Health and Development

New coaching effort enhances maternal care in Indonesia & Mexico

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A baby died the night I arrived in Chiapas, Mexico to provide implementation training on the Safe Childbirth Checklist. The mother almost lost her life, too. She was laboring at home with a midwife when suddenly, her labor stopped progressing and the baby started showing signs of distress. The mother began losing a lot of blood. The midwife was unable to provide emergency care, so the mother was taken by ambulance to the small healthcare facility where she was saved, but her baby was not. I was standing outside the facility when she was brought in and I could see her family waiting powerlessly in the courtyard.

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A Letter to Mr. Mandela

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Mandela

Dear Mr. Mandela,

I am so sorry that it has taken me this long to write.  I’ve intended to write you for ages and I am sorry that it took a glimpse of your mortality to remind me that I must seize this moment and not put it off any longer.

Mr. Mandela, when I read your book six years ago, I could not put it down.  I was completely mesmerized by your story and your heart.  I would read your words on the bus to and from work, frustrated by the lack of privacy that public transportation offered; trying unsuccessfully to hide my tears as they fell freely onto the pages.  I was moved by the mere fact that you existed – a man so wholeheartedly and single-mindedly devoted to a cause that it would enable him to lead an entire revolution from behind bars.  You, who were not free in the natural, had the ability to set others free because you knew where freedom existed in the first place.  And you held to this ideal even though it was rejected for years, and is still often rejected today.

“As a leader, one must sometimes take actions that are unpopular, or whose results will not be known for years to come.  There are victories whose glory lies only in the fact that they are known to those who win them.  This is particularly true of prison, where one must find consolation in being true to one’s ideals, even if no one else knows of it.  Even in prison, I was assured that I would survive, for any man or institution that tries to rob me of my dignity will lose because I will not part with it at any price or under any pressure.”

You humbly acknowledged that your strength did not come solely from some secret place within yourself, but that it poured forth from the strength of the collective identity that you had with your fellow man.  You wrote:

“It would be very hard, if not impossible, for one man alone to resist.  I do not know that I could have done it had I been alone.  But the authorities’ greatest mistake was keeping us together, for together our determination was reinforced.  We supported each other and gained strength from each other.  Whatever we knew, whatever we learned, we shared, and by sharing we multiplied whatever courage we had individually.”

Mr. Mandela, the profundity of your legacy is staggering.  It leaves me speechless, breathless, hungry, full of wonder and hope.  In order to lead a revolution of freedom, re-designing human thought, you had to know the life of a prisoner and the mind of the enemy who put you in chains.  Your entire platform of change was built on not only your vision, but your solidarity with those whom you were trying to set free.

“Freedom is indivisible; the chains on any one of my people were the chains on all of them, the chains on all of my people were the chains on me.”

Mr. Mandela, I’m so sorry that you are sick and that your tired body is finally giving out.  I’m sorry that I can’t sit by your bedside and sing you songs to usher you in to the other side, where you will finally shed this skin and be clothed in radiance.  And even now, I am weeping while writing this.  My heart is broken that I will never get to look into your warrior eyes and hug you and whisper words of gratitude.  But, I am confident that you are passing over peacefully and without fear.  You lived well.  You wasted yourself for the sake of others.  You achieved true vengeance over your enemies by bringing the fullness of life to those who were oppressed.  You sacrificed being a father to your own children in order to be a father to an entire nation.  I am honored to have lived on this earth while you walked and laughed and bled and wept.  Someday, I will visit Robben Island and touch the walls of your cell and cry and remember everything you did for our people and the price you paid to do it well.

May you go in peace,

Emily R. George

Helping Young People Adopt Healthy Sexual Practices

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In 2011, Fenway Health became one of 19 sites within the Adolescent Trials Network (ATN).  The ATN is funded by the National Institutes of Health (NIH) to conduct HIV/AIDS research among young people between the ages of 12 to 24 years old.  As seen in the graph below, HIV prevention research is crucial among adolescents because this is where some of the highest incident rates of HIV infection are found…

Continue reading this post here, on the Fenway Health website.

The Painful Process of Authentic Compassion

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I like to think of myself as a curator of friendships.  A content specialist of hearts painted gold, who brave the desert creatures and stay awake through the Gethsemane of the soul.

