Wednesday, March 23, 2011

Two Scratches of a Pen

The crumpled piece of yellow paper at my foot caught my eye. I bent over to pick it up. Then halted.

A flimsy piece of trash. Worthless. Discarded. Smudged. Walked upon. Crumpled. With the vague ink stamp of our clinic visible in the bottom left corner.

And above the stamp...a life altering scratch of an ink pen. A plus sign. Positive.

HIV positive.

With two scratches of a pen, a life altered for its duration.

I picked up the paper, quietly folded it, and stuck it in the back pocket of my scrubs.

Of course, I know this patient. I know this paper. Discarded trash from yesterday. That was my writing. A lab order for the cachectic, febrile twenty year old girl from a tent city. I'd ordered that test. I'd passed the paper to Sister Gloria, our nurse, and requested her to run it. She returned to me thirty minutes later, and with a stoic, kind-yet-grim look in her eyes, handed me back the slip. I'd met her eyes in silent, knowing, communication.

Two scratches of a pen. A life altering diagnosis.


The twenty year old girl, skin and bones, laid curled on her side in the next room of the clinic, staring blankly at the wall. A resident of one of Haiti's semi-permanent post-Earthquake tent cities. Mother of a 6 year old child. A quick calculation revealed she therefore became pregnant at 13 years old, and gave birth at 14. She breathed rapidly. She was fragile. Like a small bird, fallen from her nest.

I walked into her room, and through a translator, revealed her test results. "Your HIV test is positive," I explained. "This means you likely have HIV, the virus that causes AIDS. We need to confirm this with another test. But I am very concerned."

She stared blankly at the wall.

"Do you have a sexual partner?" I asked.

"No," she replied. "Not since I got pregnant."

Another simple calculation. Last sexually active at age 13. Therefore, HIV positive at age 13.
Now, likely, AIDS. At 20 years old.

"Did you get tested for HIV when you were pregnant?" I asked.

"No," she replied. She got no prenatal care at that time. At 13 years old.

"Did you breastfeed your baby?" I asked.

"Yes," she replied.

Another mental calculation. Untreated HIV positive mother, never diagnosed or treated, subsequently breastfeeding her infant. Means child at risk for "vertical transmission". Transmission of HIV from mother to child, either at birth, or subsequently through breast milk exposure.

"We need to get your daughter tested for HIV, too," I said quietly. Mother stared blankly at the ceiling. The implication, and subsequent palpable self-accusation, was strong. The risk to her daughter's health. A mother's guilt. Finally, as the information was slowly absorbed, a quiet nod. Empty staring eyes.

I flashed mentally to the World Health Organization recommendations for HIV prevention. The "ABCs" of HIV prevention in sexual relationships:

A = Abstinence

B = Be Faithful to your Partner

C = Condoms

I suddenly remember the semi-angry rant of one of my Tropical Medicine professors -- an HIV and TB expert from India, who spent many years as a physician in the urban public health trenches before becoming a professor at Tulane. To paraphrase her highly-educated and evidence-based rant, in response to the ABCs:

Don't think that women of the developing world aren't aware of how they get HIV and AIDS. They know. They are not ignorant. They know about AIDS and know that it is sexually transmitted. The bigger issue is the ability of a woman to say "no". In many parts of the world, due to imbalances of power in the role of men and women, women have no power in a sexual relationship. Whether it is through physical dominance, or financial dependency. They do not have the social power to refuse sex. They do not have the social power to say no, to demand condom use, nor to demand monogomy of their husband/partner.

I look back at my patient, pregnant at 13 years old.

Infected with HIV. At 13 years old.

Was that sexual relationship an educated choice? Or any sort of choice?

At 13 years old?

In Haitian post-earthquake tent communities, where some estimate HIV rates could, in some, be as high as 15%, rape is on the rise. One recent news article reported on the experience of a middle aged woman, who came upon a teenage girl being raped by a group of young men behind a tarp dwelling. She began screaming at the men, physically trying to pull them off the girl. The men turned upon her, and gang raped her as well.

