Culture Change

Talking about ‘changing a culture’ is quite prevalent. Topics range from institutional culture, the effects of Hollywood, anti-vaccine movements, or even how welcoming churches are to visitors. But until recently, I’ve never really understood how difficult that can be.

 

Early in my time in SL, the massive stigmatization around HIV seemed silly to me. HIV is treatable, the drugs are free, and it’s extremely difficult to transmit just with casual acquaintances or even housemates. If you take the drugs regularly, you can live a normal life. What’s the big deal with the stigma? Why are people so afraid? But the longer I’ve been here, the more I understand.

 

I’ve heard stories of a wife finding out she is positive, then her and her children are driven away from the husband’s home. Neither her own family nor the husband’s family were willing to house or support her. People lose jobs, churches, and livelihoods. With the prevalence of the disease as high as 2%, almost everyone is acquainted with someone who’s positive. But due to the extremely high risk of ostracization if the diagnosis is public, people keep secrets and so the perceived prevalence of HIV is much lower than what is actual. Which makes it all the more stigmatizing because it seems like a rare disease.

 

With all of the social pressures, I’ve really started to behave like a Sierra Leonian. Even if the patient is unconscious and on death’s door, I never tell the family about the HIV diagnosis. I will frequently write a vague diagnosis on the death certificate if the family doesn’t know the HIV diagnosis. Those secrets are just too volatile to be rash with.  If I have a patient who tests positive, I always bring them into my office to have a one-on-one discussion. But if I suspect a language barrier, I’ll bring along a nurse to translate. And that’s exactly what I did last week. I had a patient who tested positive, spoke a tribal language, and was quite obstinate and wanted to go home. I didn’t have high hopes for the encounter because often people say “I don’t believe your tests. I don’t have it.” And then they just leave the hospital and my guess was that she would be one of those types. But then something happened that surprised me.

 

The patient and the nurse were bantering in a local tribal language, Temne. It was quite clear that what I had said wasn’t the only thing being told to the patient. But I’ve had this nurse translate many times in the past and I trust her to be faithful to the concepts of my message to the patient. After the dialogue slowed down, I turned to her and asked what she told the patient. “I told her that I have HIV and you can live a normal life if you take the medicines.”

 

I just sat there aghast. I suspect my mouth was hanging open. Previously, I had no idea this nurse was HIV positive. And not only is she positive, but she just told a complete stranger!

I stared blankly ahead as my brain tried to catch up. Why would she tell this patient her secret? This patient seemed like the type of person who will walk around and blabber mouth what she found out about the nurse.

 

Words start to form in my mouth, “I had no idea.” But thankfully, my brain edited those words before they came out. Next idea came, “You shouldn’t have told her!” but those were repressed too. Eventually, after painful seconds, I said “Ok, let’s warn her that when she starts the treatment, she’ll initially feel nauseous. But I can give some medicine to reduce the side effects.”

 

As the interview progressed, the entire demeanor changed. The patient started making eye contact. Her body language opened up. She started engaging and asking questions rather than just giving the flat denials of before. With the addition of trust, the patient seemed like a new person to me.

 

I just couldn’t get this encounter out of my head. I constantly rage against the stigmatization of HIV, but when there’s a chance to make change my gut reaction is fear for my staff whom I care about. It’s like I want things to change, but I hate to see my staff risk themselves. The hypocrisy (maybe cognitive dissonance?) of that really has been eye opening for me. It’s a beautiful reminder of what true healing looks like as well as an example of how far I need to grow still. I may have more education than some people, but that doesn’t mean that I’m qualified or capable to provide healing. The healing this patient needed was trust. Something I might not have been willing to give.

 

A positive change in the culture is impossible with an attitude of fear like I had. But I thank God that he puts his people in the right place at the right time to bring healing to His children. It was truly humbling and inspiring to see that in action through that nurse. I pray that God will send His Spirit on all of us, that we can be like that nurse and have the courage and trust to do what’s right.

 

 

Addendum:

In residency, while studying how powerful placebo medicines are, I thought it would be great to be able to just give patients placebo tabs. It’s a harmless intervention that absolutely helps. Today, I just realized somebody gave me placebo.