I collected this one heart over a decade ago and tucked her carefully inside my own.  She had just returned from the West Bank where she had made her home with Palestinian Arabs.  Returned to a Midwestern town, to a small, Caucasian, pro-Israel Church, full of cars with W bumper stickers in the parking lot, where people lined up asking her, “How was Pakistan?”  And her face would glow the color of her hair and she would smile and graciously say, “It was fine,” and then swallow a fiery lump down in her throat.

That summer, I watched as she found healing and solace while tending to her melliferous bees.  We would spread fresh honey from bell jars on bread, and I would ask her question after question about the conflict within.  She would point out specific regions on the map that was hung above my bed, finding hope when I began to understand.

Little did she know that the West Bank was just the beginning of the constant cycle of suffering, compassion, and freedom that would be her life.  She wandered the streets of Calcutta, among the heroin-addicts and slum dwellers.  Built shelters in Sri Lanka when the tsunami decimated Southeast Asia.  Became homeless when Katrina blew in from the Atlantic.  Joined me as I worked with sex slaves in the red light district of Bangkok.  Provided food and housing to refugees in Darfur.  Went back to Jordan.  Moved to Afghanistan.  Fled when her colleagues were kidnapped.  Sought asylum in Amsterdam.  And then resettled in Kenya.

She has been homeless and displaced; a refugee and a wanderer.  She has seen more brutality inflicted upon the human race than most people in this generation.  She has stared at the heavens and begged for rain and then seen a small black cloud the size of a hand appear.  She is covered in spiritual DEET, capable of entering into the darkest of territories and coming out, afflicted, but not crushed.   She has died over and over again and has held tightly to the only thing this life can give to her.

And when she writes to me now, from her small cottage in Kenya, and describes the spiritual trenches with tears flowing freely and with intention, I can easily share with her about the kid I know who contracted HIV from his uncle, my college friend who was raped and is now with child, and the aching of my own broken heart from love that has been lost.

Because she walks around with her own broken heart, cracked from the hundreds of times she has known and loved and suffered.  Because she sits with me, a million miles away, but in the same Garden.  Crying out with me that the cup would be taken, dreading the constant request for another death that will ultimately bring life.  A woman who would never fall asleep while I am sweating blood, because she is sweating blood, too.

And it is for her that I write this, to remind her that he is coming and has overcome.  That where sin abounds, grace abounds all the more.  That sorrow and sighing will pass away.  That blessed are those who mourn, for they will be comforted.  That a bruised reed he will not break.  That by his stripes we are healed.  That we will no longer be called “forsaken.”  That we will run and not grow weary.  That there will be a garment of praise.  That there is always more. That the sons of Satan will fall down at our feet and confess that he has always loved us.

So, let us lift the cup and drink quickly now.

Here’s to her.

And here’s to Him.

http://whitneyfry.wordpress.com/

HIV Rates Are Rising Among America’s Youth

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Infograph Designed by John Hanawalt

The Centers for Disease Control and Prevention (CDC) recently released a report stating that over 50% of young people in the United States who are infected with HIV are not aware of it, and adolescents between the ages of 13 and 24 account for 25% of all new HIV infections in the United States.  Out of 12,000 new infections in the U.S. among this population, 72% occurred in young men who have sex with men (YMSM).

According to the Massachusetts Department of Public Health, 44% of all HIV infections occurred among YMSM.  Although this percentage is slightly lower than the national average, it underscores the dire need for therapeutic and behavioral interventions which are tailored specifically for this cohort in Massachusetts.

Addressing sexual health needs and HIV prevention among YMSM can be tricky because many are questioning their sexual identity and orientation and are not open with providers about their sexual behaviors.  Additionally, stigma and homophobia can prevent at-risk individuals from seeking medical care or HIV testing.  According to a recent report by the CDC, only 35% of young people have been tested for HIV.

The Adolescent Trials Network at Fenway Health has opened a research study for YMSM between the ages of 18 and 22 called Project PrePare which seeks to find out how youth can take and benefit from Truvada for pre-exposure prophylaxis (PreP).  Truvada was approved by the FDA for HIV prevention in July 2011; however, adolescents were not well represented in the initial research.  Project PrePare projects that by making PrEP, along with condoms and regular risk-reduction counseling, accessible to this young cohort, HIV transmission rates among YMSM will be reduced.

