Southwestern Uganda. Image courtesy of the University of Texas.

Megan McIntosh Frenzen writes:

In Uganda, every single day is astounding, in both good and bad ways. The morning commute to Bwindi Community Hospital (BCH) is very short but very interesting. It’s a bumpy dirt road with enormous ruts, loose baseball sized stones and the occasional gigantic puddle after storms pass through. Our fellow commuters are mostly women clad in brightly colored fabrics and dirty children, all with baskets on their heads in which they are carrying bananas, sugar cane or tea. Should you happen to catch a their eye, your gaze will be met with a big white-toothed smile. These smiles are intermittently accompanied by “Hello? How are you?” which is incredibly charming. On most mornings, a haunting, rhythmic drumming echoes down the jungle-covered hillside above the hospital. There has yet to be a morning that it hasn’t stopped me in my tracks and made my heart skip a beat. Just in case crapping in a bucket wasn’t enough of a reminder that we’re in “rural” Africa…

It stormed on Wednesday morning. I haven’t described much about the operating theater at BCH, but let me start and finish by saying that the ceiling is plastic. It’s a kind of plastic that looks a lot like corrugated metal; it slants downward from the apex of the roof and it has ridges running its entire length. There are several non-plastic ceilings in the hospital, so I assume this design was intended to allow maximum light into the room – which is a good thing, given how much the theater light sucks. Yes, that’s right: one light. Singular, not plural. One light that raises the temperature in the room from uncomfortable to intolerable within minutes of being switched on. When the storm passed that morning, the thunder shook the walls and the rain sounded like mortar on the plastic roof. It was both a beautiful and a sad sound.

For some reason, on that particular morning, it humbly reminded me of the resilience of these people.

That day, we’d put a split thickness skin graft on the toe we’d (bloodily) excised a mass from earlier in the week. I must admit, I’m a little obsessed with skin grafting. It’s an endeavor well suited for someone who is borderline OCD, an excellent procedure to do with neurotic precision: measure, cut, trim, remove fat (on full thickness grafts), size perfectly, suture, repeat as necessary.

In addition to the grafting, a few more extra pinky toes were removed and Seth lengthened the Achilles tendon on a boy who couldn’t walk on the plantar surface of his foot because of how contracted his tendon was. All in all, it was a good day in the hospital and it even ended “early,” around 5:30 p.m.

I was starving, so after work we headed down the road, around the post-storm mud puddles and straight to the Good Shed. I asked Maria, the striking young woman who tends “bar” there what they might have to eat. There isn’t a menu for miles, literally, which is fine–but when her response was “rice and meat of goat,” I opted for a warm 50¢ beer and headed for a plastic chair on the 5×10 cement slab “porch” in front of the Good Shed.

It seems like the entire southwestern Ugandan world could pass you by in front of the Good Shed at that hour. There is no better reminder of Uganda’s explosive population growth, or that more than half of their population is younger than 30, than an hour spent sitting in a patio chair on the Good Shed porch. Dozens and dozens of barefoot school children dressed in tattered and filthy school uniforms, some carrying books on their heads, a few with machetes (a concept I am not yet comfortable with). Young men zip by on circa 1985 motorcycles and the occasional dark green Ugandan Wildlife Authority Land Cruiser speeds past at altogether unsafe speeds.

Darkness fell quickly that night and it was time to brave dinner and head to bed. There were big plans in the works for the following day: we were eighteen surgeries into our stay and it was time for a day off.

Most of you know that I don’t really do days off per se, so in the interest of avoiding sitting still, I’d procured two of the forty day-permits issued by the Ugandan government to go tracking mountain gorillas in the jungle. Seemed like a perfectly good plan to me. However, this “day off” would now require a 5 a.m. start. I would have to do my morning spider reconnaissance in the pitch black, and stumble around between my bed, the shower, my pillow, my hair, my clothing, and the bucket we call our toilet.

It was still dark out when we climbed into one of the BCH “ambulances” and set off for the Bwindi Impenetrable Forest. I’m not kidding: it’s really called the Impenetrable Forest and we really were taking one of the two ambulances. I was to find out exactly why the forest was given such a name in a few short hours….

The drive to Ruhija (roo-he-ja), the area of the forest where we would be tracking the Bikuru (bee-coo-roo) family of mountain gorillas, was absolutely terrifying. It could be some kind of emotional block, but I can’t even remember our driver’s name. I now call him the Chicken Killer. I almost asked him to slow down. Seriously. This, coming from someone who spent a number of years on a first-name basis with several State Troopers, in large part due to my speed-related performances on interstate 89.

Not only was I mortified that I was very close to sounding exactly like my mother, I also was forced to take stock of my own decision-making history. I have spent the vast majority of my life warmly welcoming any activity or experience that might result is serious injury or death. I’ve jumped out of a plane and off a giant crane in the middle of the night, I’ve gleefully hopped into a flimsy cage surrounded by chum and Great White sharks, I’ve come far too close to wild lions, I’ve wandered (alone) through China and a few less-than-desirable regions of Africa, I’ve paddled big rivers and skied plenty of things I shouldn’t have. In other words, I’d be hard pressed to feel justified complaining about my safety. So I shut my mouth and held on for dear life.

The Chicken Killer sped around corners on the one lane road to the forest so quickly that the rear tires would skid across the red dirt and send stones flying. Should we have met another vehicle on its way to the Thursday Market back in Kabale, we wouldn’t have fared very well at all. In Uganda, there is only one clear rule of the road: you snooze, you lose. Goats, children and cows scurry out of the way of oncoming trucks and motorcycles. Chickens too–all except for the one that passed under our tires with a dull thud (hence the origin of the Chicken Killer’s title). I was a bit perplexed as to the hurry, but I had decided I was not, under any circumstance, going to ask the Chicken Killer to slow down. Many kilometers of road we covered that day would have been a challenge to mountain bike, even for a reasonably skilled mountain biker. Those of you who know me well (especially those of you who have had the misfortune of playing the 7thhole of the Burlington Country Club golf course with me), know that my repertoire of colorful language is not, well… particularly limited. Even with an arsenal like mine, I am still at a loss for words to describe how petrifying those 90 minutes were.

By the time we arrived at Ruhija, my neck hurt and my knees were sore. I’d been sitting in the back of the ambulance, which was really just an old box-style Land Cruiser, using oppositional force to keep myself upright, bracing my feet on the jump seat that ran along the opposite side of the vehicle from the jump seat in which I sat. The seats were poorly padded and easily folded up and out of the way for when the rear was used to transport patients on army-style stretchers. There was no oxygen, no gurney and no supplies, just a metal floor. The medical cross emblazoned on the front hood of the truck was the only actual indicator that it was an ambulance.

I couldn’t help but wonder how many good people had left this world, having that dusty ceiling in the rear of that dingy truck be the last thing they ever saw. Thankfully, I didn’t have too much time to ponder the thought as the vehicle approached the Rihuja gate and I noticed several men lingering nearby, all carrying machetes and rifles.

We share something like 98% of our DNA with the (approximately) 700 mountain gorillas remaining on the planet. Half of the population lives in Uganda, the other half across the Rwandan border in this sprawling protected jungle that the countries’ borders share. I assumed the likelihood of us actually seeing them was somewhere between slim and zero. Boy, was I in for a surprise. We were given a quick briefing on tracking. Apparently there were already Ugandans out doing the real tracking, and they would find the family of gorillas and radio in the location to our guide. Evidently, we’d be taking the lazy route, and I wasn’t too thrilled about it. No point in making something simple when you can make it really, really challenging, right?

With that, we headed off into the jungle. There were three men in front of me, all dressed in dark green uniforms. One was wielding a machete, another a rifle, and the third was Benson, our guide. I don’t think I’ve ever been more grateful for a machete. I very quickly came to understand the “impenetrable” part of the region’s name. We were about 45 minutes into the jungle, scampering down muddy slopes, pulling our feet through dense vines and climbing over downed trees covered in tangled messes of green when it dawned on me, if this was the easy way, I was okay with missing out on the hard way.

“Sometime you will not know what is in the gorilla brain, so he may charge at you for something you do not understand,” Benson casually explained as we clamored our way over increasingly dense vegetation, approaching the Bikuru family. “Do not move. Do not look at gorilla eyes. Just grunt like this, grrrrr. That is gorilla friendly noise. Maybe take leaf, pretend to eat like gorilla.”

Are you kidding me? Okay, I’m oh-so-sure I won’t move an inch and I’ll remember to pretend eat a leaf if a 600lb. gorilla charges at me….

Then, mid-thought about charging-gorilla-induced panic, above the cacophony of the other jungle sounds, I heard it: the absolutely unmistakable sound of a gorilla beating his fists on his chest. The hollow, drum-like sound echoed through the trees, not as loud as I had imagined it might be, but more distinctive than anything I’ve ever heard. The grunting friendly-gorilla noise soon followed and seconds later we came upon three members of the Bikuru family; one of the silverbacks, a blackblack (a young male) and a juvenile, the latter swinging off branches 20 feet above the ground. The silverback’s hand was significantly larger than my head. It was curled under his chin. There he sat, deep in the Ugandan jungle, posed like The Thinker.

It took me more than a minute to catch my breath. I felt small. I felt humbled. I felt sad and surprisingly helpless. Not because the silverback lazing on the jungle floor just in front of me could crush my skull between two of his fingers, but because there was nothing on earth I could ever do to protect him. I wondered what the future would look like for this family of miraculous creatures. If the population of an animal so huge, so beautiful, so strong and so able could be reduced to a fraction of its size, was there anything on earth that we couldn’t completely destroy?

We followed the Bikuru family for an hour, down to the edge of the Bwindi swamp. I stood there, in the relative open, up to my ankles in mud, watching a female gorilla doze in the shade 15 feet in front of me. I was transfixed by her for several minutes, until I suddenly realized that I was almost completely encircled by butterflies. I counted more than a dozen species, not one of which I could name if my life depended on it. They darted around me like brightly colored tropical fish in an aquarium. It was a moment that I am fairly certain will make the list of the flashes of your life that people say get played back to you right before you die.

The trudge uphill and out of the jungle seemed incredibly fast. I was deep in thought, processing the whole experience and still feeling amazed that I was wandering through the Ugandan jungle, that I’d just come face-to-face with eight mountain gorillas and that I still had several days of crapping in a bucket ahead of me.

We made one stop on the death-defying drive home. I had asked the Chicken Killer if we could visit a Batwa settlement. The Batwa are a people indigenous to this region of Uganda. They used to live in the forest, but when the government figured out how much money they could make by protecting the mountain gorillas (instead of passively allowing the poaching of them), they kicked all of the Batwa out of the forest and dumped them into “settlements.” It’s sad, the way we all seem to treat indigenous people. It’s one thing we manage to royally fuck up the whole world over.

The Batwa are pygmies. They’re totally proportional, just very, very short–and that’s rich, coming from me. A number of children approached me as we walked nearer to the settlement. I crouched in front of them. As they grabbed for my sunglasses, I was fairly certain the little buggers were trying to jack my Ray Bans. They successfully pulled my sunglasses to the very end of my nose and laughed. And laughed. And laughed. Then, all at together, they pointed at my eyes, up to the sky, back to my eyes and up to the sky again. The only word I understood was Mzungu, but I knew exactly what they were saying. My blue eyes were hysterically funny looking. Next came my hands, my fingernails, the skin on my arms and my ponytail. I was pet by each one of them in turn and they spent the rest of our time at the settlement attached to my legs like barnacles.

We returned to the hospital in time for some afternoon work. Clinic was just depressing. The only alcoholic we’d seen over the course of our stay was a 70-year-old man with central cord syndrome. He walked using two tall sticks as crutches and poked his way along painfully slowly. There was nothing to do but give him steroids and hope for the best; and for once, the same treatment would be the only option at home too. The two-year-old girl who followed was another story–congenital scoliosis with a hemi vertebra in her thoracic spine. If she had been blessed with Burlington as her birthplace, she’d have a posterior spine fusion and have a pretty normal life. Here, in Bwindi, we can do nothing. Nobody can.

