A Case from the Dominican Republic

It was our third day of clinic in the Dominican Republic, and I was with Dr. Naomi Hill and Alex, a first year student.  The day started out pretty typically, with a healthy mix of parasites and "gripe" (a group of flu-like symptoms common in the DR, really more like seasonal allergies).  We shared the Lord with a few patients, and one later accepted Christ at the evangelism station.  But it was later apparent that the Lord had something special planned for us today.  After lunch, while we were interviewing another patient, one of the triage team members came by our provider station to ask who was doing the gynecological exams for the day.  Naturally, Naomi volunteered, then offered the exam to me.  I was a bit apprehensive and anxious to give Alex a good experience, so we started preparing.  In taking a quick history with the girl and her mother, we found out she had just turned 16 and had been having vaginal discharge for the last several months.  She had been sexually active with her boyfriend, but only a few times, and it was about 3 months ago.  Then we learned she hadn't menstruated in 3 months, but she said there was no way she could be pregnant.  Just to be safe, we got a pregnancy test before performing her exam.  The exam was abnormal, and painful for her, and she was very scared, but she trusted me and looked to me for comfort.  We ended it promptly with a fairly certain diagnosis of Pelvic Inflammatory Disease.  While she got dressed, Naomi told me that the pregnancy test had come back positive, meaning she was likely at least 12 weeks pregnant.  We figured she must have had some idea, not having a period and all, so we decided to tell her and her mother together.  We told them about the infection, and that we could treat it today.  Then we told her she was pregnant.  Her face fell, and her mother's emotions were mixed and unreadable.  Stern at best, mingled with shock, anger, guilt, and a host of other thoughts raced through her head.  Naomi had to run off, leaving me alone with the girl, Rose, and her mother.  Feeling awkward and dealing with my own emotion, I was at a loss for words.  "Como se siente?" I asked (how are you feeling?) "Mal," she said (bad).  I put my hand on her shoulder.  She teared up.  Then her mother tore into her--something about running off to live with her boyfriend and whose fault this was and how her previous round of antibiotics may have hurt the baby--and my heart broke for the girl.  Holding back my own tears, I led them both back to my station to sit down.  The girl wants an abortion.  Abortions at any gestational age are illegal in the Dominican Republic, and she already had a serious infection, so an unsterile surgery of the area without follow-up care would almost certainly kill her.  Her mother knew this and begged her to keep the baby, even through her own disappointment.  Our translator Estenia asked us what was formed in the baby by this stage, 13 weeks and 2 days.  "Everything," we said.  Its heart beats.  It's kidneys work. Its eyes are formed. Its brain is there.  Then the thought-- we could find the baby's heartbeat with a Doppler.  We asked her if she'd like to hear her baby's heart.  She paused. The corners of her mouth turned up slowly, shyly, cautiously.  "Pray," Naomi said to Alex and me.  I don't know if we will be able to find them, but we need this.  She needs some connection to this life inside of her.  We take her back to the private room, get the Doppler ultrasound machine, and start searching.  Nothing.  The thought crosses our mind--it could be ectopic, meaning she was at huge risk and both lives could be lost soon.  Cheri, the nurse, leaves the room to ask people in the main clinic area to pray for heart sounds.  Almost instantly, we find it.  156 beats per minute--a healthy baby.  A sigh of relief and a glimmer of hope comes to all in the room.  Quarrels cease, and the Lord is present there.  We hold the speaker up to Rose's ear, and her eyes gaze up at me in wonder.  "Oh my God," she says.  "It's alive.  It's inside me!"  Yes, Rose.  If you have an abortion, you will kill your baby.  "It is a miracle that, despite the severity of your infection, your baby is alive and healthy.  This baby has a purpose," I said to her.  Alex pointed out that the women in the room--Estenia, Naomi, Cheri, and me--are wise.  We have seen more of life, and we know the value of a life, he said, more than she did at her age.  We urged her to consider adoption or allowing her family to care for the baby if she did not feel prepared to be a new mother.  Feeling our work was done, we prayed for her.  Lord, show Rose that you love her.  Show her that she is beautiful, and that you have a purpose for her and for her baby.  Give her wisdom in making this important decision.  Show her that you are with her and she is not alone.  Show her that you will not love her or her baby any less for what she decides, but help her to see life in this baby.  At this point, I'm most certainly crying.  I give her a hug, get her cell phone number, and tell her that God loves her.  That I love her.  She holds tight, and our hands linger outstretched toward one another.  Then she turns and follows her mother out of the church, maybe out of my life forever.  I'm not sure what will happen when she gets home-- she is so young, and I don't even know the emancipation laws here, whether she has a choice, or what her mom actually wants for her.  I don't even know what I would do in her situation, and I don't know if she has Jesus in her life.  I do not recall a case in my own life where I have been so sure of God's handiwork, and yet still had to place the situation in God's hands, knowing I'll likely never know whether that baby takes its first breath.  It's hard.  It requires faith that demands total surrender.  It demands my life being exposed before me and before the Lord.  It calls me to realize that I am not my own, that my relationships are not my own, and that my emotions are not even my own, but that they belong to God and to His Kingdom. I stand in awe of His grace and providence tonight like I never have before.  And it is terrifyingly beautiful.