Project PrePare lasts approximately one year.  Study participants will receive regular blood work, HIV testing and counseling, Truvada, and medication adherence counseling while participating in the study.  Additionally, each participant will participate in a behavioral intervention called Many Men Many Voices.  Many Men Many Voices is a seven-session, group-level HIV and STD prevention intervention for gay men. The intervention addresses factors that influence the behavior of men who have sex with men, including cultural, social, and religious norms; interactions between HIV and other sexually transmitted diseases; sexual relationship dynamics; and the social and psychological influences that racism and homophobia have on HIV risk behaviors.

If you or someone you know may be interested in finding out more about this study, please visit the Project PrePare website at: projectprepare.net.  On this website, individuals are given the opportunity to take an eligibility quiz to determine if they can participate in this study.  All answers are completely confidential; a simple “yes” or “no” will be sent to a study recruiter, along with optional contact information that the individual can provide so that they can be reached.  Additionally, anyone who is interested and would like more information can email Emily George, RN, MPH, the Boston site Project Manager, at egeorge@fenwayhealth.

Young, HIV-Positive MSM: Cover Your Butt Against HPV

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A new study looks at the protective effects of Gardasil vaccine in young, HIV-positive men who have sex with men.

The Centers for Disease Control and Prevention (CDC) estimates that gay and bisexual men (men who have sex with other men) are about 17 times more likely to develop anal cancer than men who only have sex with women. HIV-positive males who have sex with males are at increased risk of developing anal cancer and/or genital warts compared to the general population. However, those who receive the Gardasil vaccine could be protected.

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The Grass is Always Greener…

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I recently read an amazing blog from Tales of the Hood that I would like to recommend to you for your reading pleasure.  This post hit home for me after some heated responses (both pro and con) that ensued around one of my previous posts entitled “Redefining the Fairytale.”

The post from Tales of the Hood is entitled “Wanting What You’ve Got” and can be found here.  This post comprehensively depicts the inner conflict that many of us face when attempting to fulfill the personal and professional desires of our hearts.  Enjoy!

Inside Taiwan: How culture affects the way a nation receives, perceives, and administers healthcare

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How does culture affect the way a nation receives, perceives, and administers healthcare?  For this post, I asked Kathy Laytham, RN, MSN, to guest-write a post for my blog reflecting on her unique experiences living as an American healthcare professional in Taiwan.

Health care reform in the United States has brought the health care systems of many of the world’s countries into the spotlight as politicians, medical providers and citizens alike try to wrestle with this massive undertaking.  Taiwan’s public health care system has received a lot of attention for its ability to provide affordable coverage for high-quality care for 99% of its population.  Here are some comparative figures that help fill out the picture a little more:

Taiwan United States
Average # of patients seen by a primary care physician per week[1] 128 85
Average # of outpatient visits/person/year[2] 11.8 (this is the world’s highest # of outpatient visits per capita) 5.8
% of GDP spent on health care[3] 6% 16%
Average co-pay[4] $3 $5-$25
Dollars spent on health care per head/year[5] $1745 $6719

These facts provide a foundation for understanding Taiwan’s healthcare system, but anyone who has lived overseas for an extended period of time knows that statistics do not paint the full picture of a country’s beliefs surrounding health care. To truly know a culture, one must look beyond the figures and data and experience real life.

Gaining understanding of a culture has been likened to an iceberg. When we initially look at an iceberg, we think that what we see is what we get. The same with culture: we falsely assume we grasp a particular people group because of what we see. The truth is icebergs are only one tenth above water, so of course, that leaves us with nine tenths of the mass below the water.

There are many things below the water of a culture that affect how people receive, perceive, and administer health care; however, I will only reflect on a few of the things I have experienced while living as a health care professional in Taiwan.

Religious beliefs and the relationship of humans to the supernatural AND concepts of justice, fairness, punishment, and right conduct

Many Taiwanese people take a fatalistic approach when viewing health care, meaning they believe if they are ill, it is their fate. At the onset of their sickness they will see a doctor, but the patient lacks initiative in learning about ways to improve their outcome. This is linked to their beliefs in reincarnation, as they believe they are suffering the consequences of their former life. For example, parents who have children with cerebral palsy will not be active in finding appropriate therapies to help their child. Instead, they believe the child, and possibly themselves as parents, are receiving the just punishment they deserve.