Friday morning came quickly. The BCH community starts every day with a prayer meeting, and as you can probably imagine this news was initially met with a good deal of skepticism on my part until I actually attended my first prayer meeting.

We sit on cement benches and each meeting begins with this awesome performance of rhythmic drumming and clapping and singing (in one of Uganda’s 32 languages, although I have no idea which) and about 60 seconds of praying, which is plenty for me. Then it’s basically a staff meeting. If Champlain College started every meeting with drumming like that, I might actually go to a few. It’s a beautiful sound and it’s a beautiful sight.

On that Friday morning, I had the honor of standing up to address the hospital staff. I thanked them all for making us feel so welcome and at home. I thanked Peter and Julius for finding all the patients we saw, and for visiting church services and the radio station to let the community know we were coming. I told them that we had seen more than 60 patients, that we had performed 21 surgeries (including those scheduled for that day) and that there were 7 patients on whom we would like to operate on when, if welcome, we returned the next year. I thanked the operating theater staff who had worked very long and hard hours for us. The staff cheered and asked us to return. We were sold.

Friday started so easy and ended so hard. The first case was an infant with clubfeet. Seth did a bilateral tenotomy (a release of the Achilles tendon) to let the child’s feet rotate into a more aligned position. The second case was yet another bilateral polydactyly, extra pinky fingers on the hands. I know it sounds like there are loads of extra digits in Uganda, but there really aren’t. It’s just that in the U.S., these things are fixed before children turn one. This patient was three–not bad, considering some of the congenital deformities we’d seen were on patients well into their 20s. Julius, the Chief Medical Officer of the hospital, and I did the case together. Removing “bonus” digits really is turning out to be my orthopedic strong suit. For those of you who are worried about the thought of yours truly doing anything with a scalpel and suture, trust me – it’s impossible to screw up this procedure.

The last case of the day broke my heart, again. Chrispus is 15 years old. His x-ray showed an osteolytic mass on his right femur but he is at the age where osteosarcoma is mostly likely to rear its ugly head, regardless of your country of origin. He’s had an uncomfortable lump on his leg for only six weeks. Based on the way his bone looked eaten away on the x-ray, it was going to be a tumor or an infection. The only problem was that he didn’t present any other symptoms of infection, which meant the odds weren’t good that it’d be an easy fix. It felt like Shaban all over again. Again, I found myself somewhere close to praying as Seth made an incision down the lateral (outer) side of his distal femur (the part closest to your knee). I steadily held retractors and scissors as he tied off vessels on his way to the mass is Chrispus’s leg.

The mass in Chrispus’s leg was much different than Shaban’s. The mass didn’t feel like soft and rotten bone, but viscous, mucoid. Seth used rongeurs (kind of like pliers, but wider and rounder at the end) to pull out pieces of the mass; I cleaned the end of his rongeurs into pieces of sterile gauze each time he pulled them from the incision. I stared at tissue coming out of Chrispus’s leg. It looked like raw chicken that had been sitting on a countertop for a couple of days. It was a brownish yellow with streaks of blood and something white in it. My heart leapt; maybe it was an infection after all. The problem was, this ‘rotten’ tissue kept coming and coming and coming–and it had destroyed a significant part of Chrispus’s femur.

I looked down at the piles of revolting material, wondering how so much crap could come out of one boy’s bone and I wondered if I was (literally) holding cancer in my hands. I wished I could kill it, far more than I’d wished I could kill all the tennis ball-sized spiders in Uganda, far more than I’ve ever wanted to kill anything in my entire life. I wished so desperately that I’d had the secret, the answer, the cure.

There was no point in trying to remove any more. If it were to be cancer, he would be dead so soon that it didn’t matter anyway. If it was infection, the best we could do was pump him full of antibiotics and take him in for another surgery to try to pull it all out and wash the bone clean with a disinfectant.

Chrispus was sedated. He looked so peaceful: his wide eyes were closed and his long eyelashes stretched down to the top of his prominent cheekbones, his dark skin was flawless. If he had only been born into our lives, he’d be getting chemo. He would have his learner’s permit and be scaring the shit out of his parents as he slid behind the wheel of a Volvo. He’d be thinking about prom, sneaking beers and trying to make it to third base with the girls in his class. I put my hand on his chest and, for the first time ever I did the closest thing to actually praying that I can think of. I silently asked for help. I don’t even know whom I asked, but I know I asked someone. The truth is, I actually begged. I begged for Chrispus to have just one small fraction of the good fortune that I’ve had (but never earned) for my entire life. I still know it will do nothing.

The mass in Chrispus’s leg is not an infection, it’s either a chondrosarcoma or a giant cell tumor – both of which suck, both of which will kill him in short order. There is nothing to do but wait for the biopsy to come back from the lab in Kampala. Trying to amputate Chrispus’s leg (with no general anesthesia, no cautery, no Gigli saw and no real tourniquet) would very likely kill him – but so will the cancer in his leg. It sounds so selfish, so shortsighted and so cowardly, but I am quietly grateful to not be at the hospital when the lab results arrive. How do you make that choice? You know death is imminent, but how could you choose to have someone die on your table, as a result of your decision to operate – even if it is the best and/or only shot you have?

According to Seth, there is no class in medical school (and I am certain there isn’t one in an MBA or business PhD program) that helps position you to make decisions like that. I spoke to my parents for the first time later that day. I was still replaying Chrispus’s lousy options in my head, feeling weak, frustrated and gutless when, ironically, my father told me that he was proud of me… for the second time in my entire life. Don’t get me wrong, my father is an amazing Dad and great man, but he’s just not one for many words. When I hung up the phone, I stared at the sky and wondered if I was worth being proud of. I certainly wasn’t a Julius or a Peter and in three weeks time I’d be tucking tail, heading back to Burlington and right back onto the golf course, clad almost entirely in pink.

Ghana was playing a World Cup match later and we were going to have a late night at the Good Shed. By 9 p.m., we were parked in the plastic patio chairs, packed into the Good Shed, completely surrounded by dozens of excited dark faces, all eyes fixed on the 12” television in the corner. The hospital staff we’d been working such long hours with was seated all around us. I felt exhausted, incredibly proud and the most content I’ve felt in months. The score was 0-0 in the first half when the power went out. We sat there in dark for several minutes, laughing and talking. Someone on the porch had a transistor radio and they shouted loudly when Ghana scored their goal in that first half. The Good Shed erupted with shouts and clapping in the pitch black as the Ugandans drank their Guinness and Coke (yes, in the same glass) and celebrated so loudly that the walls shook.

Oddly enough, despite the insomnia that plagues me nearly every night of my life, I fell sound asleep sitting upright in the Good Shed that night. I made it to overtime but couldn’t have kept my eyes open with toothpicks. I said my goodbyes and shuffled back to the tent, the sounds of cheering reverberating through the forest. Tomorrow, in the darkness of the early morning, I would have to leave this incredible place behind me.

Friends have asked me how I deal with these experiences and then come home and live the way I do–skiing at Stowe, playing golf dressed in sporty plaids (or worse, in argyle sweater vests), drinking expensive beer and even more expensive scotch, living so comfortably and so cleanly.

The best way I can describe how I deal is a technique I will refer to as the Box Method. Being so anal retentive, I have a box for just about everything in my life. All of the good things and the bad things, the great things and the terrible things, the painful heartaches and the incredible joys, the successes and the failures, they all have their own boxes. They’re alphabetized and color-coded, just like my spice cabinet and my closet.

Cambodia has a box, Haiti has a box, the South African townships have a box, Uganda now has a box, and soon Ethiopia will as well. These boxes are larger than many of the others I have stored away and they have a fair amount of padding; they’re padded with humor, laughter, new friendships and pleasant memories. Without that padding, the boxes would be unbearable, impossible to keep with me but impossible to be rid of. They would ruin my heart.

Shaban is in the Uganda box, so is Chrispus, and the mountain gorillas and the filthy, barefoot school children dressed in tattered rags. The Uganda box also includes the hillsides of dense jungle, eating around the bugs, the Good Shed, more butterflies than you could imagine, extraordinary sunrises, dark faces with white smiles, Nile beer, pygmies, giant spiders, bucket toilets, and the most beautiful drumming I’ve ever heard. There is also hopelessness, frustration and incredible heartache in the Uganda box.

Those, however, are common elements, shared by many of the boxes in the International Aid section of my internal shelving where these boxes are stored. When I’m good and ready to deal with those emotions, I put away my golf clubs or skis, pull the lid off the box of interest, have a few shots of Jack Daniels and head to a couple hours of therapy. I am not worried about any of those things.

There is only one thing different about the Uganda box, and it scares me. I have this sneaking suspicion that there will be something else eagerly waiting just under the lid of that box, like my golden retrievers at the end of every workday when I’m home. I’m afraid that when I open the lid of the this box, that the first thing I’m likely to find might just be the beginning of a love affair. A very passionate love affair with this breathtaking land, these incredibly kind and astonishing people and their rugged way of existence, with the limitless room for improving the quality of their lives in this tiny corner of the world and with the beckoning opportunity to help decrease the number of motherless children living in these rural mud huts. I don’t know what this affair will mean for me or my future, I’m sure that’s why it scares me, but I guess I’ll cross that bridge when I get there.

For now, I’ll throw my bags into the back of that truck in the 6 a.m. darkness tomorrow and I’ll very tightly position the lid on top of the Uganda box. I might even reinforce it with a bit of emotional duct tape, just to be sure. The ride will certainly be bumpy. I’ll leave the hopelessness and hurt behind for now and I will look forward to the undeniable hope that follows on the coattails of watching 20 year olds, with far more promising futures than Shaban and Chrispus, experience the real world for the first time. My students will fly into Addis Ababa in a week.

I will meet them at the airport – they will be exhausted and appropriately intimidated by the task in from of them; to interview children at the HIV/AIDS orphanage where they will be living for 10 days. For every bit of faith I lose and every piece of my heart that breaks on these trips I am regenerated ten-fold when I see my students, growing up behind me in years but so far ahead of me in terms of energy, curiosity, passion and promise.

They will look at the filthy streets of Addis; they will see hungry children and desperation. Their eyes will give them away; I will know, beyond a shadow of a doubt, when the moment comes, when they are changed for life, when they see the world for what it is–full of men, women and children who have done nothing but be born into far less fortunate circumstances, left clinging to the edge of life. I’m grateful for being able to witness that moment of change in my students because it is all of those moments, collectively, that make me feel like someday, the world might actually become a better place for every one.

From here to Ethiopia…
Meg

Megan McIntosh Frenzen is an MBA and a PhD in Marketing. She specializes in Consumer Behavior with minor areas of study in Social Psychology and Statistics, but her primary interest is in health related behaviors. In December, Megan is attending London School of Economics to start an MSC in Health Policy. Seth Frenzen is an orthopedic surgeon who specializes in hand and upper extremity surgery – he is a partner at Associates in Orthopedic Surgery in South Burlington. He completed his residency at UVM and fellowship at the University of Utah. During 2006 they took a trip to a hospital Cambodia during the worst hemorrhagic dengue fever season ever recorded. When she heard about the earthquake in Haiti, Megan said “well, how do you NOT do something when you know you can? So we went.” After an impromptu meeting with a founding board member of TOUCH Uganda, Kris Owens, Megan and Seth made their way to Uganda.

Southwestern Uganda. Image courtesy of the University of Texas.