The #1 thing people on the streets need: The answer may surprise you!

Over Thanksgiving break, I was watching the news with my mom when a story came on about a preacher in Dallas who decided to be homeless for a month.  Honestly, I have thought about doing this someday but am unsure what the houseless community would think of someone who did such a thing, so my interest was piqued.  The pastor said that the thing that surprised him the most was the profound loneliness in the lifestyle.  He could handle the cold nights, the food insecurity, the lack of hot showers, and the threats to safety that he faced daily, but he found himself battling profound depression.  He spent his days playing guitar on the street corners, hoping not for spare change but for someone to walk by and just notice him sitting there-- for a compliment or a moment of small talk.  At the end of the day, he had made a few bucks but no friends.

This week alone, I've been approached by plenty of people on the streets--I even allowed a homeless man named Bo to walk me to school one morning last week.  I bought him breakfast, which he wanted, but I think he would have walked with me regardless just to talk.  Today, I was asked what time it was (a common question, and the same one that was asked of the man who kissed my hand from another of my posts).  I've also been told I am "damn beautiful" multiple times the last few days, by different people, which I'm not sure I believe but graciously said thank you nonetheless.  And kept walking. Yeah, that's right.  Not in a hurry to be somewhere, just in a hurry to get to the other side of the street, to avoid the question we all think is coming:  "Can you spare $___?"  

Now that you know that the number one thing people on the streets want is a conversation and not money (in what is likely the majority of cases), I think it's pretty obvious what I'm going to ask you to do this week. Talk. That's it! And, of course, tell me what happens. Tell the world what happens. The world needs to know.

The right to cynicism?

My very first patient in medical school, which I encountered while shadowing a 3rd year student for a day during orientation, was a man at Cooper Green with rectal bleeding.  What better way to welcome a student to medical school than allowing her to do a rectal exam on her very first patient... so naturally, that's what I did.  He had the worst case of anogenital warts I will likely ever see--how he managed to defecate at all was beyond me.  I felt bad for what he was going through but, like most medical professionals, treated the situation with a good bit of cynicism.  If it had been me, I would have never let a medical problem go that long without seeking help.  These poor people, I thought, they're so uninformed about medicine that they have to be really sick before they realize something isn't normal.  

I now imagine that this man was more than informed about his condition.  He realized what it meant to have anal cancer more than I ever will.  He likely knows a few people who went to the doctor when they thought they had a minor problem, and likely all of those people came home to their family and friends with a "death sentence"--cancer, kidney disease, lung disease, heart disease, etc.  How many family members, classmates, close friends, even friends of friends, do I know who are living with a death sentence? None. Maybe one or two, out of thousands of people. Based on personal experience, my likelihood of having cervical cancer at my next gynecology appointment is slim to none.  But this man? He knew what was coming, and we are kidding ourselves if we think blissful ignorance is any part of his life.

Until this semester, I thought that what health care needed was more free screening, more free services, more education.  I had the right idea--that health care in the United States is totally built the wrong way, with little to no emphasis on primary care services and primary prevention efforts.  Access to care is still a huge problem--you can walk into any emergency room and see that--and I still have a heart for the issue.  But, actually, we haven't done too poorly at making programs available to those who can't afford it.  This has been trending up since the '60s, so we have the hippies of our parents' generation to thank for that.  What we need now is people. Health care workers who aren't cynical.  People who refuse the idea of stigma.  People who aren't too haughty, or scared, or comfortable to share life with rougher communities.  We need to increase the proportion of healthy people in the networks of those communities, so that they have success stories to base their life on instead of a bunch of failures and death sentences.  

