Listening and Tears

I've decided to use this space to add stories from my medical career that build off of my experiences in Bogota...now, 3 years later, here is a new entry:

Listening and Tears

Observing.  Listening. Reacting.  Observing. Listening. Reacting.  Listening. Listening. That was the beat of my day. I’ll start with the last part, since my emotional reaction from the whole day decided to come out then and motivated me to write again. To write something that wouldn’t be an email, or a patient note.

After frantically flipping through one of my medicine textbooks, chastising myself for not understanding medication dosages and dilutions well enough, I decided to shut my books and take the subway down to Wall St. It’s funny because every time I go down there, it is for something that is somewhat always anti-corporation. Last time it was flu shots in Zucotti Park. This time it was “Yoga for change-makers.” I arrived and was instantly warmed by the smiles that met me at the door. We introduced ourselves, sharing bits and pieces about our professions and the way we believe we make change. After everyone spoke, it was as if a nest had been woven between us, catching us all-in our fatigue, in our failures, in our frustrations and fears. Then we closed our eyes, and followed the soothing voice of our yoga teacher, allowing her words to rub our lower backs and to let us breathe out the day.

Today was a particularly intense day for me. Another one of those days in third year, where you say, holy shit: What did I just hear? What did I just see? And what did I do when this happened? I’m guessing Palliative care must be like this every day. To see so much sadness, enmeshment between family members, existential crises, pain. In one exercise in the yoga class, we practiced the art of listening. We broke up into dyads and listened to each other for 5 minutes, without responding or interrupting the other person. The exercise made me feel like I had never truly listened to anyone before. We were supposed to speak about a strength we have, and how we intend to keep that strength growing. I decided to give an example from my day. It happened when I went into a patient’s* room, to speak with her about her pain management. She had just been readmitted to the hospital after finding out that her cancer was no longer in remission. She told us that all she wanted was to go back to her daily life, her job, her running. She said that she wanted her pain to be controlled, but couldn’t accept the fact that it would make her drowsy and unable to communicate with her husband with a clear head. While she told us about her personal goals of treatment, I felt my throat swell, my nose grow hot, and my eyes begin to moisten. At first, I was angry with myself, upset that I had let my own emotions into the patient’s personal space, and tried my best not to let the patient see me. As I told this story to my listening partner in class, I began cry again.  It’s hard to explain why we cry some times, but in that moment, I returned to myself in the white coat, by the bedside. I returned to my moist eyes and thanked them.  I acknowledged my expression of sadness as my strength. This experience brought up an important question for me: Why are we ashamed of letting others see our tears?

*identifying characteristics have been changed

The US Navy and too much T.P

These are some observations from my second week in Bogotá…funny to read them now the night before my departure!

The Supermarket:

When you pay for your groceries in Bogotá, the cashier asks you: “En cuantas quotas se lo quiere pagar?” This is the moment my raised eyebrows reveal I am a gringa. Oh! People pay groceries in quotas…when people go shopping, they are not expected to necessarily be able to pay for everything at once. How practical and thoughtful.

By the cash register, two police guards with guns stand by (I wish I could say which kind for dramatic effect, but I don’t know the terms…one big gun and one little gun each). It’s funny because they are standing in front of the toilet paper as if protecting it from thieves seeking treasure. I happen to grab a pack; only to realize that it comes with 24 rolls…I can’t help but feel everyone staring at me walking down the street with 24 rolls of TP. In my head I’m hoping they are thinking that I’m bringing it to some foundation or something. While traveling, one gets so much more self-conscious about this kind of thing!

Cash Machines:

Cash machines have little mirrors on each side of the screen so that you can see behind you when you take your money out. Just to be safe.

Names:

As in the DR and surely other Latin American countries, there are some names here that are borrowed from American or British cultural references or are the product of U.S presence in Colombia.

Some great examples are:

“Usnavi” (U.S Navy)

“Jon F. Kennedy Gomez”

“Miladis” (My lady)

“Yurladis” (Your ladies)

“Lady Diana”

“Lady Princessa Diana”

Slang (some Bogotano, some from the coast):

-Jeta=mouth...colgando jeta=gaping, practically drooling

-tienes afan?=are you in a hurry?

-voy pa esa=I’m there

-corroncho=tacky

-gusano=girlfriend stealer

-gonorrea!= insult, gross thing

-bareta=joint, blunt

-mono/a=blond

-emputar=to get angry

so many more…

Fruta:

There are SO many kinds of fruit here that I had never seen or tried in my life.

