Tuesday, June 26, 2012
6-11-12 to 6-25-12
June 11th 2012 I am reading about hypothermia and hypoglycemia in the newborn, in order to be better-equipped to explain these things to the midwives here as I try to improve the conditions meeting newborn babies in the MSF hospital. Actually, there have already been small improvements since I first started talking about this (hypothermia—haven’t tackled hypoglycemia yet) with the 2 MW supervisors who oversee triage/delivery room/antenatal/normal postpartum. This is great. I will be starting to teach neonatal resuscitation (it will be a review for many of them) to all of the midwives and auxilliares very soon, and I also wanted to use this opportunity to talk about cold stress and hypoglycemia in the newborn. (The delivery room actually has an air conditioner and it used to always be super cold in there, plus the other issue is lack of early breastfeeding. Babies are having a hard start in life here. I need to remember not to get into the expat mentality of being in a rush and trying to accomplish a million things in 6 months-- I see some people doing this around me, which makes me doubt myself sometimes, but I also know myself and know that I need to be realistic and pace myself. AND, another huge reason for not being super crazy and in a huge rush is because the Haitian staff are not like this at all, and it won’t help me in my work AT ALL if I act crazy and stress them out. So, I have to stay relaxed and combine speeds—a combination of expat speed and national staff speed. We had a woman die in Cholernite on Thursday night. It is sad…it is always sad and strange when people die…something that Haitian people have had to deal with their whole lives…this woman was 22 years old…her case was complicated, and in the end, no one knows for sure what the main cause of her demise was…several of us worked very hard to save her on Thursday, during the day—but at that point, she was already in a coma and was getting worse and worse…when I left, I knew that she was dying. The saddest part for me of this situation, was witnessing her husband as he had to deal with the reality of her death…the thing is that here, people are struggling to get the money together to even have the body picked up and buried. So, the day after Delia died, her husband of 7 years was in the street, running around, from here to there, trying to borrow money so that he could have her body picked up (we don’t have a refrigerated morgue) so that he could have his beloved wife buried. He had no time to grieve, or to hold his 4 year-old daughter who was also realizing the fact that her mother was not coming home…he had to be matter-of-fact, and tend to the nitty gritty details of having his wife’s body picked up…not just any ambulance will pick them up, because people who have died with cholera are still infectious, even after the disinfection process that is carried out after the death…(which is why MSF additionally provides a body bag and coffin to reduce the contamination risks). Friday afternoon, he had been out all day, trying to make necessary arrangements, hadn’t eaten, hadn’t sat down…I was present in the discussions between him/his sister (who were both by Delia’s bedside for 3 days until her death) and the staff who are in charge of dealing with the dead bodies as they discussed logistics…it was so sad…towards the end of the conversation, someone showed compassion and solidarity by saying something like, “It’s something you grow up your whole life with, but you never get used to it (death).” Then, the sister said something like, “yeah, you never can get used to it, but it will always be in your blood”—what she meant by this was that it is something you cannot escape. Unnecessary death, such as children dying from malnutrition or diarrhea—moms dying from eclampsia—things like this, if you’re Haitian and live in Haiti, you will always be exposed to it, and it will continue to happen. It’s in your blood, as in, you cannot get away from it. As we were walking away after this final conversation, I felt so incredibly humbled before this man and his sister, who were dealing with the reality of Delia’s death because they had no other choice. I was so incredibly humbled, and wishing to give some kind of consolation to them, wishing that I could somehow offer some support, besides my presence and my patience. I had no words to offer, no blessing to give that could possibly compare to their courage. I felt so inadequate, although I knew too that simply being present and compassionate meant a lot to them. Still, I could see myself there in such a priveledged position, having a window into their suffering, watching them and learning from them, as I have done in with so many other people here. Not one word could I give them that would possibly suffice. As we parted ways, the only thing I could think of that was encouraging and that would make sense to them was, “I’ll pray for you.” That was all I could say. I will never be able to understand or quantify the strength of the Haitian people. People notice it, but so many people overlook it. I remember in Hinche, people would always notice the “lack of compassion” of the Haitian care providers at the hospital. It was shocking to me in the beginning as well. It was hard to understand how midwives and other healthcare workers could be so cold and callous. But, I came to see many things in my time there, and one of them was the realization that there were many other acts of compassion that I had initially overlooked, because I didn’t perceive them as such. I didn’t understand the culture enough to see them. People in Hinche (short-term volunteers) always used