Megan McIntosh Frenzen writes:

We are exhausted at the end of every very long workday and, in many ways, it feels like we’ve already been here for a month.  If you’re interested in hearing what’s up in Uganda, read on. It’s lengthy, so get comfortable. Or, if you prefer, just read the first and last sentence of each paragraph – after all, that is how I survived grad school…

We left last Wednesday morning and arrived at the Entebbe airport in Uganda late on Thursday night. We collected our things and spent the night at a modest and fairly strange little guesthouse in town. It was incredibly fun to watch the World Cup match with Africans that night, they’re quite proud to be hosting the event. Thankfully, the jetlag was still on our side as we’re 7 hours ahead over here. On Friday morning we tied our luggage to the roof of a Land Cruiser and embarked on quite possibly the most ridiculous drive I’ve ever been on.

The first five or six hours weren’t that bad, people, cows and goats everywhere, but the roads were more or less paved. That was the easy part. We stopped in a town called Mbarara for lunch – it was almost edible. We continued on for another seven or eight hours on roads that more closely resembled goat paths. As the sun began to set, we found ourselves bouncing along through Queen Elizabeth National Park in western Uganda. Zebras grazed by the roadside, several annoying and confrontational baboons came looking for bananas as we passed (they happen to be my second to least favorite animal on the planet, second only to the tennis ball-sized spider I found in my hair the other morning), elephants wandered into the middle of the road with their huge eyes reflecting the headlight beams and it turns out that the buffalo here don’t have very good eyesight.

At some point after nightfall I noticed a lengthy stretch of forest fire burning on a hillside in the distance. I asked our driver if it was controlled burning, he glanced at me and said, “Oh, that. That’s just the Congo. Did you know that we have 612 species of birds here, in Uganda?” I was grateful it was dark so that he couldn’t see the stunned look on my face. 

Eventually, we arrived at Bwindi Community Hospital. Seth [Frenzen] was busy unloading gear and I was hard at work in one of my semi-neurotic unpacking/organizing fits when I discovered what will always be one of my least-favorite parts of Uganda, my aforementioned absolute least favorite animal: those stupid giant spiders. After hunting for an adequate execution device and with some small amount of guilt, I killed that first one quickly and quietly. At the time, I was frankly proud of not shrieking like a girl. Now I just growl. And then I murder them, entirely guilt-free. It’s war. After convincing myself that that first unwanted guest must’ve been an anomaly, we ate something that was referred to as dinner and headed to bed.

Our platform tent is nestled in the jungle, a five-minute walk from the hospital. It’s a commute like no other. It beats navigating Sewage Street (Cambodia-style) by a mile. At night and in the early morning it’s colder than you might expect. I’m piled under a couple of blankets and some serious mosquito netting every evening after the World Cup matches are over. Our tent has a main area just large enough for twin beds, mosquito nets and our gear. There is a solar light that works about 20% of the time. Mostly, it’s just dark. If you exit the rear of the tent, there is a small open area and then symmetrical enclosures on each side of the rear of the structure. The right side is our “shower.” It’s actually just a shower head with a large cistern above it. A charming Ugandan named Joseph comes at 6:30 every morning to pour about 4 minutes of hot water into it.

The left enclosure is our “toilet,” which is a padded plastic seat above a bucket. There is another bucket in that tiny dark cell – it contains a trowel and dirt – for “flushing” the bucket, for lack of a better term. One of the Josephs who work at the camp makes breakfast every morning–some pineapple, a banana, some toast, scrambled eggs. The coffee isn’t half bad–then it’s off to work.

Thankfully, the staff at the hospital is so happy to have us that they worked straight through the weekend (and late every single day so far) in order that we can get as much done as possible. The first morning at the hospital was rough. In fact, the entire first day was horrific. If we were not literally stuck in the middle-of-nowhere-Africa, I would’ve seriously considered pulling the plug on this little adventure.

This place makes Haiti look well supplied. No anesthesia machine, no cautery (that’s the equipment you need to get stuff to stop bleeding during surgery). There really is nothing here, just three partially empty shelves of supplies in the operating room: some suture, a few gloves, some gauze, a few sterile instruments and blades. It’s unbelievable. They do, however, have an X-ray and the very first patient we went to see that day was a 20-year-old boy named Shaban. He had fallen three months ago and gone to see a “bone setter,” much like the Haitian or Khmer “witch doctors.” It’s impossible to tell from his X-ray if he had ever had a fracture or not, the mass on his lower leg now obscures so much of the bone that there’s no way of knowing. No fever, no indication of infection, but I’d prefer to be hopeful. Seth tends to take the more realistic approach and I scheduled him for a biopsy that afternoon.

Following our visit with Shaban, we headed to clinic. Given the lack of instruments and supplies, it was not exactly a surprise, but I learned two nights ago that we are, in fact, performing the first orthopedic surgeries that this hospital has ever seen. This place serves a population of more than 300,000 people in far southwestern Uganda, nestled in the mountains between the DRC and Rwanda, where they have no other healthcare options apart from bone setters and other witch doctors. It’s hard to explain to the Ugandan physicians (without tears in your eyes) how our town in Vermont has more than 20 orthopedic surgeons when this entire country (of more than 30 million people) has a total of ten. The closest hospital with orthopedic facilities is a six-hour drive on some of the aforementioned crappy roads. In Bwindi, trauma = death.

Part of me is starting to wonder just how much time I’ll be spending here, if this might be a more regular stop on the tour, a summer home, if you will (where you crap in a bucket and annihilate giant spiders). Perhaps, just maybe, getting a functional trauma facility up and running here might be part of my special purpose. I’d like to think it is higher on the list than being a 5 handicap golfer, but maybe it’s tied?

I’m so exhausted every day but feel like I learn something amazing every other minute. I am trying to keep a journal, at least covering topics I need to research. Before HIV/AIDS, communities used to mourn deaths with 7 days of not working – 3 days for children. After AIDS, death rates rose so quickly that communities couldn’t do it, they couldn’t mourn their dead. Rural Ugandans self-selected into smaller groups, called Burial Groups, bound mostly by geographic proximity with very little socioeconomic commonality.  This is the cool part: the hospital here is trying to become self-sustaining and they are working to implement a community health insurance plan–$6 per person a year and a $0.50 co-pay for a visit. They are approaching individual Burial Groups, who are electing to participate en masse–elders make decisions and social pressure dictates that the rest of the group follows suit.

I have to say, I consider this phenomenon to be the most interesting unintended consequence of the AIDS epidemic ever. Burial Groups are an effective way to provide health insurance and fairly distribute the cost of care. Funny, rural Ugandans can figure this out, but we in the U.S. cannot?

Back to “real life.” Clinic was…busy. The staff here collected 54 of the most bizarre cases they could find. We made it through about 20 and started surgery that first afternoon. As I had mentioned, it was a rough start. The Ugandans are amazing, they make the best effort and have the best intentions, but apparently also have little understanding of the concept of a “sterile field,” or why something like that might be important when you’re cutting someone open. There is an OR staff, but no real scrub nurses or other surgeons around, which means I’m honing my techniques at the table. That first day, we excised a mass, took off an extra toe and took a biopsy from Shaban’s leg. I waited patiently for a purulent steam of something to pour from the incision. I found myself almost praying (gasp… praying isn’t exactly my bag) for an infection. No such luck. All softened bony crap. Not a drop of pus in sight.

I don’t really see tumors in my line of work, so it’s hard to judge, but Seth sure believed that it was the fastest growing malignant tumor he had ever seen: it’s presumably only been growing for 3 months and it’s the size of a grapefruit. The biopsy has to go to Kampala. It’s a 14-hour drive (back on those crappy roads again), there is a night bus, but we are still waiting for someone to be able to take the specimen to the lab there. It will probably not happen for days. An above the knee amputation is most likely the only option to save Shaban’s life (although there is no Gigli saw here to even consider performing an amputation of that nature). Most of the people here cannot afford prostheses, even if they can find somewhere to be fit for them, so when they find out they need life-saving amputations, they go home to their huts and don’t come back until two months later when they’re coughing non-stop and their chest x-rays look like a joke. It seems like they do a reasonable job with pain management here, but it’s still an unfair way to die.

People die all the time. In fact, people die in lousy ways all the time. I’m still not sure why Shaban upset me so much. I have a sneaking suspicion that it has a lot to do with my students. I look at him and I see their faces. I see Burlington and RJs and What Ales You and the waterfront. I see college campuses with perfect buildings and skinny jeans and popped collars and hangovers. I think about his future and I think about theirs. I think about anxious parents, waiting for their kids to come home for the summer. I think about what my kids deserve out of life, what potential they have and then I look into the saddest, darkest eyes I’ve ever seen. Shaban is here alone, lying on a lousy piece of foam on a cot a foot off the floor in a room with 5 other “beds.” Nobody is waiting for him and all he is waiting for is to find out roughly how quickly he’ll die. I can’t get past him.

Some other surgical news is not good. We cut off a foot mass yesterday. The guy wanted to be able to wear shoes, but had these huge masses on the dorsal sides of his feet (that’s the top). The arteries in your feet (things that should bleed a lot) are all on the plantar side (that’s the bottom), but the masses on top wound up having arterial blood supply, meaning there were lots of things pumping out lots of blood. It was awful. No cautery, no real tourniquet (we’ve been using a blood pressure cuff, but just got a tire tube today – not kidding), so there was no actual way to stop the bleeding other than to try to tie off every little bleeding hose. Imagine trying to tie off 10 of them, flying blind because the lights suck and there is no way to stop the bleeding fast enough to see what you’re doing. It was awful. Patience and applying pressure… we eventually got there, but I was afraid we would be the first people on earth to exsanguinate someone (that’s bleed them to death) from more-or-less a toe surgery.

There is some surgical news that is awesome. An 18-year-old woman who is now desperately looking forward to market on Thursday because she will buy shoes for the first time ever – we removed her extra toes yesterday. A 22-year-old woman who had a syndactyly (that’s webbed fingers) of her middle and ring finger on her left hand – she told us that she’d finally go to the church with her husband because she can now wear a wedding ring. A 1-year-old with corrected bilateral clubfeet.  In other exciting news, I removed my first two polydactylies (extra digits) today. An 11-year-old boy with bilateral hand and feet – that’s right, 11 years with extra pinky fingers and toes – he too was very excited to wear shoes for the first time. Seth took one side, I took the other. I removed and sutured and…well, not to blow too much smoke here, but I dare say my side looked just as good as Seth’s!

Apparently, it was on the local “radio station” that there were American doctors at the community hospital doing “bone” surgery, so we’ve become quite popular. Strange, strange stuff in clinic: we saw some more elephantiasis (the first case either of us had seen was in Haiti). It smelled bad there and it smells bad here. The Ugandan physicians are amazing. They do so much with so little. They told us that they like to draw blood to look for the worm that causes elephantiasis, but that they wait until nighttime because apparently the worms are relaxed when the patient has been sleeping, and they are more active and easier to “catch” in a sample.  The family hasn’t saved enough for the lab fee yet, but hopefully, we’ll get to see the worms before we go. I’ll feed them to those damn spiders.

And speaking of worms: my hard work has finally paid off. I have been hoping for a good case of worms in countless countries with real potential and I think I may have my first case ever. It’s like a badge of aid work honor. Fear not, deworming is just as easy for people as for your dogs, but I was hoping to lose a few pounds first, so I’m not in a huge hurry.

After work, we eat mostly odd food around 7 p.m. (thank you, Joseph) and then wander up the “road” to a place aptly named the Good Shed. It is a shed and it’s good. They have two 12” TVs in two separate rooms. The main room is about 12×20, the smaller one 10×10. It’s literally just a brick shack, but they play the World Cup games on TV and every night at 9:30 we head there. Many hospital staff frequent the place (there isn’t much to do around here) and they make us feel so welcome. Watching Ghana beat the US in that shack is something that I will never forget. Of course, Seth just had to root for the US – so, not only was he one of two white people, certainly the only redhead, but also the only ass not rooting for Africa’s remaining team! Now that the US is out, he’s changed his tune and we’re looking forward to Ghana’s next match. Watch the game, and think of us sitting in the Good Shed, very white, very far away and very overwhelmed.

