food distribution

In early June, four guys from my home town came to Afghanistan to make a documentary.  One of the first things that we did was a food distribution in Balkh city (about 45 minutes from Mazar).  My friend, F. who runs a kindergarten heard that there were many extremely poor people there.  One of her teachers, S. had come to her to ask if we could help.

After the horrible winter that we had, food prices soared (though this was not just in Afghanistan, it was a global price increase).  Some children in the States raised $2000 so that we could do a larger distribution.  We reckoned that with that amount of money, we could buy enough food to feed 30 families for a week.  

food for a family for a week

 

We had heard many horror stories about food distributions.  People are so desperate to feed their families, that they become violent and people who are not part of the distribution begin to crawl over walls and  riots start. So, a friend who had done this before gave us a very detailed plan to keep things organized, but we also had an escape plan if things got crazy.

S. had met with the kalontar (like an elder) of the village and made a list of families with the biggest needs.  We then made a date and headed out.

Well, the plan went flawlessly.  It went so quietly and smoothly, it was almost boring (though the joy of helping these families was very exciting)

My film guys and some local Afghan men lined up all of the food on a raised porch-like area.  Each family was to receive a big bag of flour, a bag of rice, a bottle of oil, and  a "goody" bag with beans, salt, soap, and matches. The women were all lined up against a wall, and their men were on the other side of the courtyard.  We organized it so that when we called a name, the family had to come and get their food, and they had to be totally gone before we called another name.  It worked really well.

While we were handing out the food, S. whispered the families' stories to me.  Some were incredibly sad.  Widows, men that are too weak to work, men that want to work, but nothing can be found because of the economic conditions.  Older sons who would usually work for their family died in accidents or of illnesses.  One of the most common though, was that the old (I mean like 70 year old) men were still producing babies, though they were too old to work, so these poor younger women (sometimes teenagers) are married off (actually sold) as second or third wives, have no way to feed their children.

This is a huge problem in Afghanistan. The society itself has social rules about helping widows, but if the husband is still alive, they won't help, no matter how old, weak, or sick.  So many of the younger women pray every day that their husbands will die so they can get on the dole.  This is the plight of women in Afghanistan. 

When we were finished, we had enough money left over, so F. went with A. two weeks later and gave out food to 10 more families.  That was the day before I went into the hospital.

Last day of clinicals

You never know what life will bring you tomorrow.  When I went to work at the hospital on June 24th, I had no idea it would be my last day.  

We went back to the neuro/psych ward so we could follow up on the patients we had the day before.  We were surprised to see the patients smile at us.  Though their problems are far from over, I think that just showing a bit of kindness to them lifted their hearts a bit.  We spent that day much the same as the day before, doing PT with the stroke patients and holding hands with the depressed patients.  

At the end of the day, I took my students into a room to have a post conference with them and talk about what they had learned.  After the conference, as my students were walking out the door, I said something that made one of them laugh out loud.  About 30 seconds later, and armed guard came running into the room looking for the woman who had laughed out loud.  Apparently that is still illegal to some.  I couldn't believe it.  Thankfully the woman had already slipped out of the room, and I could honestly say I didn't know where she was.  It turns out that the governor of our province was touring the hospital and heard the woman laugh and sent his guard to arrest her.  I still sit shaking my head when I think of it.

After I extricated myself from that situation, I went into the nursing lounge to change my head-covering so I could leave, and I was accosted by the head nurse.  SHe started yelling at me about the behavior of two of my students.   She said that it was completely inappropriate for the one to have laughed and the hospital had lost face, because the governor was there.  Then she said that two of them had been in the hall flirting with male med students the whole time we were there.  She said that they even winked and made kissing faces and sounds toward them.  

She said that she knew things were different in my country, but that these students just can't act like that and I need to control them.  After about 10 minutes of her yelling at me, I finally got a word in edgewise.  I said, that this sort of behavior was also not appropriate in my country (not the laughing, but flirting in the hall during clinicals is not acceptable).  I also said that I have 10 students, and when I am working with them on a patient, I can't see all of the others, and that they were old enough to govern themselves, and that I would talk to the head of the nursing school about them.  She finally calmed down. 