to try to ask me to analyze with them “why” there was such a “lack of compassion”—perhaps because people see so much death and suffering on a regular basis that they are powerless to fix—that was one hypotheses…I always remained neutral and not really willing to agree upon a certain analysis, because in reality, who am I to give a reason for anything? What do I know? Al I know is from my own observation, which is shaded by my own cultural assumptions. I didn’t grow up here. How could I possibly be an authority on the Haitian mentality? It makes you think of all of our own mortality, of how we are constantly walking such a thin line between life and death…I try not to think about it too much…those of us who are living are so lucky… Blada came here this weekend…he left this morning…we hadn’t seen each other for about 3 weeks, and I was really starting to miss him a lot…it was such a relief to see him and be with him…so joyous…so so full of joy. I miss being around him. I feel so balanced, centered, and happy when we are together. This is good, what we are doing now…we are both accomplishing important things…working on our own…but, we are going to try to see each other more often, because 2-3 weeks each time is really hard for us. He has been cultivating our little piece of land in Ti Trou. Planting trees, and making gardens. For instance, he has planted like 40 coconut trees all along the perimeter of the land. He is planting mango, cashew, almond, soursap, breadfruit, things like that. We started a little garden here too. With seeds that my mother sent down with someone for me. Basil, tomato, tomatillo, chile peppers, melon, cucumber, sunflower. So exciting!! June 16th So…this was a pretty good week at work…the people I work with (both expat and national) and the work itself (everything it entails) is so interesting…sometimes I find myself in the moment, while at work, just savoring the moment and feeling so content and optimistic, knowing that I both have a lot to contribute and also a lot to learn…and knowing that both of these things will happen….and are happening…other times, sometimes, I still feel overwhelmed, both at the massiveness of all the work that still needs to happen in all the different services I am involved in overseeing, and then sometimes feeling really inadequate, and then sometimes comparing myself to other people who appear to be accomplishing big things/making huge steps…then wondering how people see me…but in reality I know that people trust me and respect me, and that part of this insecurity I have is because I am still new and figuring out the ropes…I can see the problems, the hard part is figuring out multiple strategies to approach the problems. I am accustomed to working directly with midwives and teaching/coaching as I work together with them…but, I can’t just have this one approach…I can do this too, and in fact must do this, in order to improve some of the care, but I also need to do research, plan continuing education modules, and be more of an administrator. I see all this, but the pieces are still falling into place for me, as far as how to work within the structure of MSF and use the tools available to me. I am starting neonatal resuscitation classes on Monday. I have a feeling that this is an area that needs improvement in the delivery room. I am going to keep it really basic and practical—what to do and how to do it effectively. Blada is here this weekend again! Some of our little seedlings that we planted last weekend are coming up. Last night we had a really fun time, we went out with 2 people I live with, Charles and Adriana, to a little party at the house of an old friend of mine, who is now living in Haiti for the next 2 years. My friend is named Elisha, and we both grew up in Saxapahaw, and used to play in the woods together all day with our other friends, when we were like 9-10 years old. Then I didn’t’ see her again for like 20 years, and now suddenly she is living in Haiti. She is a really fun, exuberant person. It was really great last night because she got to meet Blada, and also my friend Charles, is from DRC, where Elisha lived for 3 years. So, really great. At the end, before we left, we were all dancing in the living room—so, yes, my kind of party. Blada brought me 12 green coconuts from Ti Trou. I was literally in heaven earlier today as I drank the sweet coconut water from 3 fresh coconuts. And then eating the flesh…soft, sweet…coconuts are amazing. June 18th Back to work today…I was sad to let Blada leave this morning…it was easier last week because I knew I would see him the next weekend…it’s hard trying to cram everything into 2 days… This morning I did my first neonatal resuscitation class here at CRUO (the MSF hospital: Centre de Reference des Urgences Obstetricales)----doing the class was really fun—really natural and enjoyable for me—I guess I miss teaching…it was partially a review for the midwives but partially new, because I really focused on doing each thing correctly…so, I think the result was good…simple, practical…how to do ventilation and chest compressions: correctly. I wanna give a big shout out to Maternidad La Luz, where I trained and worked for 6 ½ years before coming to Haiti…I got such a good grounding in midwifery skills (such as neonatal resuscitation)—and in birth, suturing, prenatal care, newborn exam, so many other things. I am eternally thankful to MLL for the opportunity I had to learn and practice what I did during that time. And MLL is still so much within my consciousness (or subconscious) that it really embodies/represents many of my ideas and feelings around midwifery… For instance, the other night I had a