 

I showed my essay above to the nurse in question. I wanted to get her permission before posting something so personal. She responded, “I don’t actually have HIV. I just saw that she needed trust and confidence, so I lied and told her I did have HIV. We might have saved a life that day.”

 

What‽ I totally believed she had HIV. But just like I sometimes want to give patients sugar pills, apparently this nurse saw that this patient needed ‘sugar trust.’ It never even crossed my mind that faking vulnerability to gain trust would be so therapeutic. But wow, lying to a patient about my own condition certainly feels a lot different than prescribing sugar pills as placebo. I’ve got a lot to think about these days.

 

 

 

Openness

 Sometimes it takes people asking me questions in order for me to be able to articulate the things that I’ve learned.

Currently we have a medical student volunteer from Germany visiting the hospital. She brought along almost €300 donated to her by her family and friends to help the people of Sierra Leone. Even in just two days of working at the hospital she already can clearly see the desperate need of people. This morning she brought me the money and said “I want to give this to you so that you can help the patients who really need it.” And that prompted me to reflect on the last several months of personal growth in new ways.

I’m finding that living in Sierra Leone is challenging a lot of my cultural habits. When living in the states, I was always reticent to give to the beggars you see by the side of the road. My rationale being that I want to make sure my money goes to the people who need it most. And roadside assistance can be hit or miss with true and actual need. As I bring these habits into Africa, I find myself only wanting to help the poorest of the poor. If I think the family can scrape together enough money, call enough relatives, or sell enough of their assets, they are somehow less deserving of my help. And the more I have stopped to analyze this behavior, the more it seems like I am somehow assigning value or “worth“ to different people. This is exactly the conundrum that our volunteer came to me with this morning. She wants her money to go to where it’s “really needed.”

But today is an unusual day. A week ago we had a patient come to the hospital who couldn’t pay a single cent. He’s a 15-year-old man who for the last six months has had a massive dental abscess. The pus has drained from his face down into his neck and in multiple places he has open wounds that continually drain pus. He’s been on several courses of antibiotics and still his disfigurement remains. Our new dentist in Sierra Leone, Mel Bersaba, saw this boy and rightfully felt pity for him. So he single-handedly pulled as many strings as he could and we were able to get this man to see the top dentist and dental surgeon in the country. He got a CT scan of his face that showed the infection has been eating away at his jaw bone. The specialist recommended surgery as soon as possible. Dr. Bersaba spent hundreds of dollars to get all of this done. But today when it came time for the driver to take the patient to the hospital for a coronavirus test prior to surgery on Thursday, the patient refused to get into the car. I looked him straight in the eye and told him that if he did not have the surgery, which will cost him absolutely nothing, he would be dead in less than a year. After a long discussion I got to the root of the problem: he says both him and his mother had the same dream. During surgery at the hospital he will die.

I begged, pleaded, and explained to him why I was afraid for him. I told him that I believe these dreams are from the devil and the devil is just trying to kill him. If he does not have the surgery, he will die. I told him that I don’t fear surgery, coronavirus, or humans. But I do fear that demons are trying to harm him. I told him the only way to overcome those dark forces is with God, prayer, and courage. He declined my offer to pray for him because he’s Muslim. Just a few hours ago he left and went back to the village.

What am I to think about this? Did we spend hundreds of dollars, waste the time of top specialists in the country, and dedicate our days to a cause that wasn’t worthy? I think a year ago I would’ve thought so. This country has started to change me. If I am truly to emulate Christ, I don’t just dedicate myself to those I deem “worthy“. How often does God “waste“ his love, time, and blessings on me or other sinners like me? The idea of worth is not how Christ sees the world. And I am slowly starting to reframe my ideas around success.

I think there is value in living a life open and generous enough that some of your projects “fail“ by human standards. In the past I have been far too stingy for fear of failure. When I think about God’s continual commitment to an earth filled with failing human beings, I think that’s the kind of love I’m expected to emulate.