I went to the head of the nursing school that afternoon (who I must say dresses like Elvis Costello).  I told him that I was having trouble with a couple of my girls flirting with boys and before I even said their names, he knew who they were, and said that he would take care of it.  That made me feel better.  Apparently I am not the only one who has had trouble with them.  

As I said, you never know what the next day will bring.  If I had known it was the last day I would spend with my students, I would have said goodbye or given them all hugs, etc...As it was, I just left them hanging.  

the psych ward

The week before I got sick, our clinical rotated through the neuro/psych ward.  They don't have enough rooms to separate the two, so they are all in one big room.  One one side of the room are older women who have had strokes.  They are pretty sad, most are poor, and one in particular touched my heart.  It was just she and her husband subsistence farming.  She was so worried about what was going to happen to her and her husband now that she couldn't work.  I worked extra hard with her teaching her some physical therapy exercises.  My heart broke for her, but it was all I could do.

On the other side of the room, there were four women who were as the Afghan doctor said "psychotically depressed".  That means they were so depressed that they were having breaks with reality.  I didn't really see that.  I think that the doctors were just tired of hearing them cry and they made up that diagnosis as an excuse to give them antipsychotic medication to put them to sleep.

The first girl was about 16-17 years old.  Her mother was with her and obviously cared deeply for her, as a mother should.  I sat on the bed with her, and accepted a warm, sweet cup of milk that her mother offered me and asked what was going on.  The mom told me most of the story.  She said that a year before, the girl had gone to a wedding and some men had come to the wedding and threatened to kidnap the girls.  Since then, this young woman had not stopped crying.  

Afghans are notoriously emotional, but this seemed way over the top, to be frightened, and then to cry for a whole year.  I had a sense that there was more to it.  In Afghanistan, if a woman is raped, it is considered her fault.  As I watched this young woman and her interactions with people, and the fact that we couldn't get her to tell her story, but just let her mom speak for her, I felt that she had probably been raped at that wedding, and perhaps even gang raped.  My heart burned for her.  I knew that if she told her parents, it may mean death for her.  I took the nursing student assigned to her (this is the same student that I took out to help me with Roqia [the little girl with abdominal TB]) out into the hall and told her my thoughts.  I asked her to just sit with the girl all day, hold her hand, and listen to her.  I told her to make sure that this girl knew that no matter what happened that day, it wasn't her fault.  I also sat with her off and on all day that day, and told her over and over that if anything else had happened to her, that it wasn't her fault, but it was shame on the men who did it.  

Another lady, near the end of the row was so depressed that she was starving herself.  She was literally just skin and bones, and she was completely catatonic from the antipsychotic medication that she had received.  She had several small children one of which would come and sit with her every day.  It broke my heart to watch these little children watching their mother starving herself to death.  I sat and held her hand as well, and cried with her (as I did with every patient that day).  I also snuck her a little money before I left that day to help her buy her medicines.

While I was sitting with her, another lady was brought in and put in the bed beside her.  She then began screaming a blood curdling scream and shouting that she will pour gasoline all over herself and light herself on fire.  

At the end of the row, in a bed beside the window, there was another young married woman.  I don't think she could have been more than 19, but already had several children.  She was also labeled "psychotically depressed".  As I was holding her hand, she looked at me with tears streaming down her face and said, "God has left me.  God has left Afghanistan."

That was one of the most difficult days for me in Afghanistan.  But my students learned a lot about caring for more than just a body part.  They learned to care for people.  The next day, when we walked through the door for clinicals, all of the patients that we had cared for the day before smiled.  Their problems are far from over, but a little kindness went a long way.

A few more notable things happened this day.  A man in the ward next to ours died.  He had a heart attack.  His family began wailing, which if you have never heard you are fortunate.  Then armed guards came running down the hall with their kalashnikovs at the ready.  When a patient dies, guards always come to make sure that the family members do not kill the doctors or nursing staff.

Did you ever see the movie "Blood Diamond?", They keep shrugging their shoulders and saying TIA (meaning "this is Africa").  The Afghans have the same phrase.  WHen you ask why something is the way it is, they shrug their shoulders and say, "Afghanistan as dega" (This is Afghanistan).