-Maracuja: passion fruit. In the DR it’s called chinola, maracuja is also passion fruit in Portuguese

-Grenadilla: like passion fruit in texture, but sweet instead of tart. Orange on the outside.

-Pitaya: looks a bit like a yellow hand grenade. Inside, melon-type texture, sweet, clear and watery. Don’t eat too many of these!

-Feijoa: Kind of like a kiwi, a bit grape like, nutty, RICO.

-Lulu: Orange and sour, but tastes kind of like grape juice (we made lulitos…better than a mojito).

-Guanabana: Big, spikey and green on the outside…I think this is dragon fruit in English. Fleshy and white and sweet on the inside.

-Mangostina: like sweet cotton balls.

Comida/merienda

-arepa: flattened corn bread patty stuffed with cheese (or meat or egg). a staple

-tamale: corn meal roll stuffed with veggies or meat (I had one with tofu…muy rico)

-ajiaco: delicious soup of potatoes, cream, capers, corn…served with avacado and rice. perfect for rainy season

-fritanga: plate of fried yucca, maize and a plethora of meat- chuchullo (intestines), blood sausage, ribs etc.

-bandeja paisa: have to try this…

La Mona

Yesterday I went to a conference led by the Universidad Nacional’s research group “Antropologia Medica Critca.” Anthropologists, doctors (both in “Western” and traditional medicine), social workers, lawyers, health insurance representatives, and students all attended. The conference focused on intercultural interactions within the health system at various levels. We discussed ‘interculturalism’ amongst health workers (e.g. doctor to nurse interactions), within doctor to patient relationships (e.g. indigenous patients with Westernized doctors), and between health workers and the capitalist system they are subjected to that influences protocols. Specifically, we focused on the problem of language and understanding with medical interpreters and the ethical/problematic implications of administering “Westernized” health care to people with different interpretations of disease or different concepts of how to confront health issues.

The most interesting part of the conference was questioning the role and responsibility of the Anthropologist who conducts ethnography within the health/medical context. One of the key note speakers, an Anthropologist who conducted fieldwork in Laeticia with an indigenous group of people living with HIV, commented: “You have to ask yourself, what is the purpose of this ethnography? If I interview someone and hear that they are having difficulty receiving care, is it ok just to sit and listen and transcribe the interview? I say no. Ethnography within the health field is political, it should be approached as Participation Action Research, or participant observation. In other words, the Anthropologist has the responsibility of acting based on the information he/she collects.” I really enjoyed this point because it gives Anthropology a significant role in its capability to produce change. I have been asking myself this question as I interview street people about their experiences in access to health. When they tell me, for example, that a doctor has refused to operate on them because the operation is costly for the hospital and the patient is entitled to free service based on their socioeconomic condition, what do I do to help them? I think that multidisciplinary teams could work miracles in these cases. If I could work with a conscientious lawyer and doctor, we could see to that the operation had to occur based on the constitution’s definition of the right to health. I am actually referring to a true story, based on an interview I conducted today with a sex worker. I’ll call her Mona because that’s her nickname (it refers to her lightish skin, and hair, people call blonds ‘monas’). Here is her story:

Last April of 2009, Mona was thrown off the third story of an apartment building. She woke up in the hospital of San Jose with a fractured pelvis, broken leg, and disfigured face, not remembering anything from the day before. Mona was held there 6 days and when she was told that she would have to pay more than 1 million pesos (over $500) for her stay, she shouted at the doctors to release her as she could not pay the fee. The doctors agreed to her leaving provided that she pay eventually, but Mona left immediately, forgoing the payment and still in critical condition. Mona arrived home in a taxi unable to move for two months. She did not want to go to another Dr. after her treatment in San Jose and was afraid that she would have to pay more fees. Then, a friend of hers came to visit and told her about Dr. T from the Parche of the Procrear foundation. Mona agreed to seeing Dr. T and received her for home visits.

Dr. T discovered that the fees Mona was required to pay were due to her pending SISBEN (System for the Selection of Beneficiaries of Social Programs) situation that did not correlate with her current economic situation. The San Jose hospital had not attempted to understand this problem despite the fact that Mona told them that she was a sex worker living in a lower class neighborhood. Mona was still declared status 3 (middle class, required to pay 30% of fees for medical visits. Note there are 6 statuses, with 0 as the lowest) under her mother’s affiliation in Medellin.[1] How was Mona supposed to return to Medellin to change her SISBEN status when she could not even walk? Luckily, Dr. T helped write a letter declaring her incapacitated so that her aunt could disaffiliate her there. Finally, Mona was able to receive a “special populations card” declaring her incapacitated and a street person so that she could receive free medical care. As a result, Mona was finally well attended to in the hospital San Permendoza and Santa Clara. Until, it came to repairing her face.