If an institution took this approach all the time, it would be exploited to bankruptcy. But I encouraged my volunteer to keep the money she has and continue to observe and learn for a few more days before deciding how to use it. Deciding how to use a limited amount of money is very Sierra Leonean. Do I feed the healthy children that I have, or do I spend money on the child who is sick? Feeling that tension will help her to understand the culture. But I also encouraged her to challenge the idea of that some people are more worthy than others. It’s a very American idea that I have grown up with and has only started to slowly change in the last several months. It’s hard to live an open life where your time in money ends up in “failure,” but it’s something I aspire to do. And daily I try to remind myself that the work we do might not bear fruit in this lifetime, and that’s not my problem. I’m called to live an open and generous life that runs quite counter to my American culture.

 

 

Furlough 2021

 

Wow, it’s been a long time and so much has happened in the past few months. To catch up, let’s go back to March 2021. Buckle up, this is a long one.

 

Rachel’s very pregnant and it doesn’t seem to faze her at all. She’s working full days in the hospital, cooking and cleaning like there’s been no change. A pregnant woman is always an exciting thing in Sierra Leone. Both pregnancy and infanthood are so tenuous that people tend to celebrate every little thing. There’s a nurse at the hospital who’s due date is just a month earlier than Rachel’s. They take maternity pictures together and it’s a very exciting time.

 

Rachel is scheduled to go back to the US about 5 weeks before her due date and thankfully travels without incident. The most memorable ‘amenity’ of being pregnant happens in the Lungi airport. The staff see she’s pregnant and decide that they need to help her move her carry on everywhere. So when she has to go to the bathroom, they follow her in , escort her to a stall, and get to listen to every detail. Privacy clearly means something different in Africa. Thankfully the rest of the trip is uneventful.

 

After her departure I’m left alone for about 3-4 weeks with plans to return to the US about 2 weeks before the due date. She left food for me in the freezer, a list of things to pack and do before leaving, as well as sticky notes around the house with cute little notes. Some of them seem like she can see the future. Sometimes when I’m hungry and too lazy to cook (or even reheat), I’ll just eat peanut butter off of a spoon. When I get to the peanut butter in the pantry I pick it up and there’s a note: “This had better not be your whole meal.” BUSTED in absentia!

 

Later in the week the nurse with a similar due date goes into labor. A nurse is called to perform the delivery and things don’t go well. The baby is tachypneic (breathing too fast) and hypoxic (low oxygen). They call Dr. Kabba and he arrives as quickly as possible, but not before some unnecessary procedures were done. He stabilizes the child who is then reunited with the mother. A few hours later the condition worsens again and Dr. Kabba is called to return. He works on the baby for several hours, even needing to provide positive pressure with a bag valve mask (forcing air into the lungs because the baby is too weak to breath). After several hours he calls me in for backup and we continue to work throughout the night. The condition doesn’t improve and by morning we teach the family to provide the breaths and we go home to rest for an hour or two. After a quick catnap, I return to the hospital to find the baby in worse condition and it’s time to make a difficult decision. Do we keep the baby here where we have good staff but inadequate pediatric supplies or do we send the baby to the government hospital where there are more resources but occasionally they are inadequately staffed? We decide to send the baby to the bigger hospital. At this point my apple watch tells me I’ve stood at least one minute out of every hour for the last 23 of 24 hours. I’m exhausted and the day has just begun and patients are arriving to be seen.

 

I check back throughout the day with both the mother and the baby. The baby’s condition slowly worsens and she dies within 24 hours of transfer. The tradition in Sierra Leone is that you don’t tell the mother about the baby’s death until she has ‘recovered’ from labor. So I’m forced to smile and nod when she tells me, “they tell me the baby is getting better at the other hospital.” The next night I get a call around 11pm and the mother needs help with her breast pump, as she’s excitedly pumping milk for her deceased child. I decide it’s better to not tell Rachel all the details and I give her a vague idea of what’s going on before I go to sleep.

 

At 5AM I wake up to see lots of missed calls from Rachel and the phone currently ringing. I pick up and she tells me her water has broken. It’s only been 10 days since she arrived in the US and a month before the baby is due. I’m not supposed to travel for another 2 weeks! I immediately start to work: buying plane tickets, packing to travel, preparing the house (absolutely everything needs to be put into totes), paying all the bills we owe, preparing for ways to pay our security and house keeper while we’re gone, and the most difficult – get a COVID test. At 7AM I call Emily and Peter Sheriff who know someone at the lab. They pull all the strings, pay all the ‘tips,’ I get swabbed, and after a few hours I’m sitting at the airport without a COVID result. I don’t have any money for transportation or a hotel. I’ve banked everything on this test coming through. And thankfully it does.