dream, in which I was in the rose room (one of the birth rooms) at MLL, and there was a beautiful laboring woman in there who was doing amazing, handling her own labor and taking care of herself, changing positions intuitively…I was just watching her, holding the space…she starts pushing, and soon the head starts emerging…well, next to me is a Haitian midwife (who I know in reality), who, once the head is coming, starts telling the woman to stop pushing so she can get her hands in there and pull the baby out for her. I gently tell her to wait and just watch, without interfering. The woman catches her own baby in front of us, with no interference. In reality, it is really hard to watch sometimes how the midwives practice, because it seems as if most of them have one single way to handle birth especially. One of the things that annoys me (since forever) is how people always make the mom stop pushing after the head is out, and then they proceed to pull the baby out by the head, with no help from the mother. It doesn’t make sense to me. But, it’s the one way that everyone learned at the one midwifery school. I’m not complaining…I’m just being honest about one of the many zillion tiny things that have been challenging for me, for the past 2 ½ years since being in Haiti. I think that I have done well accepting Haitian culture and reality and realizing that I am a guest here anyway, so why get all bent out of shape…but still, it can be hard. And I think that the dream I described above embodies some of this frusturation. The thing is that here, it’s not like at MLL where all of us held the basic principles and understanding around the way we treat pregnant & birthing women. I feel very alone sometimes. I remember in Hinche, when I first arrived, what torture it was. But, as Marthonie came to trust me and became my ally, I wasn’t alone anymore. She was amazing. I have said this before—I don’t know if I will ever find someone else like her again in Haiti. Another little dream from this same night that is kind of funny and again embodies some unspoken feelings was that I was in a group of people and everyone was speaking French, which I understood perfectly, and then one person turns to me and translates the whole conversation over again in English. In the dream I am like, “God! You don’t have to do that! I UNDERSTAND FRENCH!” In reality something like this had just happened that day, and I wanted to be polite so I didn’t say anything. Remembering the dream was funny. One thing that I really like about my house is that I get to hear people speaking German and French a lot…it is so interesting…just listening to the sounds…the French is fine, I understand it very well and am starting to speak it more and more…the German, I don’t understand it but I love hearing it. If is finally cool (for Haiti) and cloudy for the past couple of days…so so wonderful…I miss weather like this…I wish it could be like this more often. Cool and cloudy, instead of hot and really sunny. It is really nice. I have been missing my old girlfriends from MLL. Old midwife sisters, from years ago. Those who spanned the 6 ½ years that I was at Maternidad La Luz. I wrote to many of them this past weekend, (after wanting to for a long time), and I have received some responses that have been so touching and helpful to me after the almost 2½ years that I have been in Haiti. One of them was from a classmate of mine when I was a student…she is in Canada and we never saw each other again or wrote very often but she was one of those who wrote me back with enthusiasm…it helps so much, to feel that you are part of a global network of people who believe in and work towards the same thing…. Thank you, to all of you who have been with me during this time, who have been present with me, who have posted comments and feedback to me during this time…friends and midwives sisters alike…. 6-25-12 Blada spent this weekend with me—he left this morning. It was so good to unwind with him. He has come each weekend for the past few weeks. This weekend, I felt satisfied. Last weekend, I was really sad to see him go, and I felt like we didn’t have enough time to do everything we needed to. Like, simply spending time together, embracing or whatever. I was really sad when he left. 2 days is not really long enough. And it is not really feasible to do every weekend, because he comes from far away. When he left, I missed him so much, and I couldn’t talk with him for long enough on the phone either, because phone cards here are sooo expensive. That’s why Haitians have really short, direct conversations usually, like, “Did you get the thing? Eh? Ok Ok.” Anyway…this weekend was wonderful. We had a really fun going away party for one of the expats, with drinking, socializing, and dancing, national and expat staff together. This woman, who the party is for, is usually to total hardass (but is also pretty funny a lot of the time), but she really loves her national staff, and as soon as everyone left, she sat down by herself and started crying (hard). It was really sweet. Yesterday, I was tired, but I wanted to practice some salsa dancing with Blada. So, we went up to the rooftop terrace of the house, which is all covered with tile, and is very nice, and we danced up there. It felt magical. I felt so happy. There was a constant breeze….palm trees…mountains all around…gliding around together, dancing salsa…it was one of those moments. Things at the hospital are going well. Today was a good day….the sessions with the midwives for neonatal resuscitation (NNR) are going well…they all seem to know the theory well, but it’s the actual technique/practice that they are weak in…so, it has been