Professional status and level of education

I often accompany migrant workers (Filipinos, mainland Chinese, Vietnamese, and Indonesians) and expatriates to the doctor to serve as an advocate for their health. When I initially began doing this, I was appalled at the approach physicians were accustomed to using in their dealings with patients. It reminded me of the stories I heard about physicians in the States about 30 years ago. The physician is the expert and they are not to be questioned. Thankfully, I have found the doctors to be very gracious in my questioning and most of them will spend the time necessary to care for the patients. But, I have heard from my Taiwanese friends, representing multiple levels of education, that this is quite the exception (due to my being an American of Caucasian descent and a healthcare professional).  Most Taiwanese patients would not even think to question the doctor, and if they did it would not be warmly received.

 

Conceptions about spread of disease

After almost seven years, I am still attempting to understand the impact population density has on health care in Taiwan.  My background in the U.S. was in rural and suburban settings where infectious diseases were serious, but the threat of widespread pandemic or contagion was minimal. Taiwan is the second most densely populated country after Bangladesh. The density influences so many of the cultural perceptions including something as simple as hand, foot and mouth disease. In the United States, this is a fairly benign disease. I was serving as the school nurse last year when there were some cases at the American school. The school consists mainly of Taiwanese students. The parents were up in arms about this illness. I was clueless about why they were so nervous and was attempting to “educate” them about the nature of the disease. Thankfully, the school secretary educated me. She said that there was a massive outbreak of hand, foot and mouth disease in Taiwan in 1998 affecting 1 million people, with hundreds having a severe form and 70+ dying from this condition. Seek first to understand, then to be understood.

Food preferences and rules concerning consumption

One area regarding food preferences and cultural beliefs involves dzwo ywe dz. This is translated as sit one month child. It is a strongly held tradition that after a woman has a baby she is to stay indoors for one month. She is to eat only “hot” foods and drink only soup broth, usually containing chicken parts, wine and Chinese herbal medicine. The woman should never wash her hair or exercise during this time. The belief is that if the woman complies with these rules, and many others, in the first month postpartum, she will reset her body’s physiological state and have good health in the future. She also will ward off any osteoporosis, headaches and other body ailments as a result. Most of my friends follow this advice, some because of pressure from mother-in-laws or other family members. When I have questioned my friends about this practice, some of them wonder if it is nonsense, but most believe it to be legitimate and all of them are compliant.

In conclusion, I will say one more thing about icebergs.  There are still a lot of things scientists are learning about icebergs and they are extremely difficult to study, requiring much persistence and precision.  While we know where icebergs come from and have a general idea of their composition, every expedition to an iceberg uncovers something new. This has been my incredible experience while living in Taiwan – and I am loving the exploration.

Kathy has resided in Kaohsiung, Taiwan for 7 years. She is a family nurse practitioner who has found creative ways to use her skills abroad. Here are just a few positions she presently holds:

  • Instructor for nursing students at I-Shou University
  • Primary nurse for international shipping company, which includes DOT collections, CPR instruction and emergency consultations from crew at sea
  • Part-time nurse at American School
  • Health assessment consultant at local orphanage
  • Copyright editor for nursing professors who desire international publication

[1] Jui-Fen Rachel Lu, William C Hsiao Health Aff (Millwood)May 2003 (Vol. 22, Issue 3, Pages 77-88)

[2] ibid

[3] ibid

[4] ibid

[5] Reid, T. R. (April 15, 2008). “Taiwan takes fast track to universal health care”. All Things Considered. National Public Radio.

Nursing, Maternity Care, and Cultural Sensitivity

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I was asked by The Maternal Health Task Force to guest-write an article in honor of International Nurses Day on May 12.  The following post was what I submitted.

One of the most wonderful things about being a nurse is the unique role we have with our patients.  This role automatically encourages vulnerability and transparency from patients to express things that they may not express to their physician.  Furthermore, it is a role that comes with immense responsibilities to be both compassionate caregiver and attentive advocate. Part of that responsibility means acknowledging the disparities in access and quality of care that many minorities face—an often overlooked and underlying factor that can contribute to poor maternal health. Increasingly, studies are showing that patients who face cultural and language barriers have worse maternal and infant health outcomes.

Generally, research has demonstrated that patients report high levels of satisfaction with their nurses.  However, a recent study by Wikberg, et al released in 2010, explored approximately 1160 female patient perspectives from over 50 countries on the provision of intercultural maternal care in the Nordic countries and found that this area of care had been extremely neglected by nurses. These results seem especially disturbing given that pregnancy, labor and delivery are some of the most sensitive, unguarded times for any woman and should be handled with the utmost respect by clinicians.