Even though Mona had x-rays proving fractures along her jaw on both sides of her face, and that she could no longer smell or taste, the doctor refused to offer facial reparative surgery for her type of medical coverage. He simply installed some new false teeth and told her that was all he could do. She could try a private doctor, but it would not be reimbursed by the health system. It hurt her to laugh and swallow. It affected her work, because her former clients could no longer look at her face. Today, she no longer works and is still pining for the day when her face might return to normal and she might enjoy her food again.

One might ask, well what about her family? Couldn’t they help her pay for the operation if she needed it? Why did she leave Medellin and how did she fall into prostitution after belonging to a middle class family? In Medellin, Mona ran a micro industry, selling empanadas on the street with her husband. She was quite successful and had no troubles getting by with her two kids. Then one day her husband borrowed a large sum of money to be able to pay for his father’s health bills, only to realize that he could not pay it all back. He started stealing from Mona’s mother. Mona’s mother’s landlord happened to be affiliated with the paramilitary and caught on to Mona’s husband’s stealing and subsequent drug trafficking for revenue. He called upon security forces to siege Mona’s house. Her husband grabbed her and told her that they MUST leave the city. So Mona was dragged to Bogotá, leaving her comfortable lifestyle at home. She began to do drugs with her husband and drifted in to the prostitution business. And then, after sniffing many pots of glue, Mona got into a fight with another prostitute and was pushed out the window, to end up broken on the sidewalk.

During Mona’s interview, she showed my fellow researcher and I a photo of her with her smiling family from a few years back. She held the photo with trembling fingers and said, “Look at my face there. I am unrecognizable now. I don’t think my family could even point me out on the street.” Then she tilted her head down and sobbed. In addition to lamenting her disfigurement, she seemed to mourn the death of her former happy family life. Although her husband beats her, she told us that she didn’t dare going back home for the fear of paramilitaries and embarrassment from her husband’s actions. Her current situation is a product of relationship abuse and structural violence (e.g. the hospital’s negligence). Mona deserves a face, but what can be done? Beyond publishing her story in some academic journal that might stir some, but will eventually accumulate dust, how can I turn my participatory research into action? I have phoned a doctor I know in the hospital Tunal who is very supportive and proactive in sex worker health, so hopefully this case will receive the attention necessary to incite legal action and compel the hospital to pay for her reconstructive surgery.

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[1] Ironically, one of the greatest barriers in access to healthcare is the SISBEN. If someone moves, they must return to their original location and disaffiliate themselves with the SISBEN there, in order to receive a new one in the new location. This process can take months.

Carolina the hairdresser

“Ay that’s Carolina…isn’t she beautiful?” He touched the paper copy of the photo on the wall, his fingers lingering on her smiling face. “Who is she?” I asked him. “Who WAS she…she was killed 6 months ago right in front of the Procrear office, just a few blocks from here. You see how she’s cutting hair in this photo? I taught her how, when we were in prison together. You see, in prison, our sentences where shortened because we cut people’s hair, we worked. And she had 8 years, which turned to 4 and I had 6 years which turned to 2.” He took a bite of his granola bar and chewed slowly with his few remaining teeth. “Why were you sent to prison? And she?” He swallowed and continued. “Well, I cut someone’s face with a knife. And when you aim for the face, you get more time in prison. She did too, but she was defending herself because someone was robbing her. And then I got out and she did later on. And one day, she was all dolled up, with her long hair, painted nails, everything. And she was standing out side the Procrear office, on the street, and some band of guys stabbed her, repeatedly. For a while, no one came to claim her body, but eventually her family came and buried her on her land.” He placed his hand on the photo, then on his heart. Then he walked to the closet, picked up a broom and swept the trash and dust off the sidewalk.

