Finding the Answer

November 2, 2012

Kasoa

Last day

It is 530 in the morning and I am awake already. I opened my eyes as soon as the slightest hint of sunlight peeped through the clouds. My eyes fell on what I have always seen first for the past 31 days: the slats supporting the mattress of the bunk bed above me, hazy through the mosquito net that surrounds me.

I know it but I can’t believe it: today is my last day in Ghana. I am so sad that I wish I had one more day, one more week, one more month ---even though I know that one more than what I have, would not make it less difficult to let go. In another part of the world today, there are also people who await my return. But for us here, today was yesterday’s tomorrow, last week’s next week—the day we felt was too distant but like a seasoned thief has crept in to steal a day.

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(As I write, P and D also wake up. D throws me this sad face, I throw it back and say no. P also throws me a sad face, says I wish you could have stayed longer, I throw it back and say I know. And I start crying. P squats down, wipes my tears and says we will never have someone like you again. I can continue to cry, but we have a full day ahead so I wipe my tears, try my darn best to be strong. L and U are still asleep and I don’t want to greet them with tears and puffy eyes. And this is just the beginning.)

Yesterday I was overwhelmed with generosity, the magnitude of which I felt underserving to receive. I went back to Ga-South Hospital to thank G and everyone whom I worked with, to say goodbye and thank you. After G and I had a picture together, we both went to A.M.’s office where she gave me her parting gift. I thought she was going to give me fabric as she had alluded to last week, but instead she gave me a white envelope. I thought it was a clothing pattern from which I can have a dress copied. I opened the envelope and found instead, money. I closed the envelope in disbelief, looked at her and said I can’t take this! She laughed and said I’m not bribing you, and it’s for the fabric you want to buy. Awww! She and I hugged each other tightly, thanking each other. I want to hug you tight but I don’t want to crush you, she said. I swallowed tears that were beginning to swell up.

I then went to the administrator, A.Mg, who is one of my favorite persons in the hospital, next to G. I tied up some loose ends with the HIV unit we are planning to build, thanked her for having me in their hospital. Before I left she and I exchanged the Ghanaian handshake, which consists of a firm grasp, an unhurried letting go and a flick of the middle fingers. With this I knew that we have come a long way from the day I first met her when we had the usual Western handshake. When you exchange a handshake with someone the Ghanaian way, it means I like you, we are friends. Before I left her room I said, I have been practicing to say this--- nyame nhsia wo (God bless you).

G walked me to Mallam junction to board a trotro to Accra Mall where I was going to meet Tita N. G and I had one more hug and again I said, I have been practicing to say this--- nyame nhsia wo. But to her I added, me fe wo papa (I will miss you very much).

___

I arrived at the Accra Mall much faster than I expected, having passed a different route this time (Madina-Lapaz route). Tita N called as I was crossing the street and said that she was wearing green. I didn’t think she needed to say it, because come on—there can’t be more than five Asians in one place, at the same time in a mall in Ghana. The instant I met her I knew that she was one of those. One of those kindred, fun-loving spirits with whom I just click instantaneously. We hugged, as if we have known each other for a long time. We had lunch at a Chinese restaurant in the mall, where we talked about her traipses around the world (Saudi, UK, Grenada, Malaysia, Philippines, Ghana), how she met her husband (a Ghanaian surgeon, retired now), her children’s impressive achievements, how she’s worried about them being too busy and single. She couldn’t wrap her head around how I can ride a trotro, because in her 12 years here she has not been in one. Isn’t it hot, she asked. If the traffic is at a standstill, yes.

She was so fun to be with, always giggling, always smiling. Even the taxi drivers would lighten up and go along with her jokes. After going to the craft market for last minute souvenir shopping, we went to their house in the Airport Residential Area, an area in Accra with buildings of modern architecture, gated and manned by security guards. Where homeowners talk about how difficult it is to find a trustworthy and hardworking housegirls, houseboys and guards. I just fired our boy, he was lazy! I got a new one, the son of a pastor who was able to tell me what Psalm 23 was. And on drivers: I didn’t hire this man—he was rather old, in his mid 50s; he had beads in his hand which you know what it means: he is chief. And you don’t want to have a chief driving you, you know that.