Until then – lots of love from your favorite Mzungu (that’s Ugandan for really white person),

Meg

Meg McIntosh Frenzen, MBA, PhD

Megan McIntosh Frenzen is an MBA and a PhD in Marketing. She specializes in Consumer Behavior with minor areas of study in Social Psychology and Statistics, but her primary interest is in health related behaviors. In December, Megan is attending London School of Economics to start an MSC in Health Policy. Seth Frenzen is an orthopedic surgeon who specializes in hand and upper extremity surgery – he is a partner at Associates in Orthopedic Surgery in South Burlington. He completed his residency at UVM and fellowship at the University of Utah. During 2006 they took a trip to a hospital Cambodia during the worst hemorrhagic dengue fever season ever recorded. When she heard about the earthquake in Haiti, Megan said “well, how do you NOT do something when you know you can? So we went.” After an impromptu meeting with a founding board member of TOUCH Uganda, Kris Owens, Megan and Seth made their way to Uganda.

Farah Ghuznavi

Farah Ghuznavi writes:

It started out like any other evening at home. When we sat down at the table, I was excited to see the red spinach and shrimp dish that had been served with dinner. Although I was nearly nine years old, I hadn’t yet got over the childish sense of pleasure to be had by mixing my rice with the spinach, and watching the rice magically transform to a bright shade of red.
”They should make some of this for Niva’s lunch tomorrow,” I said to my mother. “I bet she likes it when her rice starts turning red!”
The baby playing on the bed in my parents’ room looked up at the sound of her name, and gave me a big smile. The ayah was vigilantly watching her while my parents, my brother and I had dinner. Ever since she’d started walking, you had to keep an eye on the little monkey all the time. The speed with which she managed to get around was pretty impressive.
”Yes, you’re right. I’ll tell the cook to make sure it’s prepared for her meal tomorrow…” my mother said, a shade distractedly. Something in her tone made me look at her more closely – was something wrong? I didn’t have to wait long for an answer. In a voice that shook slightly, she said, “I’ve been meaning to tell you. Niva is leaving next Saturday.”
I stared at her in disbelief. “What do you mean? Where is she going?” I asked stupidly, even though I knew already what the answer would be.
“You know where she’s going! She’s going to Switzerland,” came the response, just as I’d feared. My mother’s voice softened as she continued, perhaps realising the extent of my shock, “We always knew she was heading there, Farah. We’ve just been lucky to have her with us for a little while.”
”But you said….” My voice trailed away, as I realised that I couldn’t finish the sentence. Had anyone ever actually said that Niva would be staying? Perhaps not, but I’d been so sure that things would somehow work out. Niva had been living with us for nearly a year – how could they take her to Switzerland now?
“Her family are waiting for her, Farah. We have to let her go.” My mother’s voice was gentle, but firm.
I knew there was no arguing with that tone. Perhaps if I’d been older, I would have realised how tightly she was holding her own feelings in check, noticed the tremor in her hand as she helped herself to more rice. But I was in no position to consider anyone else’s feelings; I was reeling from the bombshell that had just been dropped.
Suddenly, the lump in my throat made it hard to swallow the brightly-coloured balls of spinach and rice that I had so carefully mixed together just a few short minutes ago. That, combined with the burning sensation of the tears I was holding back with some difficulty, ensured that there would be nothing more out of me that evening. But the questions lingered in my mind for a long time afterwards.
I wasn’t quite sure why I was so upset. After all, I’d known that Niva’s adoption process was underway. And unlike many of my peers, I had no particular fascination with babies. I had nothing against them; I just didn’t find them very interesting. My lukewarm attitude had taken a further nosedive a few months previously. If familiarity breeds contempt, then excess clearly led to overkill–at least as far as I was concerned.
Struggling into wakefulness on that occasion, I was still groggy. But even as I wrestled with the pillow clamped tightly around my ears, I knew it was a futile battle. I might just about have had a chance of drowning out the sound of one wailing baby, but when it came to multiples, the odds deteriorated drastically; and it was only a matter of time before the single cry that had disturbed me developed into a full throated chorus.
It was sometime in the early hours preceding dawn. The sky outside, framed against the windows of my bedroom, was a monotonous shade of pale grey, the pink tinge of sunrise yet to kiss it to life. But I knew that I wouldn’t get much more sleep that night. My only hope was that by lying quietly in my bed I might briefly doze off again before it was, inevitably, time to get up for school.
The two women sleeping in my room were already up, one of them cradling the main culprit, whose outraged cries faded away to a contented whimper once she was lifted and cradled against an experienced shoulder. But by then she had already succeeded in rousing two of the other babies–though by some miracle the remaining two appeared to have slept through the disturbance.
The second ayah stood there, between the adjoining cots where the two rudely-awakened babies lay. Having turned both of them to lie on their sides, she proceeded to pat them back to sleep with one hand clapping in a simultaneous rhythm on each of their backs. It worked like magic.
Too bad she couldn’t do the same for me, I thought bitterly. But it was clear that my needs came very far down on the priority list for the time being. After all, hardly would my mother have dumped not one, not two, but five babies in my room for a fortnight otherwise! And that too, in the week before my exams…What was she thinking of?
It wasn’t the first time that my bedroom had been invaded by infants; not by a long shot. My mother worked for an organisation with field operations based in North Bengal, which among other things ran a home for children who had been abandoned or orphaned. Some of these children–usually babies–were available for adoption by Swiss couples, subject to clearance by the governments of Switzerland and Bangladesh.
The paperwork invariably took a long time; the Swiss government was meticulous in running background checks and establishing that potential adoptive parents were able to provide a loving and financially secure home environment for any children they adopted. That process took upwards of a year. There were also a number of formalities to be completed on the Bangladesh side, once the Swiss authorities had confirmed that a particular couple were considered fit to adopt. The equivalent process on the Bangladesh side took around a year. As a result, in most cases, the adoption procedure in its entirety could take anything from two to three years.
Once all the formalities were completed, some of the babies concerned would stay at our house for up to a month, before heading off to their adoptive parents in Switzerland. During that time, additional health checks were carried out and they received more individual attention in terms of feeding and play than it was feasible for them to be given at the care institution, the aim being to get them ready for the travel and change of environment that lay ahead.
Sometimes, when occasional overcrowding became a problem in the halfway-house where the babies stayed in Dhaka, my mother would bring a few of them to stay with us until space was again available at the other facility. I’m not quite sure why, but despite the fact that we did have a guestroom, the babies were almost always placed in my room. They had individual cots, consisting of large oval bamboo baskets on stilts, well-equipped with egg-shaped mattresses and soft blankets. But I had never had five of those basket-beds in my room at one time before!
It had all started with a trio, though it was supposed to have begun with a pair: Rajani and Aleya. After being given the exciting news that we would be having two small visitors soon, the entire household waited eagerly for them to arrive. But strangely enough, they never did. I’m not quite sure what happened to Rajani and Aleya’s proposed visit to our home; perhaps the documentation got delayed (though they did ultimately make it to Switzerland), but at the time I wasn’t old enough to ask too many questions.
Besides, my attention was swiftly captured by the arrival of the triad of Rashi, Shabana and Shandhya. Of the three, Rashi was easily the most interesting to me. At one and a half years, she was walking and talking, and it didn’t hurt that she met the world with sparklingly intelligent brown eyes and a huge smile. Shandhya was a quintessentially round eyed, wobbly-necked, soft bundle of baby flesh. Despite her baldness, she was a sweet baby, but she was too young to be very entertaining to a 7-year-old. It was poor Shabana who got the rough end of the deal; she was a cranky, undersized infant, and difficult to pacify. As a result, she received far less positive attention than the other two, although her needs were well taken care of by the ayahs who had accompanied the three babies to our home.
Many babies had come and gone from our lives since then, and a few children too. Most of them left a mark on my memory and my heart, albeit to varying degrees. There was Shefali, with her bright, bright eyes that twinkled with intelligence and naughtiness, toddling around in her puffy white nappy; Rashi, with that wide, unforgettable smile; Khushi, with her dark eyes and aquiline nose, a handful to manage at the age of four, with a strong independent streak and an inordinately developed sense of self-respect; Moyna, an endearingly docile child with a sweet, shy smile; Najma, whose temper was as legendary as it was unpredictable; Chand Mia – the only boy that I could remember among all these children (providing a fairly definitive statement about son preference in Bangladesh) – memorable for his gap-toothed grin and obliging personality; Kuruni, so named because she was found abandoned as a five-year-old, a child with a club foot and a singularly gentle and loving nature.
At the time, I was struck by the fact that so many of these parents in Switzerland who were waiting for their children did not lay down conditions or show any tendency to discriminate against those who were “less than perfect,” like Kuruni. Her club foot was eventually cured through corrective surgery, but not all the children had problems that could be addressed so easily. Jobeda, for example, only had one eye, and although she was not a particularly pretty child, in later pictures taken with her Swiss mother and two Swiss brothers, she looked radiantly happy in the midst of her new family.
I couldn’t help feeling that the children were fortunate to be given to parents who were so eager to have them and so unconditional in the love that they were offering. Putting up with the intrusive background checks conducted by the Swiss government meant that the couples could have unexpected visitors dropping by at any time of day or night to see the conditions under which they lived, how they organised their homes and their lives, and even the frequency and form taken by their social lives, i.e. parties, etc. What a contrast to those who gave birth to biological children without facing any such strictures!
The families also had to prove that they were financially able to take on full responsibility for any children that they adopted – the Swiss state had no intention of taking on an additional welfare burden. As mentioned earlier, the adoption process itself could be an exhaustingly protracted affair. So it seemed clear to me that these parents must really want the children, which gave me hope that the little ones would indeed grow up in good homes.
Not everyone shared my view. Within a few years of Niva’s journey, international adoptions from Bangladesh would come to an end. It was the result of a combination of factors; one instance of mismanagement by a particular agency combined with years of pressure from among others, the Saudi and Iranian governments, who were strongly against such placements.
It culminated in a total ban on all adoptions from Bangladesh. Nor did the anti-adoption advocates mince their words. As the then Secretary of Social Welfare proudly stated, “It is better for these children to die in the gutters as Muslims than to be sent to Christian countries for adoption.” I would have felt a lot more impressed by his rhetoric if he had come forward to take a single child into his own home.
But that was not the case; and adoption not being a preferred option in most Bangladeshi families, many children–particularly those placed in state institutions–faced a bleak future. Neglect, ill-treatment and corporal punishment were rife in such places, and there were some cases of older children being injured, sometimes fatally, as a result of attempts to escape e.g. by jumping down from upper floors of buildings. As newspaper reports on events at the Panchagarh Shishu Paribar orphanage decades later indicated, things have not changed for the better in the interim.