Like Wanda, Carolina is another transvestite who was killed in broad daylight, just standing on the street. Carolina would come to the Parche and cut street people’s hair every Thursday. Now a new trans girl cuts and the street people leave happily groomed. To how many more will this happen? And how does the news treat these kind of incidences? It would be interesting compare news reports over the years of these kind of hate crimes to see if they have changed at all. In Wanda’s case, the news blamed the violence on street culture, rather than on hate/exclusion against transgenders. Carolina’s murder seems to be another incidence of social cleansing…

Street Love

Wrote this before hopping off to Tayrona and Cabo de la Vela, where I traveled all last week:

I walked back to the Candalaria watching the pink clouds swirl into the gray sky. What is this city? It is a constant mixture of beauty and ugliness. Earlier today, at the Parche, I met a street couple. This is the first pair of street people that I have seen completely in love. The girl was eighteen, tiny, and hyper active. All morning she sat writing love lyrics to Harrison, her 38 year-old partner. “Harry!” she would call him, “Ven aca! Tengo que mostrarte algo…” Then she would show him the lyrics, stare deeply at him and give him a big kiss. Harrison, a poet, told me of his travels to Israel and of his favorite writers, like the Argentine Julio Cortázar. He wrote a poem for the Parche before leaving today. It used metaphors to explain how he would always support his lover. He told me, “You see, there is a big difference in age between the two of us, but my girl is young and motivated and eager to learn. I am older so I can protect her and share my experiences with her. We keep each other going.” The girl kept coughing all morning and I asked Dr. T if I could give her a cough drop. She said I could, but that she probably had tuberculosis, so it probably wouldn’t do much.

I met a one legged man who had been in a motorbike accident. He spent two years in the hospital during which he developed gangrene and was amputated. Today he came in with some kind of polipo (polyp) growing between his toes on his last remaining leg. Other street people came in with gashes from recycling wounds. Recycling is actually one of the main causes of wounds/infections in street people. A T.V screen or broken bottles are just some examples of the objects that had shattered on them and caused severe infections.

I spoke with another woman (who I would like to interview) who kept going to the doctor for chest pain, but the medications they prescribed to her were NonPOS, and she didn’t have the money to pay for them. POS is the “Plan Obligatorio de Salud,” it qualifies treatments as refundable by the government. NonPOS means that this lady’s medications were not reimbursable by the state, or not considered ‘obligatory.’ She told me that she still suffered of chest pain and didn’t know what to do. I learned that if a doctor prescribes a medication that is categorized as NonPOS, but thinks that the patient really needs it and shouldn’t have to pay for it because of his/her economic status, the doctor can send in a request to the ‘junta medica,’ a review board, to override the NonPOS status. I wonder if the doctor considered doing this and if this lady knows that the doctor is obligated to do this if he think the treatment is really necessary…

To conclude the day, we did street outreach in the prostitution zone right by the Parche. Most of these prostitutes are quite hideous. Many are obese and look over 40 years-old. They stand behind these cage-like windows, tapping their acrylic nails on the walls. Their swollen breasts ooze out of their tank tops. We handed out condoms and told them about the Parche, where they could receive free medical consults, hair cuts, condoms etc. Most of them seemed enthusiastic and happy to know there was a support center right near by them.

Next week I’m hoping to hand out lubricant and conduct a small teach-in about how it can increase their control during sexual encounters and decrease pain and irritation. Timothy told me that these teach-ins must be intimate. You have to let them feel the lubricant and rub it on their fingers as if their fingers were a penis. Wow! That sounds a bit intense, but apparently it makes the girls laugh and shows them that they can really stimulate a client to the point where he will spend a lot less time inside them and will thus diminish the pain/irritation/unpleasantness. We shall see how this will go…

Medical Consult Day

Every Wednesday is medical consult day at the Parche. Last week, I saw three different patients, all street people. The first one complained of ulcerous pains and of coughing up blood. At the end of the consult, Dr. T offered the man some medicine and asked if he could pay anything at all for the medicine. He took out 200 centavos (ten cents) from his jeans pocket and said he would give it instead of buying bazuko (type of crack). This system of asking the patient whether he can pay anything encourages the patient to take his health under his own control. It also demonstrates a shift in the patient’s self-value.

The next man we had seen last week for a consult. Last time he came in because he had hemorrhaging in his left eye after being punched in the face. This time he came in with a stab wound on his side. He told us that around 1 am, when he was sleeping, a few men high on glue stabbed him and stole his shoes. He said that he didn’t bleed much, but the area around his lungs hurt him a lot. After examining him, Dr. T thought that the stab could have pierced one of his lungs. He was having some trouble breathing and his heart rate was very fast. Dr. T told him that he should go to the main hospital to check up on his lungs and get some x-rays. Immediately, the patient shook his head and said he would wait and see how he felt tomorrow. Dr. T told him that she couldn’t force him to do anything, but that his wound could cause serious complications if he didn’t make closely survey it. For some reason, this man really didn’t want to go to the hospital. He told Dr. T he would hang out in the Parche and see how he felt in a couple of hours. I thought this would be a perfect thing to ask him about. What is it about the hospital that made him not want to go, despite his serious condition?

