Culture Shock

Today was our first day of clinical back in the United States. As I walked to HUP in the morning, I couldn't help but think of Botswana. I thought about how I won't get to walk home in clogs covered in village dust anymore and how I had to say goodbye to a culture where there didn't seem to be such a thing as being late. There will be no more lengthy tea and lunch breaks or nurses that give inspirational pep talks about loving others to halls filled with waiting patients. We also won't have to turn patients away because we've already used our four speculums for the day or feel the pit in our stomachs when we ask about a patient's nutrition and they look at us with blank stares that say "I don't have any food".

It's already been one week since we've returned from Botswana and needless to say, some of us are experiencing quite a bit of culture shock. Life in Philly seems more-or-less normal, but we've come back forever changed. It's hard when you're bursting with stories to tell, but most people just want to change subjects after you said your trip was good. It saddens me that I can't speak in Setswana anymore or say hi to everyone I pass on the street without receiving strange looks. It's also hard to confront the affluence of American society. We've seen such poverty and such wealth in such a short period of time. Princess Marina is probably the best hospital in all of Botswana and HUP has recently reached top 10 in the US, but the disparity between the two is huge. At HUP we have negative pressure rooms instead of open windows, we don't have to use gloves sparingly, and we don't run out of drugs. Patients don't sleep on mats on the ground and we don't have 30:1 nurse to patient ratios (that definitely wouldn't make magnet status!). Part of me wants to respond to all of this by shaking someone silly and yelling, "Stop complaining! You don't realize just how much you have! There are more important things in life!" Another part of me wants to shut out everything I saw in Botswana and go back to life as it was before we left. I suppose the trick is to find a healthy balance. I never want to forget the lessons I learned in Botswana, but I also don't want to shut out American culture so much that I can't share what I've learned and affect it. I don't know how to do this yet, but I guess this is the next adventure and challenge.

Reflections

This is Ginna writing from Michelle's name (sorry, I am not normally a blogger). I want to take some time to reflect in general upon my experiences here in Botswana. Although things were slow to start for some people, I was able to begin clinical immediately at the Baylor-Botswana pediatric HIV clinic. Although I had to sometimes be creative in my endeavors at Baylor, I can honestly say that I learned an incredible amount in terms of community nursing as I was able to get a true glimpse of many different communities within Botswana, nurses' roles both in the clinic and out in the community, and pediatric HIV treatment. The most powerful thing I have learned since being here is that a person can possess all of the clinical skills and theoretical knowledge possible, yet without a positive rapport and an understanding of one's patients and community a health care provider is unable to fully care for a patient. From the very first week I was told that the majority of work done at the clinic is social work and not medicine. While that may be true on some levels, I feel that it is an admirable quality to be able to take a holistic view of a patient because in pediatrics a child cannot raise himself/herself. It requires family and community assistance, especially here in Botswana. I have had the opportunity to directly observe how the common African proverbs "It takes a village to raise a child" and "We are, therefore I am" play out in everyday life. It has brought with it a unique and wonderful learning opportunity as well as a plethora of life lessons and opportunities for personal growth. I am certain that I return home a changed person and I will carry this experience with me in my heart for a long time to come.

Community Based Home Care

So Yana and I have been working in Mmopane (a nearby village) to make home care visits with the community health volunteers. The volunteers explained that home visits involve going into homes and consulting with the family to assess the patient’s needs. First they start by greeting and praying with the patient. Then the volunteers will ask the family if the patient has eaten. If water is needed, they will fetch it. If food is needed, they will go and buy food to cook for the patient. They will also do physical labor that the patient cannot such as cleaning the yard and making sure the patient’s home environment is in order. The volunteers and the nurses play a pivotal role in this community. If there is no caregiver in the family, the volunteers and nurses become the primary caregivers. This care concept is almost unheard of in the United States; the selfless, compassionate nature of these volunteer caregivers is insurmountable. Due to the work of these caregivers, the acuity of the patients has significantly decreased making it easier for the caregivers to provide care and see outcomes. These volunteers earn a meager 100 pula/month (about 16 US dollars). Some of this money may even be used to buy food for the most impoverished of families. Needless to say, we have come to find that those who have the least give the most.