Even the most well-meaning people--mentors of mine in my road to health care for the homeless, have told me, You're gonna have to develop a healthy cynicism for this calling to avoid being burned out.  These people just aren't going to do what you tell them to do, and it's exhausting without a putting a certain amount of guard up.  Here's what I have to say: what the crap is healthy cynicism, and why should I feel like I have a right to it?  The point that I feel like I need to be cynical to get through the day is the point that I have stopped relying on God to get me through the day, and the point at which I cease to be a truly healthy influence in the lives of my patients.  What I want to do is not a job to me.  It's not something I want to get through from 9 to 5 so I can leave work at the door and sleep at night.  If that's what medicine (or whatever your job) is for you, then I would say you have some soul searching to do. For me, it's a calling toward a lifestyle, and cynicism has no place in it.

The article that inspired this post:

von Wagner, C., Good, A., Whitaker, K., Wardle, J. (2011). Psychosocial Determinants of Socioeconomic Inequalities in Cancer Screening Participation: A Conceptual Framework.  Epidemiologic Reviews, 1-13. DOI: 10.1093/epirev/mxq018

Who's in your Heaven?

This morning, over a sunrise at Railroad Park, I met two wonderful, godly men to discuss and pray for the inner city of Birmingham.  After praying, one of the guys brought up something to me, knowing that the idea of stigma in our society has been weighing on my heart lately (as is hopefully evidenced by my previous posts).  He said, essentially, most people, when they picture heaven, picture all white people or all black people... there is, in no part of the country, such a thing as a truly multiracial church, so what should people expect except to see only people who look and think like they do when they picture paradise? 

The idea struck me, and I have been thinking about it all day.  When you close your eyes and attempt to imagine what heaven will be like, who is there?  Hopefully we can all think of some specific people-- celebrities or family and friends--but who else?  Do you have room in your Heaven for the pregnant teen in your high school, for the homeless man who asks you for money on the street corner, or for the gang members in your neighborhood?  What about that patient that doesn't take his medicine like he's supposed to, or the one who shows up to your emergency room expecting some free detox? Do these people make it in, or is your Heaven more like the Brady Bunch--blond-haired, blue-eyed, well-dressed men and women who just "look" like they must be good people?

Sadly enough, having a theologically correct picture of what Heaven is or is not has little effect on the types of people we actually picture being present there.  I'm not suggesting that just anyone will be able to waltz into Heaven on Judgment day... in fact, I'm suggesting just the opposite.  If we truly comprehend the mercy of Christ and the love He has for all people, we realize that no one has an advantage.  True justice condemns us all, regardless of the choices we make and those that were made for us.  I am no different than my ER patient-- not the homeless guy, not the drunk driver, not the rape victim or the rapist.  No. different. So if, per the grace of the cross, my Heaven includes me, is it not possible that it could include these people?

Knowing this could change our lives, if we let it.  So I have a challenge.  For one day, for everyone you see, ask yourself, is this person in my Heaven? What is your answer? Who got in, and what did they look like? Why did you let them in? Does your decision reflect what you know about the grace of Christ and His attitude toward people? And after you have done that, what will you do with the information you've learned?

Jumping the tracks, pushing boundaries

Have you ever been in the position where there is something you've always wanted to do, but you keep telling yourself you'll do it when you get older?  We've all been there... waiting to become the person we want to be. Waiting until something--that elusive event or age or social status--happens to us.  Well, tonight, in some small way, I made a step toward becoming that person.  And let me tell you, it was amazing. Here's the story...

Anyone who knows me decently well knows that I want to start a homeless clinic when I become a doctor, and that I have dedicated my life to building relationships with homeless individuals and being their advocate to the general public.  While I've taken steps toward learning how to start, run, and participate in a free clinic, I haven't made much headway in the whole relationships area.  Yeah, I've met medical needs and done the occasional shelter meal, but that hardly counts.  Recently, I started going to a new church, Mosaic, which I love because it makes urban ministry a priority.  It is connected to a houseless ministry called Avail, which I have known about for several months but recently felt extremely convicted for not volunteering with them.  But tonight was the night. And it was fun. And it changed my life forever.