good to work with them. I am talking with the one of the Haitian midwife supervisors to get her interested in helping me to improve the NNR area of the delivery room, so that it’s more functional and organized, and I have also been working with her on the issue of keeping the room warmer. When I first arrived it was always really cold. The temperature issue has already improved a lot. Which is really encouraging. This needs to be continued and encouraged continually---another big area to improve is the maternal-infant separation that happens and the lack of early breastfeeding. So, hopefully these areas will be possible to really improve as well. Instead of having hypothermic infants that are separated from their mothers and not BF early, we can have babies staying on their moms, breastfeeding early, and not getting cold. This will make a huge difference in the outcomes of these babies. So, things are possible and promising…it’s just hard to have patience sometimes, because you have to go so slow with people and really take time to talk with them…there’s a certain kind of etiquette in a way…I get it, I accept it, but like many things about Haiti and Haitian culture, I also get frusturated again from time to time again and really annoyed, about things that I had thought I had already accepted pretty well. One good thing for me is that the 3 SF (sage-femme, midwife) supervisors who I work with, they are not hard people to get along with, or communicate with, or work with, etc. I just have to remember to follow the etiquette and not lose patience. But, for instance in the delivery room, there has already been a huge improvement in the temperature. I got ahold of this awesome WHO publication all about cold stress and how/why to avoid it in newborns, and got it printed out (in French!), and one of the SF supervisors asked me to borrow a copy to take home and read. This is so great. Another good sign was this morning, one of the SF in the NNR session told me afterwards that I should give them continuing education sessions every month. That was great because she had initially seemed somewhat uninterested in the class. So…my next big subject to address with all of the SF (not only the supervisors) is cold stress and hypoglycemia (which can both be avoided by not separating moms and babies and helping with early BF). There are many other things I see especially in the delivery room that I would love to help the SF to change—but, I have to pace myself, give them time to digest what I am putting forth, have patience, and choose my battles wisely. I understand perfectly well that there are many things that I will have to completely ignore because there are more important problems to address, but at the same time, being a midwife myself, witnessing how some people manage birth can be very frusturating. It’s frusturating when it’s things that are being done that are completely unnecessary or even harmful, and then other things that should be done that arecompletely ignored. It’s like, a lot of times, things are done in the wrong order, or the priorities are wrong. This is probably since midwifery school. The nursing aspect is strong, but the midwifery aspect is weak. It’s interesting that I am getting so involved in noticing the details of how the SF manage birth too, because I am already used to seeing how birth is managed in Haitian hospitals. I don’t think that I’m losing the greater perspective though. I am “overseeing” and participating in many areas of the hospital, and each has weak points and strong points, that I am coming to understand and coming to see paths I can take to address them. My friend Kirsty, who I met and became close friends with last year when I lived in HInche, is coming to visit with me this weekend. I am so excited. She is a MW who also worked with MWH and we lived in the same house together for several months last summer. She is married to a Haitian man named Mackenzy; Blada lives with them in Ti Trou and is doing agriculture with Mackenzy and his team. So, I’m really excited to see Kirsty again…she had a baby in March…so cute…she’s coming with him…. The next weekend, hopefully I will be getting a ride on a MSF truck that is bringing people to Jacmel. I will visit my house, see friends there, get stuff to bring back here (since I live here now, not there), and maybe even go to the beach. So, that’s what’s going on right now. Some days, I have a lot of energy, like today, and I can write and enjoy my time at home in the evenings…other days, I am just so tired….i lay down at like 7pm…. Up and down energy-wise, but in general feeling good about the job and myself…doing what I can…it’s hard not to compare myself to others though…not that I actually want to be like them…there is this one expat, who is always so busy, always kind of in a frenzy to get things accomplished…if I want to talk to her about something at work, I feel like I can't approach her...there's always some big crisis she is dealing with….that’s fine for her, and I think the service she works in has needed a strong push…but, I don’t want to be in a frenzy myself. I want to be calm and at a speed that makes sense for the people I am working with (even though this is a struggle sometimes)---I am doing my best to remember to follow the Haitian etiquette of communication, however annoying it can sometimes be (that you have to be this way all the time, each time…) And I also need to remember not to think that I am being compared to others and that it’s not like we’re in a factory or something. I know that if I continue building trust and following the etiquette, things will have the possibility of improving from the inside out.