Since Yana and I are making home visits with the volunteers, they've somewhat modified their approach. Our visits are more focused on disease-related issues rather than the ADL-focused care that volunteers provide. It has been a very humbling experience and what is more astonishing to me is that the volunteers and patients have trusted us to provide care. I have never been in a patient care situation where I was the sole provider. So home visits involve assessment, diagnosis, and treatment! This concept is fairly new to many of us because in our undergraduate nursing education, we're not necessarily responsible for dx and tx (obviously, this is more in the NP or doctor realm of practice). Nonetheless, it has been a very challenging and interesting experience.

Homesick as an astronaut...

(Disclaimer: I have so many nursing-related things to write about, but for now, this is all that's on my mind... I'll write something more substantial soon, I promise.)

In my room tonight, it caught up with me.

That crushing weight of lonliness that I’ve travelled so far to escape. I don’t know how it got here - which airline it flew in on, or how exactly it knew I was living at the University of Botswana graduate student dorms - but it found me tonight. My chest tightened, making breathing difficult as my mind raced to find a comforting thought, some fantasy in which I could take refuge.

It felt like I was rushing to climb a tree, so I could be safe from some dangerous predator that was biting at my ankles - only every branch I grabbed for snapped off in my scramble. I tried to think of my work here, but instead my mind flooded with images of the abject, crushing poverty of my patients and their families. I thought of home, but instead of envisioning the familiar comforts, all I could picture was the vast ocean, cold and dark, that marked the separation between where I was lying and where I wished I could sleep.

I tried to pull back and remember what I’ve been told in every study abroad orientation I’ve ever sat through: This feeling of lonliness is normal, inevitable even. Home sickness? Somehow the term doesn’t fit. I’m not sick, and I don’t necessarily want to go home. I just want to feel, see, taste something familar.

Strangely enough, the only familar thing tonight seems to be this feeling of isolation. I think of moments in Mexico, New Zealand, India - everytime I’ve moved, the lonliness has caught up with me sooner or later. Across time zones, international date lines, hemispheres, it has always found me. Each time it does, it seems to take hold of me with a grip that is even stronger than the time before. I mean - shouldn’t I be an expert by now? Better yet, shouldn’t my previous exposures grant me immunity against this sickness?

I want this tightness to leave my chest, this wave to wash over me, but I know it’s just not that easy. The truth is that it never really gets any easier.

Even when the lonliness greets you like an old, long-lost friend.

Want to help us make a difference?

As some of the other students have mentioned, we have been spending time at Kamogelo, a day care center for children who are infected with - or affected by - HIV.

We've had a wonderful time at this site because it has allowed us to use our creativity and enthusiasm for nursing and community health and channel it into something really meaningful (for us) and useful (for the people who run Kamogelo).

I put together a short video about the center, and about our work and the work we hope to be doing there in the next few weeks. Take a look and tell us what you think!



(View a larger version at YouTube: http://www.youtube.com/watch?v=flT2fya7VWo)

Let me elaborate on some of the things mentioned in the video:

What we've already done:
We've already created a health record form for the children's files, completed physical exams for about a third of the children, and held basic first aid and CPR classes for the teachers and administrators at the center. Tomorrow, we'll return to Kamogelo and conduct more physical exams, as well as provide health education to some of the childrens' parents; In the afternoon we'll tour some of the sustainable community projects that have been coordinated by Father Tony, the man who is responsible for many of the community health sites where we're doing our clinical rotations.

What we hope to do:
We have a lot of projects that we would like to take on before we leave the country at the end of the month.

• First, when school lets out for recess next week, we're going to put together food packages for the most impoverished families of the Kamogelo children. As mentioned in the video, the meals that some of these children receive during the school days may be the only food that these children eat all day. Imagine what would happen if those families are left with one more mouth to feed for three weeks?
• We hope to raise funds to start a few sustainable projects for some of the community members that live around Kamogleo - for example, we hope to buy chickens for some of the adult HIV patients in the area; these would provide both food and a source of income, which are both extremely difficult to come by for the very sick patients.
• We need to buy supplies for the center's volunteer nurse. She comes two or three days a week to address any health issues that the children might have, but as Kamogleo can't afford to supply her even with simple gauze, she is sometimes limited in her ability to treat the children. A recent outbreak of ringworm can attest to this.
• Other identified needs include preventive oral health education and treatment (we'd need toothbrushes, toothpaste, and single-applicator tooth varnish for 150+ children) and a women's health class for the teachers and staff of the center (judging from the many questions about everything from breast cancer to bathing that we received during our first aid talk earlier this week.)

So, where do you, our families and friends come in?