I met her husband and their two friends, both Ghanaians. The male friend was also a doctor, a neurologist who has made a home in Long Island, NY, Aburi and Accra. All of them had that same fun-loving spirit that just feels so light to be around with. Though I wanted to stay longer, I left at a quarter of 5 in the afternoon so I would be in Kasoa by sunset. Tita N walked me to the end of their street and saw me board a trotro. From that street I had two more transfers before I was finally on the trotro to Kasoa. It was during this transfer of trotros that I again received undeserved generosity. Unbeknownst to me, the first ride didn’t end at Nima where I thought I could take a trotro to Kasoa. Instead it dropped all of us at a market. A lady offered to go with me to Nima so she can show me how to get to Kasoa. When I handed a coin to the conductor, he refused it. The lady already gave him 40p to pay for herself and me. I looked at the lady behind me, my benefactor. She touched my shoulder and said please, it’s for the two of us. I was dumb-founded, surprised with her unexpected kindness.  She didn’t have to, yet she did. It reminded me of the Bible story where the Lord says, the poor though they give less, actually give more (or something like that).  I felt so very humbled with this selfless act. Her kindness did not end there however; upon reaching Nima she went down with me and brought me to the right trotro. There was only one space left, and she gave it to me. Whether she also needed to go to Kasoa or not I would never know. I thanked her, and asked that the Lord bless her heart.

This was when I again grasp that when we give, we get so much more in return. I thought of the time I paid for the fare of the boy who accompanied us to Kasoa from Ada Foah. When I did it I had no expectation of a reward, and yet--- see how much more I received in just one day. Last night upon reaching home, I opened the envelope that G gave me. It was more than enough for a fabric. So now I had a dilemma: do I buy fabric as G intended, or do I donate the money to P’s church that is soliciting funds for construction? Inasmuch as I want to give things forward, I also don’t want to leave Ghana without a reminder of G’s generosity.

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So today I can say: last night was my last trotro ride. And it was a long one too. Traffic everywhere. I was getting impatient, and I had to remind myself over and over again to change my perspective and just enjoy the moment. I still found it amusing that before the toll booth where tens of hawkers abound, is a sign that says:

                                    Mama Esther
                                    Back to Sender
                                    Tilapia for sale

I have passed by this sign at least ten times and I still can’t understand what ‘back to sender’ means.

Switching my mindset worked at times, but when the heat inside the trotro irrefutably transformed into beads of sweat, the frustration came again in a wave. I must have cursed in at least three different languages, a hundred times in a span of two and a half hours. Upon reaching the Kasoa signage, I decided that I have had enough. I went down and walked for about a mile and a half, meandering my way into the strolling night crowd.

The old market at the junction, though still bursting with energy had a subdued tone to it now it was dark. One step here, one step there, a twist of the body here another twist there. With each step I take there was always something being sold.

            One step to the left:              toothpastes (layers of them)

            One step to the right:           rechargeable lights

            One step to the left:              black shoes, bright shoes                

            One step to the right:           loaves of bread (only 2 cedis)

            One step to the left:              dried fish

            One step to the right:           CDs, DVDs (I always see Dingdong Dantes)

            One step to the left:              phone credits

            One step to the right:            roasted plantains

            One step to the left:              cellphone chargers

            One step to the right:           lotions shampoos soaps

            One step to the left:              keychains posters balloons

It was almost a rhythmical dance, made complete with scattered music and pungent smell, the inevitable human interaction: a bump on the side as we simultaneously twist, sweat on sweat, skin to skin.

I walked until I was too tired, and at that point luck fell down on me and a trotro unloaded one passenger, which made space for me. As I was boarding though the driver sped on almost knocking me off. I and the other passengers cried, EYYY! If Ludo was around, this would have been the perfect time for him to say, action movie.

___

Upon mentioning Kasoa to Tita N, her face distorts with mixed disbelief, mild repulsion and vicarious fright. We only pass by Kasoa on the way to Cape Coast, and…oh my god. How is it there?

Well, it has been home. It is where I have lived with 7 other people (Laura, Una, Portia, Doris, Josephine, Franklin and Wisdom) in the last 30 days, sharing the same food, under the same conditions of intermittent power and water, exchanging life stories, dancing and laughing, drinking, merrymaking under the bright moon and inside the candle-lit home.

I recall the first night I was here and how disgruntled I was at the dim light, the mattress, the toilet, the shower. Everything just dissatisfied me. And yet as the days went by my eyes have grown accustomed to the light (although I did change them eventually), my back has started to like the foamy mattress. And the toilet and shower? Luxuries compared to others.