A terrible burn

Sometime near the end of April, my driver showed up with his little nine month old boy, who had been severely burned three days before, because he pulled over a pot of boiling water onto himself.  I was pretty upset with him for several reasons.  First of all, he had taken my first aid class, and had been taught how to prevent this, and  to immediately put cold water on a burn, and to never spread mud on it.  Well, he had ignored all of those things, and when I saw the baby, he was covered in mud.  The second thing was that he had waited three days to come to me.  I asked him why, and here was his answer...

About 2 years ago, he came running to me, like there was a dire emergency, and asked me to come see his mother, because she was sick.  I asked what was wrong with her, and he said she has diabetes.  I said, well when did she find out (as he was so excited, I thought it must have been a new diagnosis, and the family was scared).  Turns out she had it for 20 years.  I asked if she was having any new problems with it and he said no.  From previous blogs, it is clear that I am over busy, and usually, when people have problems, I will drop everything to help them.  But at that time I was extremely busy, and it put me over the edge that he would try to manipulate me like that (he did this quite often.  When I did get to go see his mom, he tricked me into coming on a day when every woman in his family was there and I ended up having over 30 women clamoring for me to examine them).  So I reacted rather badly and told him to never do that to me again.

The second reason that he waited so long was because of an incident that happened about 2 weeks before his baby was burned.  He showed up at my front gate on a day when I was running late and did not have a guard working, and he rang my bells for over 10 minutes.  I finally went out, and talked with him through our tiny little window that we have cut out of our gate.  He said that his mother needed eye surgery at the eye hospital and since I know the administrator there, would I ple

ase call and ask how much it would cost. I said yes.

So, I made the call and of course there are different prices for all different surgeries and I had no idea which surgery she needed.  Later on, when I got to the office, I told him there were different prices and that she needed to go there and be examined to find out how much it would be.  He said that she had gone and they said it would be about $100.  I asked, "then why did you show up at my house and ask me to call?"  He laughed and said he thought I could get a lower price.  I talked with his boss that day, and told him that it was inappropriate for a man to show up at my house asking to talk to me, and to tell him to never do it again.  If he has a problem, he can call or see me at the office.

So, he didn't bring his son to me until he was dying.  At first I felt bad, but I know that I had made it clear that if there was a real need I would be there for him, so I gave up the guilt.

Back to the story.  He, his wife and their son showed up in front of K.'s house (she is the nurse that I work with) and another foreign woman happened to see them there and called me.  K. and I exam

ined him, and at first, because of all the mud, I thought that he was covered in third degree burns.  It was really bad.  He also had a fever.

We took him into the bathroom and began to scrub his wounds.  It was horrific to hear his screams, but very necessary.  WE finally got the mud cleaned off,and the dead skin.  His whole left arm and leg were burned, along with a spot on his scalp and small spots on his right hand and foot.  We covered the wounds in silvadene cream, Vaseline gauze and wrapped him all up.  We then made a plan to debride (scrub) the wound and change the dressing every three days. We also gave him some antibiotics and tylenol for infection and pain.  Thankfully, I had some narcotics with me,

and we began to give him some pain medicine about 30 minutes before we started.  After a couple of weeks though, he equated the me

dicine with what was to come, and he began to throw up the medicine as soon as we gave it.  So, we had to do with Tylenol suppositories.

The going was slow, as a matter of fact, I never got to see him completely well, because I got sick.  But I did get to see his leg heal, and his arm was healing well, though we feel that part of his arm was indeed a third degree burn.  It took 3 months to heal.

This picture was taken after about two months, when his leg was already better, but his arm still had a long way to go!

TB

Sometime back in late March/early April, we used our blessing fund to send a 12 year old girl, Roqia, to Kabul to have abdominal surgery. 

This little girl was born with multiple birth defects.  She had a cleft palate, and her face was malformed, making her eyes protrude.  She is also very small for her age, but that is pretty common among the poor in Afghanistan.  She had originally gone to the doctor to be examined for cleft palate surgery, but something else showed up.

 She had a very swollen stomach, which was either going to be diagnosed as liver cancer (this would have been a death sentence for her), or tuberculosis.  It turns out that she had abdominal tuberculosis.  They did surgery to clean out the abdomen and to do a biopsy.   She was then sent back to Mazar with her family.  