In April 2010, a number of children living at the Panchagarh orphanage went on a rampage, damaging furniture, buildings and documents stored at the institution. They locked the main gate and ransacked supervisors’ rooms, setting fire to files, and bringing out a procession to protest their treatment by officials. Complaints included allegations of food being stale and frequent beatings over trivial matters. Police intervened to restore stability and heard some of the children’s grievances. According to the children interviewed, they were routinely victimised by staff members, with sick children being subjected to verbal and physical abuse, while medicine was withheld. Unfortunately, the situation in Panchagarh is unlikely to be exceptional.
After the laws were amended with the aim of ending international adoptions, the situation changed completely. In terms of religious personal laws as applicable in Bangladesh today, while Muslim Law does not allow adoption, under Hindu Law only men have the right to take a male child for adoption. Hindu women are not allowed to adopt. Christians can adopt. But there is at present no “adoption law” per se in Bangladesh–meaning that what is generally recognised under law as adoption (which requires severing all legal ties between the biological child and parent) is not possible under the current law. What is available is a law of guardianship or custody–which falls short of the full range of rights that come with adoption. This option is however available to prospective parents belonging to all religious communities.
Thus, as far as the State Law is concerned, adoption of children is not permitted but Bangladeshi citizens are permitted to apply for guardianship of children, effectively giving Bangladeshi prospective adoptive parents custody of children. The 1982 Guardianship and Wards Amendments Ordinance prohibits granting the guardianship of Bangladeshi children to non-Bangladeshi parents. These restrictions have limited the adoption of Bangladeshi children to only a handful each year, as opposed to a larger number of adoption processes in the years prior to this.
But these changes lay in the future at the time of Niva’s stay with us. For the time being, the journey of some Bangladeshi children to a new life in Switzerland continued, albeit at the pace dictated by two sets of bureaucracies. And among those children was Niva. She had been found alone–either lost or abandoned, no one could be quite sure which–at the age of around six months. She came to us a few months later, with the usual understanding that it would be for a short time only.
Things didn’t work out quite as planned. Niva’s adoption process turned out to be much longer than we had expected, mainly because of the possibility that she was a lost child, rather than one who had been abandoned. This meant that every possible effort had to be made to find her family before proceeding with any adoption.
The agency conducted detailed physical investigations around the area where she had been found, also making a series of public announcements and undertaking other measures aimed at locating her parents. In the end, nobody ever came forward to claim Niva, but by then she had been living with my family for nearly nine months, and had well and truly claimed all of us as her own.
In the beginning, as far as I was concerned, she was just another baby; cute certainly, as all babies are, with her light brown hair and serious dark eyes. But she didn’t smile as easily as some of the others. She had a strong will, and an implacable conviction as to her own rights–whether to love, attention, space or food–and that didn’t always go down well with her (slightly) elders.
She was not as pretty as some of her predecessors, nor as easy to manage as others, but there was something about this child; something indefinable, but impossible to ignore. And as much as I occasionally resented being usurped from my position as the youngest member of the family–relegated instead to the ignoble status of middle child–Niva grew on me.
Because my brother was eight years older, it was me that she followed around, insistently intruding on my games and making her presence felt when I had friends visiting. In fact, she was the quintessential pesky younger sibling, and I made a suitable fuss when my mother insisted that my friends and I include her in all of our activities. This insistence went to the extent of Mum refusing to finance a small picnic in the garden for me and four of the neighbours’ children, unless Niva was allowed to join us.
Of course she got her way. Niva, I mean, not my mother, who was only a tool in the power struggle that I was so decisively losing. Our carefully chosen feast items were shared with this little child, who made a funny face at the sourness of our tamarind savouries. She spat out the tamarind mixture –unmoved by our outrage at the waste of such a delicious treat. She wasn’t too excited by the pastry triangles stuffed with a spicy potato filling either, or the Mimi chocolate that bore an uncanny resemblance to laxative in both taste and texture, preferring instead the sweet biscuits and “tiktikir dim” or lizard eggs we offered her, tiny balls of brightly coloured confectionery.
As the initial period of her stay lengthened into months, she gradually, inevitably, became absorbed into the family unit. The process took place with surprising swiftness, because she was an unusually intelligent and lovable child (not withstanding my very particular reservations in this regard).
There were moments of pure joy, like the time when we witnessed her first steps. There was a tiny wooden side-table in my parents’ room, with a surface area the size of a coffee table book; this we used to turn upside down so that Niva could “walk” by holding on to the legs of the table as she propelled it forward. I will never forget the day when she suddenly let go of the table and stood on her own two feet, albeit in a distinctly wobbly manner. It was only for a few seconds, before she landed squarely on her small bottom, but my brother and I – the only ones home at the time – were beside ourselves with excitement.
And sometimes, the nicest thing about having a small child around was the way that it made you recognise certain everyday miracles. My brother, at that time a teenager, was a typically music-obsessed adolescent. One day, when he was lying on the floor with his earphones on, Niva began using his prone body as an amusement park. Eventually, he got up and decided to see how she would react to the music. I still have a clear picture in my head of the wide-eyed look of utter wonderment on her face as she listened to the sound coming through the headphones, the huge white earpieces dwarfing her small head.
But of course – eventually – the approval process was completed, and it was time for her to go. By that time, she had well and truly entrenched herself in every aspect of our family lives. It was unimaginable to think of her leaving, and inevitable that she would someday do so. I didn’t find out until many years later how close my parents had come to cancelling Niva’s trip to Switzerland and adopting her themselves. But it would not have been fair; the Rueggs had been waiting for their baby for a very long time. In the end my parents gave up the idea, and Niva was lost to us.
My mother travelled with Niva on the journey to Switzerland, since each group of five children was accompanied by one adult. She later described that trip as one of the worst experiences of her life, and not because she had to single-handedly manage three toddlers, a baby and a young child by herself. The baby was Shandhya, and the little girl was Kuruni. In fact, having Kuruni along would turn out to be the single blessing of the trip.
After they had reached Switzerland, and the children were due to be taken into care by the Swiss authorities, my mother warned Kuruni that she would need to take special care of Niva. “She’ll cry when I leave, you see.” My mother said that she would always remember how Kuruni smiled sweetly at her and gathered all four of the little ones around her, promising that she would look after them. And she did; the nurses at the institution later told my mother what a huge help Kuruni had been in assisting the children to adjust to their new surroundings.
They were all a little wide-eyed and apprehensive in this new environment, but it was only Niva who began crying as the time for my mother’s departure drew closer. Perhaps she sensed trouble. Nothing anyone did could calm her down, and as Mum told me later, she broke down in tears herself as she left with Niva’s desperate screams ringing in her ears.
The next few days were hell for my mother, unable to go back into the facility to visit the children, and all too aware of the distress Niva must be going through. She once told me that it was the hardest thing she had ever done to walk out of that room, leaving the children with the nurses. She never again travelled to Switzerland with any of the adopted children, though her work regularly took her there in subsequent years.
A few days after her traumatic arrival, my mother received a phone call from Niva’s mother, with her father translating their conversation from German to English. Mrs Ruegg assured my mother that Niva was now calm, and no longer crying, but that she seemed unable to sleep. Through the woman’s husband, my mother explained to Mrs Ruegg that she had to put the baby to sleep through a time-honoured Bangali technique, patting her gently and rhythmically on her back with one hand. She stayed on the line while the Rueggs experimented with her instructions. And within a couple of minutes, the exhausted Niva succumbed swiftly to the long-overdue invitation of the Sandman.
There was no question that Niva’s departure left a vacuum in our lives, one that was difficult to talk about. In the initial period after the adoption, my mother looked up Niva’s family each time she went on a work trip to Switzerland. They lived in a small village outside Zurich, and from the regular photographs we received over the first few years, it seemed clear that she was a happy and well-adjusted child. That thought was an enormous consolation for us, still sore from the loss of her.
There was one picture in particular that captured my imagination: Niva at the age of about five or six sitting with four of her friends on a large boulder in what appeared to be a lush, green meadow. Although Niva clearly stood out as the only dark-skinned child in the group, the body language seemed to indicate that the baby with a strong streak of bossiness had grown into a child who was definitely the leader of the gang!
In fact, Niva’s status as the only internationally adopted child in her village brought her a lot of positive attention – to the extent that her brother Sammy, who was the biological child of her adoptive parents, began to suffer from a sense of neglect in comparison; not in relation to their parents, but from all the attention showered on her by the other villagers. But there remained certain poignant aspects to this. For one thing, in addition to being the only adoptee, Niva was for many years the only brown person living in their village, with the commensurate amount of curiosity this generated.
On one occasion, my mother and her Swiss friend, Ellen Richard, had gone to visit Niva and her family. Niva – who was at the time six or seven years old – suddenly pointed out to her mother that while Mrs Ruegg and Ellen were the same colour, Niva and my mother were also the same colour. She was clearly excited by that realisation, and the awareness that there were others who looked like her, even if they didn’t live in her village.
After that initial period, it would be many years before Niva again re-entered our lives in any substantial way. Yet although we didn’t often talk about her, she somehow remained a presence in my family. Not least because of the enormous, poster-sized image of her that always hung on the back of my parents’ bedroom door. It has remained there for more than a quarter of a century, surviving the moves between four different houses. That picture was one of a series taken when Niva was a baby, and she featured in an advertising campaign for Savlon cream – an early sign of the charisma that would, a few decades later, take her into a media career.
In the years immediately after she left for Switzerland, we received, in addition to the occasional photographs, a huge box of biscuits for Christmas every year. My mother took pains to explain to me how special the biscuits were; handmade and very expensive. It was perhaps the Rueggs’ way of thanking us for helping to bring their daughter into their lives.
Those biscuits were unlike anything I had eaten before or since. Rectangular and chewy, made with nuts and dried fruit, they resembled small pieces of Ryvita. But like the spinach and rice balls at that meal many years before, they were hard for me to swallow. So no matter how unusual anyone else may have thought they were, I didn’t like them; and after a few years, I even gave up pretending to.
I would much rather have had Niva instead.

