in PNG. Unwanted pregnancies are rampant here due to rape, ignorance about contraception methods, and lack of education. Unwanted children end up born into poverty, where they enter a cycle of starvation, neglect, disease, or prostitution. A spell cast by lawmakers and religious figures that they will likely never escape.

As in other countries where abortion is illegal, maternal deaths from unsafe abortion practices are high. No one knows the real numbers, but it is thought to be one of the top causes of maternal death. Abortions are carried out at a similar rate in countries where it is legal and illegal. The difference lies in that “illegal” abortions are poison to a woman’s body…the unsafe, unsupervised procedures kill or scar her.

The decision to undergo an abortion is not an easy one for women, and it is never taken lightly. Instead of supporting that difficult decision, and creating a circle of safety, states where abortion is illegal are bogeys in these women’s lives.

It’s taken me a long time to write this entry. I felt compelled to read about the issues surrounding abortion laws and to deliberate every pro and con argument. By doing so, I have come to an important realization: there are no pros and cons. It’s a woman’s choice. You might agree with it or not, but ultimately it is her decision. No one else’s. Simple.

A religious belief imposed on a woman leading to her demise is equivalent to beating a woman in the name of witchcraft. The hand holding that stick was the hand of patriarchal law and religious benightedness.

I left the Angau hospital today, and I took the emergency department home with me. It’s been a while since I have done that. When I finished residency, I was at the top of my game, armed with 9 years of training, and an armamentarium of medical knowledge. Then my life shifted…from one day to the next I was not a resident anymore…I was the staff, the attending, the consultant… the one that residents and medical students would turn to if they had any problems. For the first few months, the responsibility and the stress of the ER would filter into my daily life. But one day the feeling was gone, and as I’d leave the ER, the internal dialogue would whoosh away as I walked past the security guard, the paramedics lined up in the hallway waiting to be triaged, and the patients waiting to be seen.

But today was different. Today, I took the ER home with me again.

I was showing the emergency department to Leslie and Rob at the end of my shift, when a man holding a floppy baby walks into the room. He is dazed with panic and looks around in confusion, taking a step first in one direction and then another. No real purpose to his steps except to find someone that would help his baby in the midst of the chaos. I notice him, and direct him to the “resuscitation” room, where there is only one stretcher. It’s occupied. I ask the woman to sit next to the stretcher with her IV pole, and lay the child on the bare metallic surface. There are no blankets.
“How old is she?”
“Three”.

I am not sure what’s different. I am finding it difficult to find my place in the chaos around me. I am trying to wrap my mind around the fact that Angau hospital is a “referral” center and that there are tons of people in the periphery that get no healthcare at all. It also happens to be “the best” hospital in PNG.

Her little body is under the spell of spasms, her eyes closed. Her heart is thumping in her chest, holding on.

What is different is I am trying to erase the image of the 30-something-year-old women’s breast eaten up by her cancer, and knowing that she has no chance in this healthcare system. No chance either for the 30-year-old man with a broken neck whose quadriplegia is a tragedy anywhere, but here it sentences him to isolation from life as he knows it.

We start an IV on her and give her a bolus of fluid while I ask here father a few questions. Fever. Decreased level of consciousness. Vomiting. Spasms. Meningitis? Cerebral malaria? We bolus her with anti-malarials, antibiotics, diazepam and give her more fluids. Then we wait.

What is different is the gush of mixed emotions that rushes from my heart to my head when the medical student, giggling nervously, translates the story of the 30 year old woman that had a stick stuck up her vagina by her husband in order to terminate an unwanted pregnancy.

I went home waiting.

***************

Back in the ED, the morning sun is steaming the nightly rain. Stethoscope around my neck, pen in hand, I turn around and there she is, looking up at the “white mary doctor” with her dark brown eyes, holding a cookie with her 3 year old hands, her curly brown/bleached-by-the-sun hair making her irresistibly cute. We keep looking at each other, and I smile. Shyness tilts her head down but her gaze does not let go of mine. “White mary doctor” is a novelty to her…and she a gust of relief to me.

Remember your first day of school? Mine I remember with pristine clarity. Tehran. Warm, sunny day. Hair combed back in pigtails. My mom and I walk through the gates of an all-girl school into the midst of an ocean of blue-uniformed girls, running, playing tag, chatting in groups. I remember my mom letting go of my hand and how I tried so hard to hold back the tears. I did. I held them back.

Here is what I have been doing the last few days…meetings, planning, drug orders, clinical protocols, meeting the national staff, discussing legal issues, medical issues, security issues, political issues, supply issues. And more and more issues related to the set up of our clinic. But that’s not what I want to write about. Not today.

I decided that while our clinic was being set up I’d volunteer my time in the emergency department in the Angau Hospital. First things first. When I say hospital, well, if you consider buildings that are collapsing under the attack of termites, or patients lying on cardboard on the floor, or a place that does not have anesthesiologists, obstetricians, radiologists, surgeons, then you are at the right place.