"Why did you try to help this girl?" asked the reporter. "Weren't you afraid?"

"I have a daughter her age," replied the older woman. "All I could think was, if it were my daughter, I would want someone to help her."

Emergency surgery was required to save the older woman's life...from hemorrhaging....from the injuries sustained during her gang raping. Trying to save an even more powerless woman from sexual assault.

I stared back at my patient.

Like the paper I found at my feet today...

A crumpled, discarded, treaded-upon form. A tragedy.

Haiti has the highest rate of HIV in the Western Hemisphere. 2.2 percent of the population -- more than 1 in every 50 persons -- has HIV.

How do we stop this epidemic?

Increase access to healthcare.

Reduce poverty.

Promote safer sexual practices.

Empower women, first through education. More power naturally follows.

Fund education for all.

Work to remove the social stigmas associated with the diagnosis of HIV.

Is this an impossible task? No.

Start with you.

And not just in Haiti.

Start with you. Start with your community. Your children. The young women and young men in your life. And the older women and men in your life. Teach abstinence. Teach faithfulness. Teach condom use. Teach respect. For self. And for others. Encourage the education of girls. And boys. Encourage the human rights of girls. And boys.
Get tested for HIV. Encourage others -- especially those you love -- to get tested, too.
There are 33 million people in the world with HIV today. Nearly 2.5 million more will acquire HIV this year. And an expected 2 million people will die.
Lives transformed, with two opposing scratches of a pen...

Thursday, March 10, 2011

Riding the Bus

As I sat, going on hour number eight, plastered against the Haitian stranger to my left in the very back of the bus to Santo Domingo, I was reminded of a joke I heard while living in the former Soviet Union years ago. There, too, bus rides were intimate affairs of stranger on stranger body contact, wherein the rules apparently state that the physical contact is to be tolerated, but not acknowledged with eye contact nor spoken word.

The joke was told to me by a Russian colleague, after a particularly sardinesque trolleybus journey, wherein most passengers are standing, and pressed into each other lengthwise like standing matchsticks in a can.

The story, made all the better in the low, monotonous tone of a large Russian woman's broken English accent, goes something like this:

"An 18 year old girl, riding a tightly packed city bus with her mother, decided -- as her mother could not move, and therefore could not beat her -- that this was the perfect opportunity to make a confession.

'Mama,' whispered the girl. 'I have something I must tell you.'

'Yes, darling,' her mother whispered back cautiously, alerted by the concerning tone of her daughter's voice and the shameful downward glance.

'I...I...Oh, Mama. I'm pregnant.'

'No!' whispered the older woman harshly, in a mix of growing anger and horror. 'How can this be?!'

'I'm sorry, Mama,' returned the girl. 'I'm sorry!!'

'Who is the father?!!' demanded the older woman.

'I don't know, Mama,' whispered the girl. 'I don't know."

'What?!' the angry woman whispered angrily. 'What do you mean you don't know?'

'I don't know, Mama,' she cried, 'I cannot turn around.'"

Yes. Exquisitely politically incorrect. Yet, an apparently well loved and popular Russian joke.

And, oh, so true.

You know it. The truth of the overpacked, oversold, overwhelmingly anonymously intimate third world bus experience.

If you have ever ridden a public bus in a developing country, you are smirking irreverently at the uncomfortably too-close-to-the-truthiness of this story.

I know I was grinning, as I contemplated my situation, pinned intimately against the side of my anonymous Haitian seat companion by yet another bump in the highway. I attempted to turn and make eye contact with him, thinking that perhaps an "uh, sorry" sort of look, with a small smile to lift the corners of my lips would ease the social discomfort. He refused to look my way or acknowledge me.

I suppose pretending that the other person in the human sandwich doesn't exist makes the intimacy less traumatic -- or perhaps less potential for an emotional commitment -- if one does not acknowledge the spiritual presence of the other. In the five components of the human sandwhich making up the back row of our bus, if the two window passengers were the bread, my anonymous Haitian companion was the lunch meat, I the mustard, and my American friend to my right -- the pepperjack cheese.