Farah Ghuznavi is a development professional who has worked for organisations that include the Grameen Bank, Christian Aid UK and the United Nations. She also writes short stories and creative non-fiction, and is a columnist with the Star Magazine, affiliated with the Daily Star newspaper in Bangladesh.

By Audrey Merriam

As a future Ob-Gyn, I spent a month in Dhaka, Bangladesh doing research on first-hour breastfeeding–the act of putting the infant to the breast within the first hour of life. The ingestion of much if any milk–considered colostrum or first-milk at this point–is not even considered the most important part of this act. First-hour breastfeeding introduces healthy bacteria into the baby’s gut, helps the mother’s uterus contract and produces better temperature regulation in babies thanks to skin-to-skin contact with the mother, and leads to babies who are less stressed.
We were also researching exclusive breastfeeding–the practice of giving the infant only breast milk for the first six months of life. Exclusive breastfeeding leads to a decrease in diarrhea and pneumonia in infants, and an increased weight gain. In addition, breastfeeding decreases rates of breast cancer in the mothers and suppress ovulation, helping with family planning and the spacing of children.
We were hoping to survey women who were employed, predominantly in the garments industry, which surrounded the hospital. The surveys were conducted at Center for Women’s and Children’s Health (CWCH) in Savar, Dhaka.
Savar, where the garment factories are, is just on the edge of the capital city and was until recently just rice paddies. International garments factories have since taken over the area and as the population in Dhaka grows, Savar is becoming more urbanized with a rapid increase in the number of shops and apartment buildings being built in the area.
CWCH primarily treats women and children but is also the first stop before heading to a trauma hospital for many who are hit on the busy road outside. The inpatient population primarily consists of obstetrics and children with either diarrhea or pneumonia. The obstetrical population is largely post-partum status post cesarean section as many women, even in this semi-urban area, still labor and give birth at home: women who come in usually have had an obstruction of labor or some other complication during their labor or have had a previous cesarean section and have scheduled another. This skews the hospital’s delivery statistics towards cesarean sections by almost 3 to 1.
In general, women in Bangladesh tend to breastfeed their children up to 2-2.5 years. However, recently trends in both exclusive and first-hour breastfeeding have been decreasing, which is why we were interested in exploring this area. The survey consisted of questions on the economic backgrounds of the families, the women’s work environment and potential for maternity leave and child care at work, the women’s obstetrical history, the women’s knowledge of breastfeeding and the questions specifically related to their experience with breastfeeding.
We also asked women about first-hour and exclusive breastfeeding in relation to their youngest and second-youngest child to see if their practices changed or were consistent between children. One of the pediatricians at the clinic told me that many mothers stop breastfeeding because they feel they are not producing enough milk to satisfy their child. For this reason, we added questions to the survey about why mothers feel they have insufficient breast milk.
My commute to CWCH from the major teaching hospital in Dhaka, only about 20 kilometers, took anywhere from 1-2.5 hours depending on traffic, illustrating why it is so important to have a hospital with obstetric capabilities in the Savar area. Over nine visits to the clinic I was able to collect 114 surveys with the help of three different translators.
We collected the surveys in the waiting room of the outpatient and vaccine clinics at CWCH. There was no place to take the patients privately to give the surveys but the women shared their stories with us freely. Almost every time we administered a survey other patients would crowd around, curiously listening in on what questions were being asked. I found this curiosity to be a central part of Bangladeshi culture. The other patients were respectful and did not interrupt the person being interviewed or try and give her answers on the knowledge portion of the survey. More often than not this would give us a line of women very willing to share their stories with us.
The summary of results reported here are purely observational as the statistics on the data have yet to be run but I feel there are some definite trends that are worth reporting on now.
The first shock in our data collection was how few of the women we interviewed were employed. We collected surveys Thursday-Sunday between 8 a.m. and 2:30 p.m. when the hospital outpatient pediatric clinic and vaccine clinic were open. We assumed by surveying on those days we would be able to talk to working women on their day off. However, out of the 114 women surveyed only 18 women were currently employed, 16 of them in the garment industry. In Bangladesh, the workplace is still very dominated by men but in recent years, especially in the garments industry more and more women are being employed. In talking with the women we found that there were another 20-30 women who had previously been employed, usually in the garments industry, but had quit working just before giving birth to their first child. Of the women that worked the average length of maternity leave was around 3.5 months. The women who worked were also asked about the presence of daycare at their place of employment and if they breastfed at work. The majority of women denied breastfeeding at work and even denied taking advantage of the childcare at work. The women felt it was better to have the child cared for by a family member at home and switch to formula rather than bring the child to work to be cared for by a stranger and continue to exclusively breastfeed when their infant was around 2 months old.
Women were also asked who was there when they gave birth and during the first six months of the youngest child’s life. In this instance it was found that most women gave birth at home, even if they received prenatal care in a clinic (which almost all women did). Of the women who gave birth at home, the vast majority went back to either their or their husband’s rural home to give birth, some remaining there for the child’s first six months of life. The women who did not travel back to their rural homes to give birth often had their mother or mother-in-law come to stay with them for the birth and the first few months of the child’s life. The fact that women are still traveling to their rural homes to give birth or having relatives come to them for the birth and first few months of a child’s life indicates how important familial relationships still are in Bangladesh, even if they are no longer living in extended family settings all the time.
The women overall scored very high on the knowledge section of the survey. The most common questions the women got wrong were about if the mother should breastfeed during illness (most responded no) and if the mother could run out of breast milk (most responded yes).
For first-hour breastfeeding many women reported putting the baby to breast within an hour even if they gave birth at home assisted by a Traditional Birth Attendant (TBA) or had a cesarean section in a hospital, two common reasons typically reported for not breastfeeding within the first hour. However, around a third of the women also reported giving another food to the baby within the first 1-3 days, typically honey, honey water or sugar water. Women did this even if they felt their breast milk had come in. When asked why they said that it was a traditional custom and suggested by the TBA, their mother or their mother-in-law.
This shows the important influence of family members and the importance of knowing who is present at the child’s birth. Traditionally in Bangladeshi culture women will go live with their husband’s family, which puts their mother-in-law in charge of them in the day-to-day upkeep of the multi-generational household. This is what gives in-laws such sway over mothers—not only in terms of the way they care for the first child, but for subsequent children as well. Women who had more than one child tended to follow the same breastfeeding practices for both children unless there was a difference in the mode of delivery or the health of the child immediately after delivery.
In response to our questions about exclusive breastfeeding, many of the women reported giving formula to the infant at the suggestion of a physician. Of the women who did not breastfeed exclusively for 6 months, common reasons for the introduction of other foods included suggestion of family members (including the women’s mothers and mothers-in-law) and the women feeling they did not have enough breast milk. As with first-hour breastfeeding, women tended to follow the same practices if they had more than one child unless they or a child became ill, which prompted the women to add formula or other foods.
If the women felt they did not have enough breast milk during breastfeeding any of their children they were asked why. Common answers were that the baby was crying soon after feedings, the mothers thought the babies were malnourished (without seeking the opinion of a physician) or the mothers themselves thought they were malnourished (without seeking the opinion of a physician). Yet out of the 114 women and more than 114 infants, only 1 or 2 infants and none of the mothers appeared malnourished.
I was struck by how many women seem to feel they do not produce enough breast milk to feed their baby. As health care providers I think we need to take a major look at this feeling and look at ways to address it. Family practitioners, ob-gyns and pediatricians all need to be able to counsel women on breastfeeding and feelings of inadequate breast milk. Women should feel comfortable talking to physicians about this in any country and as physicians we should be supportive and encouraging of breastfeeding mothers.

At 4:00pm, I show up for my first day at the Special Care Unit of the International Center for Diarrheal Disease Research, Bangladesh (ICDDR,B) to observe afternoon rounds.

The room is quiet, except for an occasional burst of crying from one of the tiny patients. The SCU currently houses about ten infant patients with sepsis, pneumonia, and other co-morbidities commonly associated with diarrhea, dehydration and severe malnourishment.

I decide to wait around to see if a doctor appears, which usually pays off because rounds must be completed before the day is done. I sit in an orange chair by the door, trying to look busy writing in my small ringed notebook that I use to record interesting facts and findings. After a few minutes, I rise to my feet, and walk slowly from bed to bed, looking at the tiny, fragile patients and the women, some young and some old, that accompany them.

The “beds” are not as we know them in the United States. Rather, they are simple cots with vinyl coverings, a hole in the center for defecation and other bodily fluids. I scan the pieces of paper taped to the bed, reading the lists of medications and nutrition for each patient. I stop at bed three, a bed I took note of earlier because the girl sitting on the cot with the baby looked no older than 15. This afternoon, the girl is holding a plastic ventilator mask over the patient’s tiny face, and gauze is taped over his eyes to protect the corneas. He is suffering from sepsis, and a vacant stare is one of the presenting signs. Since he is not blinking, any pathogens or particles that get into the eyes can cause irreversible damage, and this is avoided by shielding the eyes with gauze. I can’t help but notice how the gauze covers most of the patient’s tiny face, and it seems to steal his identity.

Rounds begin shortly with several of the medical officers, and the patients in beds one and two are stable. As we move to bed three, they seem concerned with the heartbeat of the patient. The rounds are conducted in Bangla, so I usually try to grasp an English word that I understand, such as “hypokalemia,” amid the rapid flow of Bangla, and then try to formulate an educated question to ask in English. While it is frustrating to feel lost amongst the stream of unfamiliar words, I recognize that this is what I signed up for.

As a visitor in a new culture, I am hesitant to interject and interrupt rounds. There must be a balance between curiosity and respect. That being said, the physicians are typically gracious when questions are asked. In this case, I understand that the patient is 21 days old, has a low volume pulse, and is suffering from hypovolemia as a result of acute watery diarrhea. At this point, the senior physician approaches the bed, and I gather that the medical team is infusing IV dextrose to combat the hypovolemia. The patient’s tiny fingers and hands are showing signs of hypoperfusion, turning a shade of blue-gray described as cyanotic. They start to move to the next bed, and it appears as though they are going to assess his response after completing rounds.

As the team moves to the next bed, my gaze falls back on the patient in bed three. The young girl sitting on the cot with him turns out to be his sister.  His mother was hospitalized in Dhaka for postpartum hemorrhage. I watch one of the doctors move back to the bed to auscult the heart with the tiny bell of her pediatric stethoscope. While no one appears concerned and rounds continue, I can sense that something is not right. The doctor looks frustrated as she places the stethoscope over the infant’s thorax, straining to hear a beat. She shakes her head, and beckons one of the medical officers. The doctor uses her index and middle finger to pump the child’s chest, compressing the thoracic cavity in an effort to stimulate the heart. The medical officer alternates with pumps of the oxygen mask: they are beginning CPR. I have never seen CPR performed on a live infant, and the baby is handled much like the dolls I saw in my Red Cross CPR class. There is nothing delicate about this process. This is a last attempt at saving a life.

The chest compressions are violent, and the doctor flops the infant. In the chaos of the CPR, the infant’s sister is standing at the side of the bed, and no one has said a word to her. She begins to cry, and the incredible composure she has maintained melts away as she watches her baby brother fade. There is nothing for me to do but beckon the girl toward me and hug her. The intensity of the situation overwhelms me, but I try not to manifest my own shock and sadness. I need to keep my composure for this girl. As I squeeze her and rub her back, I can feel her rub my back in response. This hospital is not a place where the staff provides physical comfort: in June 2008 alone,­­ ­11,442 patients were admitted to the ICDDR,B. The sheer volume of patients makes brevity the law. But instinctively I know touch to be one of the most healing forms of attention. Even if the girl is not consciously aware of it, I hope she feels my support.

The CPR efforts continue for about ten minutes, and one of the other young mothers escorts the baby’s sister out of the SCU to alert the baby’s father and grandmother. While they are gone, the baby dies. I watch his tiny body lie motionless on the vinyl-covered cot as the doctors mill around the front desk, laughing and in seemingly good spirits. I suppose it is possible to become immune to the sadness with time, but I do not know if I will ever reach that point.

At the front desk, the death certificate lists the cause of death: severe sepsis. Something as simple as clean drinking water would have prevented all this.

The baby’s sister, father, and grandmother enter the room and approach the cot. The sister touches her brother’s motionless body gingerly. The grandmother lifts the tiny body from the cot and together they wrap him in a blanket. The grandmother holds the body close to her, much as we carry infants away from the hospital after birth, their lives in this world just beginning. And just like that, they are gone.

Tara Song is a Seattle native who is beginning her fourth year of medical school at the University of Vermont College of Medicine. She will be pursuing a career in Otolaryngology and hopes to incorporate more international work into her ongoing training.

Photo by Suzanne Germain

Descending the bumpy drive of the Hopital de la Commaunite Haitienne in Port au Prince, Haiti, on Good Friday, we passed a  woman in a T-shirt that proclaimed, in bright pink letters, “Shut up and dance.”


Dancing is big in Haiti. Only the night before, I walked up the steep rocky roads of Petionville to a Methodist church service. We passed the church, which had been reduced to a pile of rubble in 45 seconds, in the January earthquake, and turned into a big vacant lot, set up with rough pews.

My Haitian friends and I took seats under a mango tree, where a cool evening breeze was blowing to break the day’s heat, and we could look up at bougainvillea blossoms, palm trees and the mountains rising above. Along with 500 Haitians, we danced, waved our arms and sang gospel rock, accompanied by two electric guitars, keyboard and drums, while inhaling diesel fumes from the generator (no electricity there) and the ubiquitous smell of charcoal.

There were no hymnals, but everyone else knew the words: “Merci ampil seignour” (Thanks so much, God)
was the reigning theme of song and sermon. The pastor told stories from the earthquake and gave thanks to God to be alive and have all limbs present. But the dancing was the best and went on and on, rising to a cadence that could have converted a rock to Methodism.

Night fell abruptly, as so much does in the tropics, and Orion and the Great Hexagon shone overhead, looking no different than they do back home.

As part of that swaying crowd I knew I was in love with something, and I guess it was just life.
Like the day at the hospital when we rounded on the ward. I tried to be as gentle and respectful as possible, saying to each little child, “Bonjou madame (or monsieur), comment ou ye?” and the mothers would poke them into saying, in a tiny voice “Pa pli mal, grace a dieu”–not too bad, thanks to God.

Some of the girls would present their cheek for me to kiss, in the Haitian style. The mothers were laughing at my Creole accent, rusty from disuse, as one told how her child had stopped nursing, but would sneak into her bed at night and steal the breast. In order to make sure I understood, she pulled her breast out of her shirt and presented it to me. This brought down the house, and the ringing laughter seemed to role out the windows and up the impossibly steep hillsides, filling my mind.