And with this I grasp that our ability to adapt and accept things as they are and live within them can be a two-edged sword. While it can certainly help us thrive in a new environment, it can also blind us and desensitize us. Numb us even.  The HIV/AIDS patients and staff at Ga-South come to mind. They have been, for the past years now, making do with what little they have: a table, a chair, a hall, a room sometimes. But is this how they should remain? The enemy of good is better. And the challenge, I think, is for us to be able to oscillate readily between these two vital capacities so that we can accept things with peace without being too anesthetized to some realities that need to be transformed.

___

This trip is what you make of it. A previous volunteer inscribed this on the wall at the back of our house. I saw it on my first week and has been the one gentle reminder that has stayed with me throughout my stay here.

I think, I hope, that I spawned love. Love for the work that I do, love for people, love for discovery, love for the kind of travel that transforms you inside and out. I hope I did, because that is what I certainly received. That is what I will bring home with me.

Shortly after P sees me cry this morning, she sends me a text message:

Hi love, you are amazing! You are so much fun to be around! You are so fun and adorable you were like a big sister to me but I can’t believe that you are leaving, I’m so sad, Portia.

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When I woke up this morning and saw for the first time the sun rise from beyond, a song emanates from me. It is the song that the Ateneo College Glee Club used to always sing when we leave a place and move on to the next.

Morning comes and I must go; day is breaking yonder

After all the places I have been, now I’m going home.

I have been to seek the sky, to travel on the highway

And the time has come, I don’t know why

I am going home.

Where is the answer to so many questions

I don’t know, so I begin another journey

Where is the meaning for my world

I see the answer now.

Though we came by different roads, now we walk together

Stay beside me all our days, strangers never more.

Through the cool of summer rains; by the heart-side fire

Here I’ll be with you when nothing remains

I am home to stay.

Love is the answer to so many questions

Now I know, and I can stop my endless wand’ring

Love gives the meaning to my world

I see the answer now.

Love is the Answer. . .       Love!

(by Raymond Hannisian)

Indeed:

Love is the answer. It gives the meaning to my world.

The sunrise this morning

                 

Firsts and Lasts

October 31, 2012

Kasoa

Today was a day of firsts and lasts.

The first delivered baby in Ghana.

The last visit to the maternity clinic.

The first group lesson on Azonto dance.

The last trotro ride to Bajwasi.

You have to understand: I am trying not to be sad here.

___

This morning was all about perfect timing. M, L and I went together on a trotro toward Bajwasi to see the Margo Maternity Clinic. It is a small, private, for-profit clinic run by Margaret (I guess I should call her Auntie Margaret, as a sign of respect), a nurse midwife who still practices. It is a gated compound that houses six discrete buildings:  on the left side are the screening room, waiting area, injection room/recovery ward/wards a and b/pre-labor ward/labor ward/consulting rooms; on the right side are the dormitories for the midwives and I guess, Auntie Margaret’s home too; on the center is the dispensary or pharmacy, facing a shady mango tree under which we first found Auntie Margaret and greeted her and told her of our intentions for the day.

We wanted to see a baby being delivered. I have seen it multiple hundreds of times before, but seeing how a baby’s head starts to show, teasing excited spectators outside, always gives me tremendous joy. I don’t grow queasy about it until the baby really descends with magnificent pushes from its mom and its head crowns, the labias are pulled apart like a woman bellowing out in laughter and staying in that position. I grow queasy because I know it is painful for the mother. I feel it, and I know it is more than painful. It is at this moment that I always feel in awe of all the mothers who deliver vaginally. If every one of us would see the torture that women go through in child birthing, we would appreciate our moms more. Men would have greater respect for women. With every inhale the baby’s head retracts, and with every exhale and PUSH, PUSH, PUSH (!) it swells again. Whenever I see this, I think: this is why we are all inexplicably and undeniably linked to our moms, why even the elders, whose mothers have long gone, still call out to their moms in trying times. Because child and mother have shared the same harrowing pain, and have together breathed to live the same exhilarating miracle, the bond is never severed. It is a friendship that is borne of shared adversity, of parallel labor, and ultimately of communal triumph.

As soon as we walked into the labor room and saw a hint of the baby’s hairy head, we stayed. M and L looked uncomfortable and curious. L remained on the side for the most part, seeming hesitant. I goaded her to come nearer especially when the head was definitively crowning.