Camp #1: Under an overpass on the Northside of Birmingham.  We met 3 people-- we'll call them George, Andy, and Bob (of course, names have been changed to protect the people).  We cooked a meal and shared it with them... the six of us volunteers with the three of them, all eating chili dogs and cheese puffs together.  I learned that Bob has been houseless for quite some time, down on his luck and just can't seem to break the cycle.  He used drugs in the past but doesn't now (which I fully believe).  Talking to me, he became emotional-- he hasn't opened up to anyone like this in years and, embarrassed to cry in front of a girl, he runs off.  Andy and George travel together.  They are staying under the overpass and saving up money to get an apartment together.  They've found one that costs $195 a month, and a social worker is helping them move in.  George is from Milwaukee, while Andy is from Birmingham.  Andy is turning 60 in a few months, and she has been in Birmingham her whole life.  She was even in 16th Street baptist church the morning it was bombed, and she knew the four kids who were killed.  She lives on the streets because she moved in with her mother to take care of her, but her mother, sister, and father all died within the span of a few months, leaving her with an unfinished college degree and nowhere to live.  She spends her days at the library reading mystery novels, and she loves poetry and plays.  She and George can't wait to join our Bible study next week and ask us to pray before we head out.  Beautiful.

Camp #2: Across the train tracks, also on Northside.  This was a bigger camp-- a community of sorts, where everyone knew each other and they all had a role to play in society.  We ate with them as well-- more chili dogs-- and I met a few more people.  Among them were Annie and James, and also Gavin (again, names have been changed for protection). Annie and James were a couple who lived in Oak Grove before moving to this camp.  They were in their basement when the April tornadoes hit last year, and they lost everything.  Annie has two kids, both grown, and one granddaughter.  They are all housed and she gets to see them occasionally.  She is already saving money to get her granddaughter a Justin Bieber backpack for Christmas.  She is the only woman, hanging out with a bunch of guys, and as I am leaving she begs me to come back next week.  Gavin went through a recovery program and graduated not long ago as a "success" of the program.  He is now back on the streets, not having the resources he needed to maintain the lifestyle he'd been taught about.  He also begs me to come back next week.  And of course, I will. Because this experience was beautiful.

We packed up and headed back to the car.  We had to jump a train that had stopped on the tracks, blocking our way.  It was scary, but exhilarating! As I jumped down from the train car and ran across the tracks, I began to reflect on the night.  To think about what my parents would think, and how I would be back next week no matter what anyone would think.  To begin to understand the hearts of a misunderstood people group firsthand, and experience the healing that comes from loving someone despite what their past has beheld--maybe even more so because of what their past has beheld.  Thank you, Avail, for pushing me over the tracks and into the person I have dreamed of becoming.

Until next time,

Jessi

PS: check out the ministry at www.houselessness.org

The right to healthcare: what does it really mean?

I'm gonna preface this post by saying that I might meet some disagreement.  All I ask is that it be read with an open mind, as from someone who's been there, and then you can go on thinking whatever you like.

The literary journal for the School of Medicine finally came out, in which I submitted an entry entitled, "A New Perspective" about my trip to a hospital in the Dominican Republic last summer.  I'll include an excerpt so you can see where my thinking was going:

My next patient, in the orthopedic unit, was a man with a broken leg from a motorcycle injury.  He needed surgery, but was waiting on his family to bring back a surgical screw from Santo Domingo.  In the meantime, he was lying in bed with two gallons of water hanging from his foot—makeshift traction.  He was not sure when he would be able to have surgery, but in the meantime he appeared comfortable and seemed to enjoy the company of other patients in the large, multi-bed room with him.  [...] Although many of my classmates were gawking at the substandard level of care, I was able to see the truth:  If these patients came to the United States, they wouldn’t receive care at all, except maybe in the Emergency Room after waiting several hours, and even then being looked down upon by hospital staff and hurried through the system to be thrust back to the curb.  Maybe the Dominican Republic doesn’t have everything right in terms of health care, but neither does the United States.  No matter where I am, there will be some people I can treat and some I cannot.  Sometimes it will work and sometimes it won’t, even when the answer seems clear.  But in every case, I have a responsibility to listen, smile, and pray with my patient, treating them as an individual and making their hospital experience seem as much like a home as possible.  I am convinced that the Dominicans are much closer to mastering this skill than the best American doctors we have to offer.

As I read my entry again, one thought occurred to me: This is Cooper Green. Cooper Green is Jefferson County's hospital, run by government tax dollars (1% of sales tax, to be exact), to care for citizens with no insurance. Recently, there has been a debate around closing the hospital's inpatient side because funding cuts have been so severe that patients are not getting the care they need.  This is true-- A fellow classmate of mine informed me a few weeks ago that they had run out of pillows, and I know they have run out of certain medicines as well.  Yes, this is a huge problem, and I do believe that people deserve better care.  What strikes me as dangerous, though, is that we are deluding ourselves if we think that this particular population of people will get better care. Sure, from the comfort of our own, middle-class American homes, it seems an abomination for a hospital to exist that can't even give our patients pillows.  But what if some patients don't go to the hospital for pillows, or even cutting-edge medical care? 