Later in the day, we sat on the veranda of a mansion in Petionville, with a view of ocean and mountains that was to die for, rivaling any house in California, sipping cold Coca-Cola, and discussing how to rebuild the nursing school and old times at the Hopital Albert Schweitzer, where most of us had worked in our youth.

Meanwhile, spread below us, a million people were living in tents in a crumpled city. It was hard to know whether to cry or laugh. Mostly in Haiti, people laugh.

Morris Earle notes: I was recruited by the Academy of Pediatrics (Bron Anders) to work at the Hopital de la Communaute Haitian in Port-au Prince for eleven days. The language is in Creole, my spelling.

The cemetery is next to the hospital, situated as if to avoid a long walk for the mourners of the dead.  The road is dusty, rutted and unpaved.

A masonry wall blocks the view to the interior of the burial grounds.  The rusted gate yields to a strong push.  There is a large field, overgrown with grass and thistles.  Aboveground crypts, poorly tended, have faded family names painted on their sides: St. Pierre, Charles, LaFond.  Two tethered goats bleat plaintively, complaining of their surroundings.

Rubbish is strewn about: bottles, cans, plastic bags and newspapers.  Lying casually amidst the detritus of the living are human remains:  skulls, jaws, femurs, ribs–dismantled skeletons strewn randomly among the weeds.

In the tropics it is important to bury a dead person’s body quickly before the heat causes unpleasant rotting.  If you have no money for the funeral you can arrange for the various services–coffin, undertaker, priest, hearse, etcetera–on credit.

The body is buried, the familial duties fulfilled, and life goes on.  If the family fails to keep up with the payments, the casket may be exhumed and the remains removed. The plot can be reused.  The casket may be refurbished and used for a newly deceased.  The bones are strewn about randomly.

Sometimes the casket and its contents are burned.  Sometimes the casket and its contents are left on the ground, the skeleton waiting patiently. A woman lies in a white coffin dressed in her Sunday best.  She wears a white suit with large white buttons.  She was a small woman and the suit hangs limply on her fleshless skeleton.  Her matching white-lace gloved hand rests on the edge of the coffin as though she is about to pull herself up and hurry to the church for services.

After the chaos of the hospital, the cemetery is quiet and peaceful.  The only sounds are the protests of the goats and the distant whining of the ancient motorcycles in the street.  There is no pain here.  All are silent.

David Siegler is a pediatrician in Westchester, NY.  About five years ago he began participating in international medical projects in Vietnam, Mexico, Guatemala, Honduras, El Salvador, Cuba and Northern India. He traveled to Milot, Haiti with a group called Crudem.  They run Sacre Coeur Hospital which was unaffected by the earthquake and as such served as a major receiving facility for patients from Port of Prince and the USS Comfort.  ”The severity and sheer number of the injuries,” he writes, “is impossible to imagine.  The gratitude, patience, humility and generosity of the Hatian people was inspirational.” All photos by the author.

Trauma surgeon Dr. Steve Johnson arrived at Santo Domingo in the Dominican Republic on January 20th, 2010. He and twenty one other volunteers were eager to make a difference in Haiti, and the following day they would arrive in Jacmel, Haiti, where their efforts would help save many lives. The following are edited entries of the blog that Dr. Johnson kept while in Haiti.

After three and a half hours by air into Santo Domingo, six hours by bus to Cabo Rojo, and five hours by boat to Jacmel, our team and medical equipment finally arrive.

Today, we meet with the director of the only public hospital in Jacmel. During the meeting I feel like he is nodding his head without understanding us. He is a tremendous bureaucrat and cares more about how he is perceived than the patients. Only after lots of negotiations are we allowed to practice in the hospital.

The next hurdle is trying to join forces with the Cuban and Haitian physicians already practicing. Cultural stigmatism and language barriers sometimes make working together difficult, but here and now medicine is the universal language and we are united underneath it.

Right now there are dead bodies piling up in the rubble and, crooked officials, and red tape paralyzing relief efforts. No one seems to be taking the lead and there is a lack of coordination.

We plan on a full day tomorrow.

Sunday, January 24^th, 2010

Today, an eight year old named Agaella was brought in by her mother to have a large wound on her thigh examined. I was able to talk to Agaella’s mother through a translator.

“Darlene, what have you been washing the wounds with?”

“I used water,” she replies.

“From where?”

“From the street.”

“What have you fed the baby?”

“The water.”

That same water that pigs, chickens, and people, trudge through every day.

Tuesday, January 26^th, 2010

The highlight of today is an operation we performed on two and a half month old baby Frantz who had an incarcerated umbilical hernia. The surgery went well, but post procedure problems are causing difficulty with breathing. The child remains on the ventilator here in the operating room.

Tonight, I volunteer to provide critical care for this baby, along with my colleagues. As I watch him breathe in unison with the ventilator I realize that this child is part the future of Haiti, and I have impacted at least his life.

Wednesday, January 27^th, 2010

We are in need.

Baby Frantz has been having a tremendous amount of difficulty breathing. Without communication and military muscle this child will die—he needs to be transported to the Jacmel docks where the Canadians have set up tents.

I’m clinging to the back of a HumVee at 3am and we are in route to the docks where the Canadians can provide the oxygen that baby Frantz needs. Our homeward bound transport leaves in four hours, but we refuse to leave this child behind.

Thursday, January 28^th, 2010

At 8:30am, January 27^th, Colonel Paulette Schank pulled off the impossible. Out of the sky descended a medivac helicopter from the USS Comfort. While the US military did not have any presence in Jacmel while we were there, they did not abandon us in our time of need.

Baby Frantz and his parents are now safe as American medical teams take over our relief efforts.

Edited by staff writer Dan Ritter

Dr. Jane Aronson is Director of International Pediatric Health Services, PLLC, and CEO of Worldwide Orphans Foundation

We spent the day in the city surrounded by rubble. The driving from one destination to another in heavy traffic allowed us to see some of the scope of the disaster, but tomorrow we will go to the downtown of Port-au-Prince and there will be the heart of the devastation from what we hear from the owner of the guest house. It was so weird that one building is standing perfectly and then next door, another building is completely destroyed…flattened and when I stared at the concrete and metal rods all tangled up, I could not help think about the people who were trapped and killed. The death toll went to over 150,000 today, but we still have no idea about how many children have perished.

Off to the city again, we waited patiently in traffic and found the Petionville Country Club where a refugee camp had been placed. It was on this lengthy trip through the city that we saw a lot of the earthquake’s devastation…though from what I heard tonight from our hosts, this was nothing compared to what we will see in downtown Port-au-Prince tomorrow. The country club was beautiful and yet it is now the home of the U.S. Military and the refugee camp below where 40,000 Haitians live with homemade tents and meager food and supplies. The soldiers are bringing them the rations daily, but there is insufficient food for children, and strong men often steal the food from the women and children….

We hurried home at 5:30 p.m. because there is no electricity and lights downtown and frankly there were many stories today about looting and gangs and riots that have broken out over food and water. No one is out at night.

We listened to our Haitian hosts talk about how they suspect the millions of dollars being raised for their country will not be directly received and used for the people who live on this beautiful and helpless island.

We are struggling with the constant questions about Haitian adoptions….I have been interviewed a few times and people somehow think that adoption of all the lonely and abandoned children will solve Haiti’s orphan crisis. This is not true…there were 380,000 orphans on this island of 9 million people before Jan 12 and 20,000 of them were living in pretty poor conditions in 187 accredited orphanages; there were many more smaller creches in Haiti unaccredited, but all the same housing orphans all over the countryside….and then were thousands of orphans trafficked, sold into slavery and prostitution. The health of Haitian children in general is substandard and has been for decades.

Day Two

Rebecca and I ran into an exhausted hospital worker at the Plaza who helped us to visit…the largest public hospital in Port-au-Prince. We went there to see the pediatric patients and get a sense of the primary care needs of the people. The first week after the earthquake was about search and rescue and medically there were thousands of surgical procedures (crush injuries and amputations) and emergency medical treatment. By the second week, the disaster plan began to change as surgeries slowed down. Those people who were injured by the earthquake and those who were not are now seeking primary medical care as there are many international organizations who have set up treatment tents in various locations and are offering free medical consultations.

We visited two tents of children in beds with intravenous lines getting antibiotics and fluids. There were doctors from Haiti with medical students and many other doctors from all over the world doing rounds at the bedsides of the sick children….ministering to the sick and teaching as hospital doctors do daily all over the world…in a tent and it all the same if it had been in a building. What was quite special was the families…mothers, fathers, and other family members were at the bedsides of each child nursing and feeding their babies.

We arrived at La Maison des Enfants de Dieu finally at midday. All the kids were outside because they are too afraid to be in the building for fear that they will be crushed and killed. So there were sweet camping tents procured from the military and the Nannies were seated on benches and chairs enjoying the sun and taking care of the very sweet 50 plus orphans….

The kids were depressed and most of the babies had colds, but they were cared by the Nannies and that was evident. I liked the Nannies. They were well-groomed, clean, neat, and pretty. They were not young–middle aged and older and experienced and comfortable in their roles. They were holding and touching the babies and older toddlers in a way that was natural and looked genuine. I sat between two Nannies and picked up a sweet little baby boy who I had begun to play with when I first arrived; he and I fit right between the Nannies and their babies. And I spoke some simple French with them…..the barriers were broken and we were hanging out together…enjoying the children. Steve Nagler and a group of 4 girls were doing a kind of Hokie Pokie and one older girl was the leader. Steve and the younger 3 girls followed the leader and they sang and then wiggled their booties….Steve included…I had a view of Steve’s wiggling butt and watched the giggly and exuberant girls. I could have stayed for hours….as I sat with a group of young infants on a blanket, I massaged their little shoulders and bellies; then I petted the velvety skin on their backs…such sweetness.

The kids were tired and it was nap time. They held tasty sweet crackers in both fists for dear life. And their noses were runny and they were all coughing….postnasal drip and maybe even some wheezing/asthma. I had TB on my list as well…TB is huge in Haiti.

All the coochie coos weren’t changing the sad expressions on this group’s faces…I tickled them and pet them, but they had psychomotor retardation and their muscles of facial expression were not in full use. They all had that reddish color hair that indicates protein deficiency called Kwashiorkor. And they had the usual array of medical conditions that are common to orphans, i.e. molluscum contagiosum (viral wart), eczema and scabies (a mite that burrows under the skin and causes bad itching and can set off an immune mediated eczema), and distended bellies from malabsorption of nutrients due to parasites and lack of muscle mass. Their legs were skinny and their heads looked especially enlarged and box-like in shape due to rickets (vitamin D and calcium deficiency). These are all things that can be prevented by the way and had nothing to do with the earthquake. This is how orphans can look over time when they are not fed properly.

Day 3

We went to five orphanages as part of our orphanage tracking task and we saw hundreds of kids. The vast majority of the kids were in poor health, dirty, likely had at least a few medical conditions, and were not getting educated in a consistent daily program.

Many of the kids we saw today were moved from their orphanage to another building due to the damage from the earthquake.

[At] the first orphanage we visited…the kids were in the basement of a big beautiful building that is used for religious retreats. The building was beautifully constructed and painted and there was a swimming pool…but the babies were in the basement; the basement smelled like kerosene and urine. I am sure that they had cooked cereal with kerosene stoves–so dangerous because of the fumes and then the chance of a fire with these babies all around in one crowded room made me very anxious. The kids were wet and their diapers filled with poop. I held a few babies and my pants became wet…There was no chance to get a smile out of these children.