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So this is what happens: baby’s entire head pops out of the vagina and hangs in the introitus for what seems like forever. I knew there was something wrong, the way the head just hung like that, with that ashen color.  Typically when the baby’s head comes out the rest of its body just follows rather easily. This baby was not typical. The cord was wrapped around its neck. The midwife immediately but calmly uncoils the cord. I quickly scan the room and search for gloves. I know it--- I would need to attend to this baby. Just as I don a pair of gloves the baby is set loose, its shoulders slide out, then its torso then its pelvis then its tiny feet. IT is a HE. He is a boy. I love boys. I smile.

He doesn’t cry. He is pale. And limp.

I rush quickly to the bedside, grab the suction bulb and start sucking away all the muck from his mouth and nostrils. First he gasps, and then he gives out a faint hint of a cry. Encouraged I suck out more and with my left hand dry him vigorously and stimulate him.

He cries. It is definitely a cry. I almost cry—in delight; in relief. He is alive. The first baby I helped deliver has made it to this world, has opened his eyes.

___

After quickly scanning him for his APGAR scores, I brought him to the counter by the wall to further dry him and examine him. Counted his toes, 10. Counted his fingers, 10. Checked his anus, patent. Checked his palate, approximated. Checked his chest, belly and back, what needed to be robust was and what needed to be straight was. He was perfect. Re-checked his heart and lungs, beating and breathing. He was alive. That thought kept repeating itself in my head. Alive. Alive. Alive.

Only later on did I realize why it mattered me to that much for him to be alive. It was because he was the first baby I delivered in Ghana. Heck, the first baby I have delivered ever, on my own. On my own, without anyone looking over my back. Holy cow. The baby and I made it. It is an exhilarating experience.

We asked his mom, the superstar of the show, what his name is going to be. ‘I don’t know,’ she said. M said ‘well, how about MJ for Michael Joseph?’ Michael Joseph is the name of her yet unborn nephew. He is set to be born today in the States. So we turned to his mom, ‘we have given your baby a name. Michael Joseph,’ we said.

Me and MJ

Later at night when we went back to the clinic, one of the midwives said, ‘oh Michael Joseph and his mom have left for home this afternoon’. We asked if he was indeed named Michael Joseph. And the answer? Oh yes! Woohoo. Would it not be great if two Michael Josephs in different continents shared the same birthdate?!

___

Apparently, according to one midwife whom I spoke to this morning, they never have sick babies in the clinic. I find it hard to believe, but I hope it is true because babies here are just secondary priorities. I saw with my own eyes how they almost ignored a limp, pale, non-crying baby. Now, it might have been because I was there; but--- the first reminder they gave me as I brought the baby to the counter was, ‘here take this cup, this is oil; use this to clean the baby.’ Second order was to put the baby on the scale, then measure the head, the chest and the length. Nobody asked me how the baby was doing; only if the baby was already clean.

You can always clean a baby anytime; but for me I would rather clean a living baby over a dead one. I had to remind myself to accept things as they were and to just adapt to the circumstance and make do with what I had and what I didn’t. 

Being a doctor for kids, I worry when there is not even a stethoscope in the room, nor a suction machine, nor an APGAR (a brief scoring system to see if a baby is doing well or not in the first 1,5 and 10 minutes of life) scorecard on the wall, nor a lamp for heating, nor a thermometer. I think this is appropriate worry, no?

____

This afternoon we went back to the clinic, this time with Una who was going to work with us for the first time in 6 days since being sick. We were hoping to get timing as perfect as the one we had this morning. On the way to the clinic, which is a good 30-40 minute ride from our home base, this was what I saw:

It’s nostalgically beautiful.

When we arrived at the clinic, the midwives were gathered in a circle near the wards talking amongst themselves. They called us and as inclusive as ever, they invited us to join their circle. When we finished our introductions and basic getting-to-know-yous, and after they clarified that condoms here are referred to as condoms and that romantic is just a brand, someone noticed U dancing in her seat. ‘You are dancing,’ she tells U. U says she was. I took this as an opportunity to ask for a dance lesson so I say, ‘actually we are all trying to learn Azonto dance.’

‘Ahhh!! Azonto!!’ They giggle and rise from their seats, immediately goading us to rise and dance. Music starts to boom from a cellphone and we have fun.