That's when I came in.  They had left her abdomen open so that the TB drainage could drain out of it.  But, apparently during the surgery, they put a small hole in her bowel, so it wasn't just TB drainage coming out, but bowel contents as well.  In Kabul, they had placed a colostomy bag over the wound to catch the drainage, but since she didn't have a protruding colostomy, the bag wouldn't catch the drainage.  

I went to her house (they are very poor, so their house isn't the nicest or the cleanest on the block).  She was in a great deal of pain, and the drainage was unbelievable.  It was (if you have a weak stomach, please don't read this part) part white cheesy TB drainage mixed with bowel contents (diarrhea).  I washed my hands, and put on gloves and took off the bag.  She had a big X shaped hole in her belly, and gunk (the official medical term) was pouring out of it.  I cleaned her up, and tried to put a new bag on, but so much stuff was oozing out, that I couldn't get the bag to stay.  It was a different sort of bag than we have in the states.  There wasn't any adhesive on it.  Instead, there was a strap that wrapped around your body to hold it in place.  It was also very heavy, so that no matter how tight I wrapped it, if she sat or stood up, it would slide down and the edge would sit on top of her wound giving her excruciating pain.  

Speaking of pain, in the midst of all this, she was recovering from surgery, and pain medicine is not usually prescribed after surgery in Afghanistan.  I examined her,and found that her stomach was very distended (swollen with air), so I called a pediatrician friend in Kabul, who had been following her case (Dr. J), and he felt that she should have an enema.  He said that after her surgery, the swelling was down, the drainage was minimal, and her pain was under control.  So, it was a bit disconcerting that she was doing so badly.

I didn't have access to an enema that day, so I taught her mother how to keep the wound clean, then went home.  That night, my roommate gave me a great idea.  She told me to get a nursing student to come help me with Roqia.  She said it would be a great way to mentor a student in nursing care.  

I went out the next day and bought an enema, then went to the nursing school to find a student.  The head of the department thought it was a great idea as well, and went to a classroom with me to find someone.  There, he gave a long speech about how whoever went with me would need to behave and they couldn't look at the drainage and faint or throw up or react in any way what-so-ever.  This speech had to be made, as they needed to know this wasn't about prestige and getting in good with the foreigner.  It was about taking care of a sick child.

I was hoping to get a student of the same ethnic group, as this family's ethnic group is the most persecuted ethnic group in Afghanistan.  Well, the girl that volunteered was not just of the same ethnic group, she had also spent most of her life as a refugee in Iran (as had this family).  So, she could relate to them very well, and would treat them with respect.

I was very impressed with this girl.  She washed her hands before and after and wore gloves.  She also was very patient and did a lot of teaching with the family.  Later on, I was to have this girl in my clinical group, just before I got sick, and she indeed will be a good nurse.

Back to Roqia.  She felt much better after the enema and the drainage slowed down considerably.  I visited her several days later, though and all of her symptoms had returned.  I talked with Dr. J again and he said to give her another enema then start her on some medicine that should keep things moving along better.  When I gave the enema this time, (warning, again, don't read this part if you are squeamish) I looked in the pan afterwards, and a long white worm had come out.  So I added some worm medication to her treatment.

Thankfully, after that she began to make steady progress to get better.  She was due to have her cleft palate repaired in September, but since I got sick and had to come home, someone else is following up on her care.

An aside about the family.  They love this child.  They are however, a typical Afghan family and don't know much about hygiene.  Roqia's mom did her best to keep the wound clean, but in the process, not much else stayed clean.  She had a box where she kept the rags that she was cleaning Roqia's wound with (both clean and dirty were in the same box, along with her TB medication).  One day, she served me tea.  When an Afghan serves tea, they must serve some sort of candy (sweets they call it).  After she served me the tea, I saw her reach into the box and dig around finding all of the candy that had spilled out into the bottom of it, then she served it to me.  Though I am usually not very careful with what I eat at Afghan's houses, I had to draw the line there.  As a matter of fact, it almost made me retch when I saw her do that.  I had to finagle around to find an excuse to not eat the candy, but I managed to get out of it.

Trip to theouterlands part 3

When we left for the mountains, we decided as a group, that I would be anonymous, meaning that we would not tell anyone that I was a nurse, for fear of me being overwhelmed with work.  I did not bring any of my diagnosis books or assessment tools (not even a stethoscope).  But, the woman who runs the CP clinic did not get that memo, and she mentioned to all of the patients families that a nurse was coming. Oh dear...

