Posted by: rhoban | March 11, 2009

Day 10 – UTH, Lusaka, Zambia

To hear yesterday’s story, listen here, or here: 

Privacy??

I returned to CO3 – the obstetric emergency ward at the University Teaching Hospital for one last day, hoping to take some photos to illustrate the ward for this travelogue.

In the West, we’ve been exposed to many photos of desperate looking African people waiting for care, or food, or assistance of some sort.  But I wonder how often photographers ask permission of the people they see through the lens, and if they did, how often those people would decline being photographed.

I think part of the assumption is that these folks don’t really care as much as we do about privacy.  This is a society where entire families live in a single room – privacy’s not an issue, right?

Well… maybe it is something people desire, even when it’s not something they frequently get.

Case in point:  I wanted to take a photo of people crowding the waiting room at CO3. I wanted to show an image of how 30-40 women – minimum – cram themselves into a waiting room space that’s about 15’ x 15’. Most sit quietly for hours at a time. Some are doubled over in pain, some lie on the floor or lie with on the wooden benches with their heads in the lap of the woman next to them – frequently a stranger, but united in need.  There isn’t a lot of talking. And they can hear moans and screams from within.

To get my photo, I walked out into the room and stood there for a few moments, trying to work out the best way to frame it.  Everyone turned to stare at me.  No one smiled. I stood for a few minutes, feeling profoundly uncomfortable.

I’ve rarely felt so… foreign… in every sense of the word.

Then, the midwife stepped outside to see if I was done.

“No… I’m… I’m thinking I should ask their permission,” I said.

“Why would you want to do that?”

“I’d just feel more comfortable.  I feel …really weird about just taking the picture,” I said.

So, she translated for me.

“Hello, I’m a reporter doing some stories about health care for women in Zambia.  I’d like to take a photo of the waiting room to show how crowded it is. Would it be OK if I take the photo?  If you don’t want to be in the photo, let me know.”

No one responded, but they let me know all right.  As I stood there, many of the women peeled themselves up off the floor and the benches.  Two-thirds of the women filed past me, and away from my lens.

Needless to say, I didn’t take my photo.

Witness to suffering

If you found yesterday’s entry was disturbing, you may want to skip what comes next.

Mupeta comes to me and says there’s a 16-year-old girl who’s been brought to UTH by her mother.  She’s about nine weeks pregnant.  They came to Lusaka from a small city, traveling on a bus six hours to UTH. The daughter had gone to a traditional healer already and had spent the past few days passing blood.  Mother and daughter are asking for a legal abortion. Mupeta asks the girl and her mother and they say it’s OK for me to sit in on the procedure.

In the US, many routine medical procedures get performed using anesthesics, that can include local anesthetic, such as Novocaine (for dental procedures) or Lidocaine, which can be injected at the site of an incision. Patients in the US also routinely receive medications to reduce anxiety, such as Valium and Versed.  There are also options for opiods, such as Percocet or Vicodin.  As a matter of fact, six countries – the US, Canada, France, Germany, Britain and Australia – use 79 percent of the world’s morphine.

But many countries in Africa don’t have much access to pain medications… from  opiods to non-steroidal anti-inflammatory drugs such as diclofenac and ibuprofen. They’re often not available… or affordable.

The procedure begins . For privacy I sit on a stool behind the patient’s head, so I can only see Mupeta, but not the patient’s genitalia.  The midwife, Iness Kabamba, keeps up a steady stream of conversation with the girl, asking her questions to which she mostly gives one word replies.  They call it ‘verbal anesthesia.’

Mupeta talks to her and she nods.  From what I can see, he examines her, but without that slippery gel that makes vaginal and rectal exams a little more comfortable.  The girl whimpers a little. Kabamba talks to her.

Then Mupeta uses a speculum so he can see the cervix.  Again, no gel, but this is not terribly different than a woman’s annual pelvic exam.  The difference comes when Mupeta inserts a catheter into the girl’s uterus.  I can tell this is what’s happened because the girl arches her back and cries out in pain.

Mupeta attaches the manual vacuum aspirator, an instrument that looks like a big syringe. Although it sounds archaic, the difference between this instrument and what women in the villages have inserted into their cervixes is enormous . For one thing, the catheters used with this instrument are blunt-tipped, the MVA’s and catheters are all sterile and the MVA can evacuate the entire contents of the uterus.  That last point is important… if products of conception (that’s the medical term for the fetus, placenta, uterine wall lining, etc) remain in the uterus, it causes a life-threatening infection.  So, for women who receive unsafe abortions in the village, if the sticks placed into the cervix don’t cause massive infection, the retained products of conception will.

By now, Mupeta is extracting bloody material from the girl’s uterus.  She moans, writhes, breathes heavily and at times, howls.

Meanwhile, Kabamba chatters away, looking the girl in the eye in an attempt at distraction – ‘verbal anesthesia.’  As the procedure goes on, Kabamba asks the girl more questions that require answers… several times she calls her name to refocus her on the conversation.  Mupeta offers reassurance, sometimes in the local language, sometimes in English, “very good, very good…”

But the girl is writhes in pain.  I get up and wander into the hall… indeed, you can hear everything out in the hallway.

Finally, after 7 – 8  minutes, the girl plaintively asks Mupeta if it’s finished…  he says yes, and she sighs in relief.  She groans as she sits up on the table and starts to cry. Kabamba rubs her back and talks to her reassuringly.

Mupeta looks at me and says, “You’re uncomfortable with this…”  I nod. This has been awful to watch.

Mupeta and Kabamba seem unflappable.  I suppose they’re used to it, or use that unemotional façade that many health care workers use to keep from upsetting patients.  In the past, I had perfected that blank mask. But I’ve let it drop over the years since I’ve stopped practicing nursing.

If it were me, that façade would be protecting me from the frustrations of this situation – the unavailability of contraception, the powerlessness that many women have over their sexual and reproductive lives, the basic lack of knowledge about biology and sex, the lack of options for women who do get pregnant but might want to keep the child, the unnecessary deaths of both women and fetuses, the lack of health care resources. I wonder how health care workers keep from burning out.

Leaving Lusaka

I was pretty shell-shocked by the time I left Zambia, and was glad I’d planned for a few days’ worth of R & R in South Africa.

Now,  I’m not a wimp. Really. I worked as a trauma nurse in an inner city ER in DC when it was also the gunshot capitol of the country (‘92-‘94) and saw my share of blood.  I worked in a drug treatment program in NYC, where I witnessed how some women were willing to degrade themselves and abandon their children, to get a fix.  I later worked in a program where I saw elderly people die alone, abandoned by their families (or they outlived all of them) and listened to the stories of my Holocaust-survivor patients.  I worked in a camp for people who ran away from their homes because some other ethnic group was intent on hacking them to death with machetes.  I’m not a shrinking violet… yet I was deeply disturbed by what I saw in Lusaka.

Watching what unfolded there, I realized that women will seek out abortions –whether they believe it’s legal or not, whether it’s safe or not, whether it will cause them extreme pain… or not.

Quick update: May 27, 2010 – this story has won multiple awards, including a Gracie for the best investigative feature (American Women in Radio and Television); Best Health Feature (both North Carolina Associated Press and Radio and Television News Directors Assoc – Southeast Regional)

Comments? Send them to ncvoices@wunc.org

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