Me trying the Azonto

Group lesson

Girls having fun

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After calming down from the dance, we heard a car pull into the driveway. ‘We have a case!’ C excitedly tells us. U, who just pulled out her packed dinner and was about to start digging in had two people telling her different things: ‘eat!’ ‘No, don’t eat yet!’ I said I didn’t think the baby would come out within the next 5 minutes. Seconds later, two men came in carrying a frail looking, middle-aged woman by her armpits. My eyes immediately go down to her belly and the first thing I say is, ‘but she’s not pregnant.’

Apparently they also accept non-pregnant patients. As this woman was. I let the nurse and the midwife attend to her first and only went to the woman’s side when the nurse said she couldn’t get a blood pressure. The moment I was at her side it struck me how sweaty she was.

I felt her pulse rate and I didn’t have to count through the full 60 seconds to know that she was tachycardic (has a fast heart rate). At 15 seconds she was already a 30-40. I still went ahead and attempted to get a blood pressure though. Three times I tried and I could not get anything.

Sunken eyeballs. Skin tenting. Cool, clammy arms. No blood pressure. Fast heart rate. S***, I thought, this patient is sick. Immediately I ordered for the woman to be laid down on a bed, given an IV fluid bolus. This patient is clamping down on us, I told the nurses, we need to assist her heart to pump blood. I went to the dispensary with the nurses and together we picked out IV fluids and medicines to give. They asked me if I could do the IV insertion. I said yes, but when I realized that this woman had only one or two chances for an IV insertion and that the family may not be able to afford a second IV kit (should I fail), I asked the nurse to do it instead. The unfortunate thing about training in a hospital that is well staffed is that residents like me don’t get enough opportunities to do simple procedures like this, and even when we do there are non-resident trainees and PAs and NPs who sometimes fight tooth and nail with us to get it. So a simple procedure like an IV insertion, once a natural skill I had, is now lost on me. Hopefully I will have a chance at redemption.

After 1.5L of IV fluid boluses and 2 hyoscamine injections, the woman regains an acceptable blood pressure of 90/60.  Whew! Now I can wipe the sweat off my armpits. She lived! Like my baby this morning, she was alive.

I cannot even begin to explain how rewarding it is for me to feel that the work I do, actually matters. That what I know, can save a life (and what I don’t know, can fail to). My heart swells just thinking about it. What utter privilege it is to be able to care for people, to be able to touch them in ways that probably go beyond the present moment. An utter privilege.

As doctors it is frustrating to be unable to practice ‘right Medicine’ each time because of the unavailability of services or financial limitations. Tonight after the woman regained her blood pressure, the nurse and I had a discussion about the IV fluids. The outgoing nurse told her during their sign out that it was ‘ok not to give the 4^th IV fluid for 30 minutes because she has already received 3 bags.’ Don’t ask me where they got the 30 minutes. I reasoned that the woman still needs the fluids. The nurse, hesitant to carry out my orders, finally says ‘but the family will need to pay for the 4^th bag.. does she really need it?’ I look at her in the eye. I say I truly understand but I ask, ‘how much is her life?’

I know how it is to lack, and I always explain to my patients and sometimes to nurses like the one tonight that I am not one to order labs and medicines unnecessarily. I always say that I apply the same principle to myself. I give thought to each order I give, fully aware that these orders don’t act in isolation.  A patient, a relative will have to pay for each centavo, sacrifice upon sacrifice, blood upon blood.

___

L and U meanwhile busied themselves practicing BP measurements on each other. U learned it in school, L learned it from me this morning. U did it several times on L that by the end, L’s arm had indentations.

'My heart is beating!'

Writing orders

They came with me to the labor room when I did a cervical examination on a woman who has been laboring since this morning. It has been at least 7 years since I last did a cervical exam on a pregnant woman, so I had to ask the midwives for assistance to help me measure the cervical opening. 4-5cms of thick cervix was what we estimated. I regretfully told the girls that it was impossible for the woman to give birth within the next 30 minutes, and that we would have to leave the clinic without having a delivery tonight.

R, one of the midwives, insisted that L and U come back. She reassured them, saying, ‘don’t worry before you leave here you will come to something.’

I thought her choice of words was spot-on. You will come to something.

On my last few days here, this has left me thinking. Indeed, what have I come to, what have I arrived at?  

­­­On a day of firsts and lasts, I know that whatever virgin place within me I have arrived at and whatever sacred truth I have come to since coming here --- I have been changed.