Twins came into this orphanage last night and they looked about 3 lbs. The one twin I held was having repeated seizures over and over while I held her. She had the classic lip smacking, eye rolling and staring over and over again. The babies had not been examined by a doctor yet; the birth mother had died in child birth 26 days before. So the orphanage staff person told me that the twins would be going to the hospital soon. Other kids just were staring or moved around the room aimlessly. Caretakers were also without affect and overwhelmed by the numbers of children they were supposed to care for in this little room where the floor was covered with filthy mattresses.

One orphanage was clean and had great caretakers who were very engaged in loving the children. I had my stethoscope and listened to each chest one by one….they all had colds, but only one child was wheezing and we told the head Nanny and she indicated that she would take the child to the clinic. We also were able to help the Nannies with the many other questions they had about the rashes all the kids had: ring worm, eczema, scabies, failure to thrive, growth stunting–all things that can be easily managed, but the problem of course will be that you have to wonder why we would even treat these conditions, when it is just a way of life for kids in orphanages to live in filth and to have very poor nutrition and be repeatedly exposed to infectious diseases. These physical diseases have an effect on the emotions of a child; they are uncomfortable in their own skin and they live in a state of discomfort which may cause them to withdraw and become depressed.

One orphanage was very upsetting because there were too many kids and they were wild; the staff were tired, overworked and angry. I watched one Nanny grab a toddler by the shoulder and just pick her up and throw her on a mattress. These kids were especially dirty, and most of them had shaved heads and fungal infections. One boy, Jean, whose photo will be included in the journal was recently in New York for a shunt operation. He had pressure in his brain and had a special procedure that placed a tube in his brain ventricles so that fluid could drain into his stomach. He never had the stitches taken out of his scalp after his surgery and they were embedded and causing infections of the skin…in the middle of the orphanage play area, I snipped 6 stitches and removed them and cleaned the pus from under the skin.

Then we returned Jean to the wild pack of children who were his friends and in a few minutes they were all using cardboard from boxes of rations delivered in a big truck while we were there, to surf a cement slant at one corner of the orphanage play area….they stood on the cardboard and slipped/surfed down the cement in a few seconds all the while laughing and taking many turns. Jean got into the mix within a few minutes of returning.

I couldn’t see another dirty faced depressed infant or smell another filthy rented old house. And I couldn’t see another fake soccer ball (rolled up socks) or more children with lice, scabies, bald heads, rotted teeth, broken and poorly healed fractures, limps from bone infections, silent toddlers with empty expressions, and babies with wasted buttocks and sunken eyes.

The health conditions of Haitian children, whether orphaned or not, before the earthquake were marginal. Infant mortality is 80 per 1,000 live births in Haiti. And immunization rates are about 50%.

Day 4

As Marina drove us out of the city, we saw hundreds of thousands of people up and about brushing their teeth, washing their faces on the streets near their tents…tarps, sheets, towels, clothes…anything that hangs can be used to make a tent. We all wondered the same things…where are they urinating and defecating? Do they have fresh water? What are they eating? What are they doing all day and night? What are their children doing because there is no school?

The children of Haiti were at risk before January 12 and they continue to be at risk in the same ways after Jan 12. The health of children in Haiti is unbearably and unimaginably abysmal. Children grow up dirty, poorly fed, anemic, filled with parasites and bacteria from undrinkable water, ricketic (lack of vitamin D and Calcium), exposed and infected with Tuberculosis, incompletely immunized and at risk for the complications of measles, chicken pox, rubella, mumps, tetanus (yes, there is tetanus here right now), polio (still here in Central America believe it or not), meningitis, syphilis, and more. And then they are undereducated and have little access to mental health services when they are at risk from the irresponsible care of adults in their lives. Child slavery and child prostitution are rampant here and the earthquake is just a dot on the continuum for these practices…

Day 5

There is a holocaust for children in Haiti. [T]he earthquake is what everyone will focus on now because it visually destroyed thousands of homes and businesses and uncountable bodies were bulldozed into ditches, [but] I believe that the earthquake allows us an opportunity to see the reality for the lives of children having nothing to do with this obvious disaster. Hundreds of thousands of children are living under dire circumstances and we need to pay attention.
Trafficking has caught the attention of the media because it is dramatic, but it is just a symptom of an underlying lack of care and respect for all children in Haiti and in many developing countries where there is rampant extreme poverty.
The disaster in Haiti now should remind us that all around the world there are millions of orphans who suffer and the earthquake in Haiti is a wake-up call to come to the aid of all children living without parental care, living without the right to just be a child. The world has failed its children. We cannot ignore the deep systemic failures of societies around the world for its children.

I ask that everyone try and get back to the work that must be done for children and not get distracted.

Jane

–edited by Jennifer Lunney and Stacey Kilpatrick

Lubna Yeasmin, at the time a student at the James P. Grant School of Public Health, BRAC University, Dhaka, wrote this first-person field report on the MANOSHI maternal, neonatal and child health project. The photographs are hers.

The raw sewage from Gulshan—one of the posh areas of Dhaka, popular with elites and diplomats—runs down a drain and into a small lake.

The lake festers between Gulshan and the slums of Korail and Shahtola, and the only way for my partner Christine and me, on our way to investigate birthing conditions in the poorer parts of Dhaka, was by a small wooden boat. Crossing the lake, we felt as if we were suffocating from the pungent horrible smell of the sewerage. Before landing, we had to take off our sandals and jump barefoot onto the muddy embankment.

It was August 2007, and I was pursuing a Master’s degree in Public Health at the James P. Grant School of Public Health in Dhaka. I was taking a Public Health Nutrition course, a course I had been looking forward to do for a long time. At the end of the course, we had a group assignment where my partner Christine, who was from Uganda, and I were taken to a field visit in an urban slum of Dhaka, to see a pilot Maternal, Neonatal and Child Health Initiative (MANOSHI), initiated by BRAC.

BRAC is trying to improve the health of the poor, especially the mothers, newborns & the children. The aim of MANOSHI, a five-year project that began in 2007, is to change people’s attitudes and behaviors concerning health and nutrition issues, and to improve the quality of health services.

We were visiting MANOSHI to see how well the program worked, to try to understand its nutritional aspects and to explore ways to integrate its ideas into the design, implementation, monitoring and evaluation of public health and other development programs.

It was raining. The narrow roads to the slum were made of brick and mud are had become slippery. Some of the pipelines for drinking water and sanitation stopped at a street corner without reaching individual houses. In some cases the fresh-water pipes and waste-water pipes ran next to each other or on top of each other, and were clearly leaking: someone had tried to fix them by simply wrapping them in plastic tape or tying them with rope. Diarrhea, a common killer of newborns and infants, is a very common disease in this area, mostly because of the unhygienic sanitation system.

A very narrow road led through the slum. Here and there women and children were selling vegetables, dried fish and ingredients on the street, but always in small portions, perhaps a day’s rations for a family.

Finally, down a narrow alley between shacks made of corrugated iron, we reached the Birthing Hut, a delivery center that was also used for health services for the neonates and children under five. It was a simple, clean building, with two rooms: one used as delivery room and the other used as an office for the Shastha Karmi, or health worker, the Shastha Sebeka, or health volunteer, and the traditional Urban Birth Attendant or UBA. The office room was sparsely furnished, with just a cupboard to keep the register book and other equipments, a folding plastic table and few chairs. Mothers sat on the floor, which was covered with matting.

As soon as Christine and I entered, we heard cries coming from the delivery room. A mother had come in that morning with labor pains.

The delivery room had a small washroom attached with it, where we saw a drum and a medium size bucket, filled with water. A kerosene stove stood unused in the corner. The birth attendant was a community midwife with no formal education, but she had been given a basic training in how to attend a normal delivery at a Birthing Hut.

When a woman has a home birth, the neighbors usually come to visit the mother and the child. In the Birthing Hut, while the delivery was taking place, we could hear the crowd in the other room. The women were talking each other about the new born. “Is it girl or boy?” someone inquired. Someone else answered, “It is a baby girl.”

Conditions at the center were far from perfect. There was not enough clean cloth to hold the baby. The birth attendant delivered the baby without gloves. There was lot of blood in her hands as she was trying her best to handle the situation. The normal drum of water was used for cleaning mother’s breast while she was nursing the baby.

We were worried about these conditions, because cleanliness and hygiene are vitally important during childbirth. Despite all our medical progress, mortality among newborns has changed very little. It’s estimated that 34 out of every 1,000 babies born in developing countries die before they reach one month of age. Three-quarters of neonatal deaths occur in the first week of life from severe infections (including pneumonia, tetanus, and diarrhea), premature birth, and suffocation.

The delivery was not easy. The UBA was trying to get the mother to push hard to deliver the baby, but she had been laboring all morning, and by midday she had lost all her strength. I was struck by how different the situation was from the normal delivery of my first child in a posh hospital in the Dhaka city—although rich or poor, normal or abnormal delivery, all mothers go through pain.

Meanwhile, a conflict between new ways and old ways was developing between the Health Worker and the laboring woman’s mother, who in traditional fashion was present at the delivery. As the pregnant woman was delivering her baby, her own mother kept on interrupting, pressing her waist and neck, and praying verses from the Holy Qu’ran.

The Health Worker clearly felt the woman was invading her work.

“Don’t do that,” she insisted. “Do you think it will reduce the pain? Just sit there, and let us handle the delivery. You people aren’t being of any help. You’re just disturbing our procedure.”

Finally the baby was delivered successfully, though again not everything was done by the book. The Birthing Hut staff paid little attention to the details. The birth attendant didn’t check the baby’s weight or note the time of birth. Christine was also very unhappy with the delivery procedure, and the fact that nobody took the baby’s weight at the moment the baby was born.

However, I saw it differently. The poor people in Bangladesh who suffer from delivery complications can’t even afford to go to a public hospital. The MANOSHI project was a step forward: at least now they can get some birthing services. However, with only two people onsite to take care of the entire process, it was not surprising they didn’t have time to take the baby’s weight.

While the staff were cleaning the baby, we went out to the other room, where several mothers and their children were waiting to see the new mother and her newborn baby. Curious about their nutritional practices, we found that all six mothers had eaten fruit such as mango and jackfruit while they were pregnant, and all had nursed their babies for six months, though they’d faced difficulty getting their children to take food other than breast milk. These practices seemed to be improving where the initiative was taken by the projects supported by both the Government and development agencies.

Once again, we found new practices clashing with old. One mother had a 45-day-old baby with respiratory problems. Two of her previous children, she said, had died of acute respiratory infections. She was a Hindu, she explained, when her baby was suffering from cold, she went to the kabiraj (traditional healer), and according to her, the healer suggested giving the baby honey with juice of Tulshi leaves. Honey is not suitable for a baby under six months of age. Our nutritional programs insists that mothers not give anything to the baby other than breast milk, even water, until the child is six months old. We call this “exclusive breastfeeding.” We have found that the juice of Tulshi leaves reduces cough but is not of any help in curing acute respiratory infections. So it is not a good practice for the newborn.

There is a strong case for incorporating some traditional practices in modern healthcare. Funds are limited and post-natal care and postpartum care treatments are expensive in hospitals, where beds are also limited. We can and should increase the family’s understanding of postnatal care of both mothers and newborns, especially in issues of cleanliness.

Similarly, we feel there’s a need for developing post-birth practices to introduce prophylactic eye care, to keep the newborn safe from catching cold, and to prevent hypothermia (by drying and warming) and hypoglycemia (by immediate breastfeeding).

The MANOSHI Birthing Hut, it seems to me, is a good initiative undertaken by BRAC and brings hope to me in the care of maternal health. They are using largely traditional birth attendants in a professional manner that enables them to use their skills and experience to provide a healthy and normal delivery.

We have lots of traditional practices; some are good and some are not. We need to change or modify unhealthy practices and appreciate and incorporate the best practices. This is the only way to improve our health and nutritional status, not only in slum areas but also in every household in our country, Bangladesh, no matter whether they are poor or rich.