Saturday, February 18, 2012

A Unique Approach: Addressing Sexually Transmitted Disease at HAS

One of many STD awareness posters around HAS. These campaign posters are otten entertaining but have a serious message for patients visiting the hospital.
      “You need to have a frank conversation with your boyfriend.  He and his other girlfriend need to take the medication too, otherwise the cycle never ends.”
    The young girl hung her head, with a look of such despair and shame, I felt for her. She was only 21, a few years younger than me.
Dr. Carmen spoke again.
   “There is no need to be ashamed. It hurts the heart but look at the white hairs on my head,” She said. “I know about men and their dalliances, as does your mother.”
   The young girl looked up, quietly reappraising the frank speaking doctor. Her mother regarded the foreign doctor with newfound respect.
    She continued, “You have to protect yourself and speak frankly with him.”
   Several moments later, mother and daughter were headed out of the examining room, prescriptions in hand, with undoubtedly much to discuss.
   Dr. Carmen absently dismissed them with her customary goodbye.
Que Dieu vou benisse and Bonne Guerrisson! May God Bless You and Good Healing! ”
          I was assigned to work with Dr. Carmen in the afternoons on my two very first days in the hospital. She sees patients in the outpatient Polyclinic in each afternoon, addressing everything from tuberculosis to managing hypertension.
      Dr. Carmen is a Colombian born-doctor who came to Gabon over seven years ago. She received her medical training in Colombia and Spain.  Dr. Carmen lost her mother soon after completing her studies and overcome with grief, decided she needed a change of pace. She had always dreamed of visiting Africa,and after contacting several organizations she came across another doctor who was coming to Gabon. She leapt at the opportunity and, in less than one month, she was working in the Hospital Albert Schweitzer. Like so many foreigners who work here, she fell in love with the hospital and its patients. The patients fell in love with her as well and she was asked to stay.

     It is easy to see why she is beloved by her patients. HAS patients are accustomed to foreign doctors but there is a special familiarity and intimacy in the way that they interact with Dr. Carmen.
     On our second day in clinic, a young man came with his older sister because he had been coughing for many months. Like any teenager worth his salt, he slouched in his chair, with a sulky look on his face. As his sister painted a picture of a very ill young man, who had lost weight and had coughed for more than six months, he downplayed his symptoms: He insisted that he hadn’t been coughing for that long.  Then came the inevitable questions about sexual history:

     “ Vous avez une petit amis? Est-ce que vous vous protégé? Do you have a girlfriend? Do you   
       protect  yourself?”

     The young man squirmed, his “too cool for school” demeanor forgotten.“Oui,Yes.” He mumbled, casting a quick eye in his older sister’s direction.
When his sister made a face and looked surprised, Dr Carmen chimed in.
Men, on est sur la planet terre! Ca arrive comme ca avec les filles et garcons. On se voit et le coeur se mettre a battre,” But, we are on planet Earth! It happens that way with girls and guys. We see each other and the heart begins to pound” she said vigorously tapping her chest to demonstrate.
The young man’s older sister laughed at this unexpected dramatization by the doctor and all of the awkwardness was forgotten.
     Perhaps it is because of her accent, with its endearing latin undertones, or her very easy smile, but Dr. Carmen is able to put her patients at ease and discuss the most delicate topics as if she were discussing the weather.
     I came here to learn how to be good doctor outside of the United States. There is a unique skill set for each setting and the setting of a rural hospital in a developing nation requires a unique set of skills, both clinical and personal.
     The most important thing I have learned from Dr. Carmen is to be frank and open with my patients. I’ve learned that to be so blunt, you need a sense of humor and, at times, a few personal anecdotes. It is an art. In the US, it is usually possible to develop a relationship over several visits and address delicate topics once you have established a rapport. But here, where patients come from many kilometers away and may only come once, you have to address the delicate things immediately.
    Approximately 6-8% of the population in Gabon is HIV seropositive, giving the country the highest prevalence in Central Africa and the 13 highest in the world.
      In Gabon, the forms for HIV explicitly classify interpersonal relationships: There is box for married, celibate, widowed and divorced. And also a box for “Concubin” referring to a couple who lives together but is not married. In contrast, positive HIV results are never listed as positive, only subtle markings (such as line under the title of laboratory)or a tiny scribbled CD4 count let you know that your patient is HIV positive. And there are many charts with such notations. 
 One seropositive patient's chart. The circle around the word "Labo" signifies their positivity. It is rare to see "HIV positive" written anywhere on a chart.

     While medical records might be discreet, a doctor in this setting cannot be shy. Rather, they must address the issues surrounding sexual health head on and unblinkingly, because it is a major determinant of health in this population.
On Friday, we returned to the clinic in the afternoon to see our last patient of the day. In fact he was Dr. Carmen’s very last patient in Gabon before she leaves for Germany. 
     The patient was a very nervous gentleman who needed to get the results of his STD panel. We had seen him earlier in the week and finally his lab results had arrived. He sat in the chair with his hands clasped tightly together, almost afraid to move as we opened the envelopes. When we gave him his results: all negative; he jumped up from his chair, both hands in the air.
     “Oh, Merci Dieu!”  he exclaimed and hugged Dr  Carmen and then me.
     Almost as soon as he finished with his hugging and celebration,  she leaned across the table and fixed him with her intense gaze:
 “Men la prochaine fois, mettez vos capotte! But the next time, wear your condom!”

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