Similar to Alice in Wonderland…

The researchers compared the women in the study to Alice from Alice in Wonderland.  Like Alice, these pregnant women find themselves caught up in the wonder of a foreign land – not knowing where to go or whom to trust, experiencing communication problems, and meeting strange or unkind people – all the while desperately needing medical and emotional attention.  The common feeling these women described was powerlessness: not knowing what was happening to them, not being listened to, and not being able to influence the situation.  Consequently, these women became silent, passive, and avoided or interrupted the care being provided to them.

A few nursing considerations…

Education of different cultures is not enough because there is a risk for stereotyping when differences are focused upon.  Nurses need to not only learn more about the specific cultures of their patients; they must learn what their patients need, want, and expect on an individual basis.  During the initial visit, the nurse must inquire after the patient’s personal wishes and concerns surrounding her care.

Secondly, professional interpreters of the same sex need to be available for the patient.  When this is absent, true communication that promotes the relationship between nurse and patient cannot occur.  Educational materials in other languages must be available, as well, so the patient has a variety of resources to ensure complete understanding of what is to be expected during pregnancy, birth, labor, and the postpartum period.

Finally, a culturally diverse staff of nurses is also important so that when situations arise like a patient who has undergone the trauma of female circumcision, culturally and medically competent clinicians are available to provide optimal care.

In conclusion…

Walking through pregnancy, labor and birth with a woman is a privilege and an honor for any person, especially one who is responsible for providing medical attention and care.  As nurses, we must strive to protect this vulnerable and beautiful time for every woman by honoring her personal wishes and providing her with the highest quality care despite language or cultural barriers; thus preserving every woman’s dignity – and even our own.

Cultural Incompetence Leads to Maternal Mortality in Uganda

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Uganda is a country in East Africa that has been ravaged by war and ethnic cleansing for several decades, leaving the country in a state of political and economic instability.  Civil unrest has led to the weakening of health infrastructure and perpetual shortages of medical supplies and trained physicians.  Uganda currently has one of the highest maternal mortality rates in the world.  For the past 5 years, several organizations, such as UNICEF and USAID, have been working with the Ugandan government to strengthen health care facilities in order to improve emergency obstetric care.  Despite these concerted efforts, there has been only a small reduction in maternal deaths.  A recent study by G. Kyomuhendo demonstrated that pregnant women in Uganda declined emergency obstetric services resulting in death.   Kyomuhendo showed that Ugandan women did not seek care because of 1.) an adherence to traditional beliefs about pregnancy/birthing, 2.) belief that health care providers were poorly trained, 3.) past experiences of abuse/neglect when accessing care.

Quick Stats on Uganda:

  • Maternal mortality rate – 510 maternal deaths per 100,000 live births.  (Switzerland’s MMR is 7 maternal deaths per 100,000 live births.)
  • 14 women die every day during childbirth
  • 1 in 8 women have a lifetime risk of dying from pregnancy complications.
  • 80% of maternal deaths are attributed to sepsis, hemorrhage, unsafe abortion, obstructed labor and hypertensive disorders.
  • 34% of health care workers are equipped to treat obstetric complications
  • 42% of women who claimed to have pregnancy or delivery complications did not seek medical care.

Why don’t Ugandan mothers seek medical care?

According to study by Kyomuhendo, women in Uganda believe that seeking medical care during pregnancy or delivery is lazy, weak, or not respectable.  Ugandan women hold superstitious beliefs that the outcome of pregnancy is predetermined before even going into labor.  The woman who attempts to seek medical care when faced with complications is believed to be intervening with something that is beyond her control.  The woman who endures pregnancy or labor with no outside help is esteemed, as if the positive outcome was determined by her own inner strength Ugandan women claimed that health care workers were unethical, rude, and verbally abusive when providing care.

Another complaint voiced by Ugandan women in this study was the supine position in which they were expected to deliver. Traditionally, women in Uganda deliver in a kneeling position, which is preferred because it makes delivery less painful.  However, when health care workers were interviewed regarding this complaint, they revealed that they were not comfortable delivering babies in this position.

UNICEF and USAID can strengthen health infrastructure and provide state of the art medical equipment to facilities within Uganda, but those efforts should not be the only paths taken to reduce maternal mortality.  The sensitization of health care workers to the cultural beliefs of Ugandan mothers is imperative.