I was excited about my first day. Excited about diving in, doing some clinical work, about doing what I have come here to do. Also a bit worried…what if I am double-crossed by all these cases I have never seen before…the cases that have been eradicated from our memory in the western world, so much so that after medical school we tend to forget about them. I am talking about the –asis and –osis diseases…leishmaniasis, donovanosis, shigellosis, amoebiasis, borreliosis.

I walk in through the emergency door. The first 10 minutes I see a woman stabbed in the chest by her sister causing a collapsed lung (they fought over a cell phone), a severe pre-eclamptic woman (a condition in pregnant women that, unless treated, can lead to seizures and death), and an overdose in a woman beaten by her husband. That was the first 10 minutes. For the medical people reading this…3 cases of cerebral malaria, 2 cases of meningitis, 1 Ludwigs angina, a woman in shock slouched in a chair, a status asthmaticus sitting in a chair, a severe head injury where there is no neurosurgical backup, a splenic rupture in a man beaten by the police, resistant TB, typhoid fever, a sucking chest wound in a 5 year old. All those on top of the usual gamut of broken bones, lacerations, vaginal bleeding, pneumonias etc…without the usual comforts like an ophthalmoscope, otoscope, ECG machine, blood-work, a glucometer…gauze!

Add an emergency department that I do not know, that has no formal triage system, staff that don’t know me, a hospital system that I cannot figure out, nurses that have to clone themselves to get anything done, a language that I do not speak and….oy!!!!!! The doctor I joined to work with left to his daughter’s graduation and did not return for, let’s see, 5 hours. But who was counting.

That was my first day.

At the end of the day, I am not the child who cannot keep his eyes open because he is using all his energy to breath. I am not the woman whose leg was sliced open and dislocated by her husband in February 2007, who could not get to see a health professional due to the remote area she lives in, and who will walk with crutches for the rest of her life. I am not one of the medical officers that struggle to learn medical skills while staying afloat in the tsunami of under-resourced shifts.

At the end of the day, I get to leave back home to the comfort of my life. Today could be my first day and last day…I could leave tomorrow if I wanted to.

At the end of the day, all I can do is fight back the sheer sadness and insanity of it all and ask the universe for the resolve to do what I have come here to do.

All those back in the western hemiphere, miss you. Internet and time have been a scarcity…but I do get to read your comments…they make me smile.

My watercolor memory of Papua New Guinea, hazy and indistinct, is touched up with new paint-strokes of color and images. PNG is beautiful. We have been in Port Moresby (capital city) for the last few days. It is cradled by an oceanic tapestry of greens and blues, and lush hills lined by palm trees, banana trees, rain trees, and, well, other trees whose names have never been registered into my knowledge-base. The scenery is brought to life by the luminosity of the sun, while I try to shun it out with my newly purchased 19.95 Kina sunglasses after losing mine somewhere along the way. It’s been a long way here.

Port Moresby is where the MSF main office will be based. The team, brimming with enthusiasm, has converged here. Rob, Silvia and I flew in from Amsterdam. Kara flew in from Australia. Karen will fly in later. Lauren has been briefing us on security (including curfews and radio transmission lingo) and health issues (including the procurement of anti-venom for snake bites!).

In the afternoon, I walk around in the market with Billy (our local driver and “fixer”) picking out fresh coconuts, pineapples, and pitpit (a sugar cane-like vegetable that tastes like artichoke). Men, women and children look at me with curiosity; they smile and nod. I bend down to take a photo of the market and the vendors volunteer to have their photos taken. They grin bashfully when I show it to them, though the image on the screen is stolen by the brightness of the sun. Their kindness and friendliness make me at ease. As I take in the scene in snapshots – the multi-colored umbrellas casting shadows over the vegetables, the smiles, the heat of the sun -I am happy.

Yet, words like Koruptem (corruption), settlements, violence and images of barbed wire, guarded compounds and cars, hang in the air. They seem out of place. As if someone put them there by mistake; tacky Christmas decorations that nobody takes down. Maybe someone could pluck them out of the air, and nobody would know the difference. Poof…they’d be gone.

Dusk. We walk to Billy’s friend’s house for a soiree consisting of pitpit barbecued over the fire and local SP beer. The sunset stencils out the trees in the background. No high-rises. The squeals of a pig, protesting the presence of the barbecue fire, break the evening silence. Richard, in his Stopim Koruptem (Stop Corruption) t-shirt, speaks of issues that affect PNG: deforestation due to coffee plantations, poverty, unemployment. His dog MDM (massive democratic movement), nervous for reasons other that the barbecue, pops his head in and out between our legs like a cartoonesque mushroom. A Tribal Freedom banner presides over the evening, as our features are slowly smudged by the darkness.

We are heading to Lae today. We leave Rob (Finco) behind in Port Moresby in our main office for his one-man show. Siliva, Kara, and I head with Lauren to Lae where we will meet Leslie, our logistician. Tomorrow we start the task of coming up with timelines and objectives to set up the clinic.