The third case was a 49 year old who looked about 70. He was a complicated case, because he had developed some kind of dementia and was fairly incoherent. He had a long knife cut scar along his cheek. He came complaining that he was going blind in his right eye and had a lot of liquid coming out of it. Dr. T inspected it and thought he had a cataract and potentially something else that was causing dimentia and chronic headaches. We asked him if he was on any medication and he showed us: flucanozole, iron vitamins and antibiotics. She asked him if he could read, and he said not very well since he had stopped school in the third grade. This was a crucial question to ask, because he clearly was confused about which medications he had and when he should take them. After he had left, Dr. T told me that this was an odd combination of medication and that perhaps he had HIV. He had told us that the family he lived with were all drug users, so they couldn’t come with him to his medical visits, this further complicated the case because there was no one we could ask about his medical history.

After the consultation, Dr. T looked over some of the histories of past patients and gave me eight different cases where patients had experienced some kind of barrier that prevented them from receiving or seeking appropriate care. Dr T. is going to contact these patients via phone or through house visits together so we can see if they wouldn’t mind being interviewed.

Dr. T also gave me some great ideas for other potential research topics. One was researching sex workers’ myths and practices to avoid pregnancy and deal with menstruation while working. Some of the myths to avoid pregnancy are the following: drinking alka seltzer, standing on your head. To keep working during a period, some prostitutes stick sponges up their vagina before intercourse and then pull it out and reuse it for the next customer (infections!!). Another research idea was to knock on doors of the inquilinos (dingy tenements around the Parche) and ask about recetas caseras. The goal would be to produce a whole cookbook of home remedies that people use to cure themselves in these settings. It would be interesting to see the effectiveness of these home remedies and if people use these instead of seeking care in hospitals if the sickness is serious. There is so much that could be researched here. I think a major project should be conducted by public health specialists on housing and its effects on child development…I know this has been done in East Harlem, but I’m not sure about here.

One thing I’ve noticed is that a lot of the students here are extremely motivated and concerned with the conditions perpetuating poverty and conflict within the country. The elections, for example, are a hot topic…although it is debatable how much a new president can change the current situation. An article in the Washington Post evaluated the current state of poverty in Colombia despite massive financial aid. Instead of investing money in the war on drugs, perhaps the U.S should give more money to research involved in discovering, deconstructing and dismantling those structures that perpetuate poverty and fuel drug production/selling/consumption. Is poverty a major cause of the drug war? I know that it is much more complicated that that, but if so, could solutions to poverty (i.e reformed health care system, less taxes for the war more taxes for public services etc.) be offered before increasing military/police action (bottom up)? I obviously feel way too uninformed to offer a complete opinion, but these ideas have been floating around mainly due to listening to student conversations and spending so much time with street people.

I don’t mean to paint an ugly picture…Colombia is a mosaic!

Looking over my blogs thus far, I notice that they all seem pretty gloomy. In reality, I have had a wonderful time in Colombia these past 3 weeks. I feel more motivated to write about my work here, which is difficult and somewhat depressing…I seem to write when I am particularly moved by an experience. But why are we moved by extremes? I guess this is why I admire Hemmingway’s writing, because he writes so simply and clearly about potentially mundane events, while saying so much...(I am referring to A Moveable Feast , but this could be said about others too).

Besides wandering around prostitution zones and hanging out with street people, I have participated in lots of other activities. I went to this extreme sport place in sugarcane-covered mountains where I went rappelling in a cascade with two Canadians and my lovely Brit colleague Rosie ($20 for a whole day of rappelling and horse riding without a single safety training course to deal with!), went hiking in cloud forest at Chicaque National Park, saw Macbeth in the park during the Festival Iberoamericano de teatro, took this drunken party bus to the kitschest-hip club in Bogotá, and shared a massive plate of fritanga (intestines, blood sausage, ribs, fried yucca the works) with a group of gringas frustrated with teaching English to wild children, to name a few. I hate writing in lists, but this is sort of how I remember these events…like a shopping list of delicacies that I can linger on and taste, but don’t need to flesh out.

I mainly wanted to write this to express how much my perception of Colombia has changed since I have been here. Although the media reports many true events that occur in Colombia, it only focuses on the drugs, the hostages, the misery. Why did so many people think that I was CRAZY for coming here? I have experienced so much more than that and have been floored by the affection and warmth with which I have been welcomed by Colombians. This might sound obvious to some, but I thought it was worth sharing.