We refuse to accept health care, for ourselves or anyone else, if it is anything less than the best.  That is why we produce top-notch doctors, medicines, and equipment here in the United States.  But when we resolve to offer nothing less than the best, where does that leave the non-middle-class Americans? The dichotomy for us, when presented with "best" or "just okay", seems an easy decision. But if we come to grips with the fact that we have two dichotomies at war here-- the other being "just okay" or "there's nothing here for me"--does a role for "just okay" suddenly emerge? And if so, how do we define this substandard set of standards, so that we in medicine can maintain our Hippocratic oath of "Do no harm?" 

-Jessi

Hidden agendas in walking downtown

My story (actual)

It was 8:24 am, and I was hurriedly walking from my apartment to school from orientation, which was supposed to start at 8:30 am. I decided to dress nice--not too nice, but just enough to pass as business casual, just in case there was a dress code for the day that I was unaware of. At the corner of 20th street and 5th avenue south, I encountered a man riding a bicycle.  Being cautious, I gave the tiniest of smiles.  He quickly stopped the bike, maybe a foot in front of me. "What is the time on your watch?" he asked.  Not wearing a watch, I pulled out my phone to check the time. "It's 8:24," I said, and turned to keep walking. But he did not move out of the way. Instead, he held his hand out awkwardly.  My first thought: Dang it, he wants my phone... what have I gotten myself into!  My second thought: Oh, maybe he just wants to shake hands. Hmmm, never shake hands in the STD clinic... but I'm sure this man doesn't have syphilis, so okay. I tentatively stick my hand out, and he grabs it, and kisses it! Repulsed, I pull my hand back, turn, and scamper off.  "I'm sorry," he calls out behind me, but I don't even turn my head.  

For the rest of my walk, I smile at passersby only occasionally and talk to no one.  I'm not even that attractive, I think. All I want to do is be friendly without being approached for money, cat-called, or touched!  And then I really thought about it. How cold and calloused I was.  How hard it is to practice what I preach about people on the streets.  Being a single girl in my 20's, I know I need to be careful, but really, Jess? You won't even smile for fear of, what exactly-- being talked to? No wonder these people don't trust mainstream society, rarely open themselves up to others, and have less-than-refined social skills, if this is what they are repeatedly greeted with in return for even the most genial interactions.  If that poor man never talks to a young white girl again, I have no one to blame but myself and the hundreds of others just like me.  I know what you're thinking... It's okay, Jess! There are strange people out there. You have a right and good reason to be cautious and callous toward strangers. I would have done the same thing. But consider the story from this man's point of view:

His story (conjecture, but probably more true than we realize)
It was only my 4th day at my new job.  I woke up at sunrise to get in the breakfast line at the shelter early so I would have plenty of time to make it to work by 8:30.  Breakfast was out by 7:30 this morning, so I scarfed down some grits and orange juice, packed my belongings up from the shelter, and started the 20-minute bike ride from the shelter to my job.  I was cutting it close and didn't have a clue what time it was.  I know better than to approach people, especially around the medical district since most of them are always in a hurry, but then I saw a nice-looking girl smile at me from about a block away.  I decided it was worth it to ask her for the time.  I think I've startled her... oh no... ok, well, at least she told me what time it was. I have 6 minutes before I'm late to work, and I'll surely get fired if I'm late, but I really want to thank her. I'm so embarrassed, I have nothing to give her to thank her for her kindness. I've seen men kiss a lady's hand to be very polite before, so maybe I'll try that. Oh, no, I don't think she liked that. "I'm sorry," I said. What did I do wrong? I didn't mean to frighten her. I stand there, dumbfounded, watching her hurry away. I can't ever get it right, I guess she's just like the rest of them after all.  And now I only have 4 minutes to get to work... f***!  

What is this? Just an unfortunate interaction, or some commentary on social and societal conditioning? What gift would I have received if I hadn't just gone into survival mode and run off? I'll never know, because society says I'll do exactly the same thing tomorrow.

"Do not neglect to show hospitality to strangers, for thereby some have entertained angels unaware." -Hebrews 13:2

-Jessi