In the next few weeks, we'll be doing some fund raising via paypal. Donations can be made to holshue@nursing.upenn.edu via the paypal website; feel free to donate as little or as much as you would like. Even just a small amount will go a long, long way here.

And of course, we'll keep you updated on our progress. Thanks, everyone!

Poem 2 - "Compression, Bandaged"

"Compression, Bandaged"

his thumb:
the pulp of a blood orange
throbbing, pulsing
in her trembling hands

her calm words coming out
from some other
mind

his infected blood
spilling over her
white white
gloves
his gasps
his eyes clenched squeezing
out this sight
like two swollen fists
on his face

she wrapped
around and around
and around and around
until the red heat
was tamed
into nothing but gauze
into a secret underneath

but the scarlet splashed
dripping
across his chest
it gave her away

and she lifted his elbow
the very simplest of measures
and told him to squeeze
to make pressure

pressure pressure,
to disobey his instincts

but did he even understand her?

and then the doctor
said put him in an ambulance
but he was already gone
so she ran

out
into the parking lot
into the street
past the hoards
the throngs of people
staring
like meerkats
frozen
watching the others out of the corners of their eyes
to know what to do

she yelled
she yelled
but she did not know his name
still she yelled out for him

and then
there he was
his blue overalls
deep purple now,
these from the job
he might never do again

he'd become another one
of the jobless masses
sitting all day
underneath the trees
shooting the breeze
and starving

crushed by some machine
lost: a thumb

the thing that separates us
from all the other animals
somehow tied to wisdom

My First Post - A Poem, "A Fence for the Wild"

Glossary:
chibuku - a local alcohol, like beer
thebe- Botswana "cents"
pap- a local maize meal, like grits
Pula- the Botswana currency, money
pula- the Setswana (The local language) word for rain
Turkish Delight - A food which casts a spell on you, from C.S. Lewis' Chronicles of Narnia




"A Fence for the Wild"

my hands have broken
frozen in this heat
they have no electricity
no tools
not even rags to wash with

gray dust is turning everything to ash
the green gone in the leaves
our skin
white and black
is all the color
of under your tongue

mouthes are snapping
like venous fly traps
but empty
these flies are clinging
to our ankles, cheeks,
to inside our ears

they've licked clean the coke cans
swirling in the dirt
around our shins
rolling hills of beer cans, chibuku cartons, chips
all these non-foods
that somehow sustain them

and everywhere, like confetti
crinkling candy wrappers
from the women selling them
on the side of the road
for thebe, only thebe
for a whole day in the sun

Father comes up with that plan after
each other fails
Are they too sick to cook?
To ill to crochet?
Or too content sitting all day
watching the children run
somehow, some magical carousel
around them?
dust devils spinning, disturbing
the carefully combed yards, of dirt
they sweep each morning
backs bent
hunched over like the old women they'll never live to become
Or are they too hungry?

Botswana takes such pride
in their ARVs
and yet
Where is the water
to swallow them?
The pap, the maize
to keep them down?

this sun dries everything
except for the tears
they never arrive
they have gone to where
anywhere
they still bring relief
Here there is no Pula
no pula
and no one remembers the prayers
to call it down
they know the Our Father though
in a language they don't even speak

We hold hands
making some kind of fence
to keep out the wild
to keep in the hope
a wild animal itself
always finding holes
to sneak out from
We must cling tightly

I saw a boy today
raised by a wolf
swooning, moaning in the sun
drool and porrige covering
his chest
wracked, mucous dried black
in his nose
he cannot open his eyes
But what is there to see?

only a mother who raises glasses
more than children
whose barred teeth
look like gaping windows
shut
keeping us
and everyone else
Out.

in this village
donkeys and wheelbarrows
(usually reserved for farms
but in this dead earth
not even cacti are growing)
these wheelbarrows are Trucking
water jugs
Thank God!
and on the side someone has painted
"We are fighting the wrong war"
here
The water is work
it does not quench your thirst, only creates it

I smack my lips
stomach clenching hungry
but what fraction of hours ago
have I eaten, less than they?
i dig
for a granola bar
in the bottom of my bag
and break it into four
peices
so we can go on, together

these angels
to be paid in another lifetime
these people
who walk and pray and clean and cook and wash and cry
for the people who can not
any longer

She holds hers
minutes longer
than the rest of us
gazes at it
like it's Turkish Delight
and slowly licks her fingertips
for every last bit
of sugar