 

I get to check in and the agent says, “there’s something wrong with your ticket, they’re waiting for you in the office upstairs.” I go to the office and the problem is that I have two layovers in the EU. After the US banned EU citizens from entering due to COVID, similar restrictions were placed on US citizens. Individual airlines and cities negotiated exemptions, but my ticket violated that. I told the agent my story and he looked at me and said, “you’re a desperate man aren’t you?”

 

With the changes, I wasn’t able to fly directly to Bismarck without an 18 hour layover. So we orchestrated a plan where my mother would meet me in Atlanta airport and join me on a flight to Minneapolis. My long time friend, Chris Block, would drive from Bismarck and pick us up in Minneapolis. Mom would drive through the night and Chris would sleep as he had to work at 7AM the next morning. By the time I arrive in the hospital, it’s been 52 hours since Rachel called.

 

I get to the locked maternity unit and my sleep deprived brain says into the speaker, “This is the late husband of Rachel Fernando.” Only the next morning did I realize it sounded like I was dead and not just late for the birth. Rachel sleepily greets me and we had a brief conversation before heading to the Neonatal ICU.

 

Liam was born more than 24 hours prior to my arrival and was tachypneic and hypoxic, so he was admitted to the NICU. Sound familiar? It quickly dawned on me that my son had exactly the same symptoms as the baby I had just worked on for days. But Liam had the luck to be born in the US.

 

The culture shock was like nothing I had ever experienced. As I sat in the NICU, I had absolutely no concerns for Liam. He was in the best hands and improving with ‘simple’ things I was unable to provide to another new born just days earlier. The relief of arriving and the joy of a first born child mixed with the fatigue of travel and grief of losing a different baby just unlucky to be born in different circumstances. I couldn’t help but think that my son lives simply because of our wealth while our friend’s baby is born with identical symptoms and dies. The culmination of those few days left in me a strong understanding of the cruelty of this unjust world. All we truly have to cling to, regardless of our place of birth, is the hope of the second coming and resurrection. What good news it is, but how easily we forget until we are jerked to our senses.

 

Liam recovered quickly and was discharged without incident a week later. We spent some time in North Dakota with Rachel’s parents, then went to Tennessee to spend time with my family. After our arrival in TN, Rachel began to have severe abdominal pain. We did some investigations and found out her IUD had perforated her uterus and was loose in her abdomen requiring surgery. Coordinating all of the imaging and surgical preparation when your primary doctor is in ND and the patient is in TN is quite difficult. Finding someone to perform the surgery took another several days of struggle. Eventually the surgery was scheduled, but it became clear that we would have to delay our return to Sierra Leone.

 

The surgery went off without a hitch and Rachel recovered quickly. But soon another deadline approached. The day after we received Liam’s passport, we mailed our passports to the Sierra Leonian Embassy in DC for visas. Things went smoothly with the embassy but the US Postal service lost our passports in the mail. The tracking showed that they bounced between DC and North Carolina for 2.5 weeks, then went to Atlanta for a few days. We called every number we could find, but nobody could assist us. It came down to Friday when we were scheduled to fly on Monday. Should we get a mandatory travel COVID test on Friday even though we don’t have passports? The mail runs on Sabbath but not Sunday, and our flight leaves at 7AM on Monday. We decided to step out in faith. Sure enough, the passports arrived on the last possible day.

 

We arrived in Sierra Leone two days ago still shell shocked by the last few months. It’s wonderful to be back and every old challenge seems new and different now that we have Liam. COVID is still a huge challenge for Sierra Leone and the 3rd wave has been much more lethal than previous waves. Looking back, it’s easy to see God blessing through difficult circumstances and we believe he will continue those blessings now that our family is just a little bigger.

 

Thanks for reading and thanks for all your prayers and support.