One day while we were on our trip, an employee at the CP clinic asked me to go look at his daughter who had been sick for a while.  So, we went out to his village and it turns out that his daughter has malaria.  She had already been diagnosed, and was taking medicine, but I didn't have my drug book with me, so I called a friend back in Mazar to get the right dosages.  She was not taking enough, so I corrected the dose for her.  About a month later, I found out that all Afghan malaria was drug resistant, and that what the doctors prescribe is useless there.  Ugh...well it is a lesson learned.  During our surveys on this trip, we found out that in the mountains, most people get malaria every summer.  So, they desperately need some prevention measures, like mosquito nets, and getting rid of standing water etc...

After we finished with the little girl, one of the women in the house said that she was suffering severely with gall stones.  She had lost so much weight, that she was a stick and her shoulder blades were sticking out.  She said that the doctor told her she needed surgery,  she couldn't afford it...again the public hospital is supposed to be free, but the docs and nurses want bribes to treat you.  Thankfully there is  a Turkish run wing of the hospital and we had made some contacts there, so we got her into see someone.  It is s frustrating to deal with the apathy of the medical community there!

As we left the house, people started coming out of houses and streets all over the village, asking for me to come and examine their sick loved ones.  This is my biggest struggle in Afghanistan.  The need is so incredibly great, and the resources are so few.  I long to help everyone in need, but I am only one person, and sometimes I work until I have nothing left and I get so sick that I can't go on for a while. (more about that in a later blog)  I did something that day that I don't do very often, but for my sanity I am having to learn.  I walked away.  

The next day, at the clinic, a baby was brought to me who had pneumonia.  Since I didn't have anything with me, I couldn't treat him, and once again, I had to walk away (though I did tell the mom to get the baby to the hospital).  I really struggled that night with what I should do, and I finally came to the conclusion that I wouldn't travel without my medical things again.  The basic things do not take up much space, and it will be worth it.  Second, though I can't go into a village and treat every single person I see, when individuals come to me (like the baby with pneumonia), I need to be ready to treat them.  

Trip to the outerlands part 2

It has been a REALLY long time since I blogged, and tons has happened.  I'll try to write in order.  At the last blog, I was traveling in the outer lands.  I will pick up from where I left off.

While F. and I were working in the CP clinic, A girl of about 12 was brought in.  She didn't have use of her legs, and they were stiff with contractures. Her mom said that she had CP.  The problem was, that she had an open sore on her foot, and the clinic cannot treat children until they are otherwise healthy.  I asked the mom to take the bandage off of her foot so I could examine it.  It was completely gangrenous.  All of her toes, through the middle of her foot was black.  Then there was a diagonal split that was entirely open flesh.  It was one of the worst wounds I have ever seen.  

I asked her mom if she had been to the hospital, and she said they had, but the doctors wouldn't treat her, because she was handicapped.  F. and I bundled her up and took her back to the hospital.  We went into the ER with her, and the ER doc recognized her.  He said it didn't matter, because she didn't understand what was going on.  He said that she had polio and shrugged.  We told him that she was a little girl in pain and that she needed treatment.  He said that they had treated her, but that the parent's had taken her out before treatment was finished.

Honestly, I didn't know who to believe.  It was quite possible that they didn't do anything for her, because of her mental and physical state, or that they were expecting bribes to treat her, even though it is a free hospital.  But, it could be that they were treating her, and the illiterate parents took her out, because they didn't understand the length of the treatment.  

One thing was for sure, the doctor didn't think her worthy of treatment.  We dug our heels in, so the doctor came and cleaned the wound and started and IV.  Then, F. and I stayed with her until she was admitted to a ward.  We made sure she was scheduled for surgery (for amputation of her foot above the ankle), and that she was getting antibiotics.  

We then sat and talked with her and her mom, and though there were some obvious problems, it was clear that the little girl had a good intelligence level, and that she understood what we were saying to her.  

We went back two days later to make sure everything was going well, and she was scheduled for surgery the next morning.  We loved on her and her mom and then had to leave.  They wept hard, as we were probably the only people who had ever shown compassion to them.