Pepperjack sat semi-apologetically half on and off my lap -- thankfully a petite and slim young woman. My right leg was long-since dead, having become tingly then completely numb approximately four hours prior. I imagined blood clots forming threateningly in my lower calves, as my arms compressed rigidly against my chest by my backpack into the useless appendages reminiscent of a tyrannosaurus rex.

I hope we're on the right bus, I thought briefly to myself. How can I be sure we're not going to a secret work camp, on a sugar plantation or some other site. I can't, I thought. I'm here on faith alone.

I turned to Pepperjack. "If this bus were to bring us to a slave camp," I began cautiously, "would you rather hammer rocks with a sledge hammer, or hoe fields under the blazing sun?"

She glared at me quietly for a moment with piercing blue eyes. Then declared firmly, "Hoe."

"Ok," I replied. "Then I'll hammer rocks."

I noted that there are no seatbelts on this bus, but that, of course, would be redundant and unnecessary. As passengers, we are wedged solidly together like blocks in an igloo. Together, we -- like individual cells -- form a strange, immobile, the cell wall of a strange organic creature. If this bus were to flip and roll on this dark, rural highway through western Dominican, I know for certain that not one of us would budge a millimeter. Even upside down we would hang, unscathed, as the tyrannosauri that we appear to be. Silently staring forward. Wedged. Inverted. Wondering if, upon rescue, we would finally be released and allowed to seek a place out on the roadside to empty our soon to rupture bladders.

There is a baby girl one seat up on the right held by its anxious mother. She appears to be a month or so old. We have discovered that this child does not have a passport. We know this because every ten to 30 minutes, our bus is stopped at yet another wooden roadside shack, and is boarded by a man -- sometimes in military camouflage, and sometimes in traditional Dominican dancer-bling of jeans encrusted with shiny faux diamonds and decal-emblazoned black t-shirt. Each man carries, in a show of power and intimidation, a big pistol tucked into the back of his waistband. These men -- sometimes immigration officials and, I suspect, sometimes bribe-seeking impostors as faux as the diamonds on their back pockets -- command us to hold up our passports. With intimidating glares, they slowly wander their dark eyes in inspection over the captive passengers.

By now, we have discovered that if we tuck our passports into our bras, accessible to our tyrannosaurus hands via our front collars, we are able to repeatedly comply with the gun-toters' demands with minimal effort of our largely useless upper extremities.

"Lift your passports," snarl the men as they stand in the doorway of the bus.

Everyone holds up their passport, except the small infant to our right. Of course, developmentally, she has not sufficient neurological wherewithal to find one of her own hands with another, let alone grasp and hold up her Haitian passport. Which is perhaps why she chose not carry it with her on this trip to the Dominican.

Unfortunately, her non-compliance repeatedly and predictably raised the ire of the different immigration officials/disco dancers (hard to differentiate their identity at times) who appear in the bus doorway.

Myself and my two American companions -- overtly white faces glowing palely from the back three seats of the darkened Haitian bus -- attract attention on these stops as we hold up our American passports. Repeated commentary at the door, involving pointing, chin gestures, glares, and the words "tres gringos" is not hugely comforting.

Do our white faces draw attention to the woman in front of us, then to the wiggling, passportless infant in her lap? Does the stopping of the bus, and subsequent absence of rolling/humming/rocking stimulate the infant into its unhappy wails? Or, as a predictor of the young teenage girl she is destined someday to be, is she just trying to give her mother a hard time?

"Hey, Mr. Angry Passport Checker," cries the infant in her secret language. "Look here! Look at me! I've infiltrated your country...without a passport. Nah nah..."

At the first passport check, five minutes from the Haitian/Dominican border, it was first established that the baby had no passport. The first intimidating man who boarded the bus grabbed her papers -- apparently a birth certificate and a shot record -- then berated the infant's frightened mother into tears. In Spanish, he ranted at the mother that the child's documents were not sufficient, that the baby needed a passport, that she couldn't enter the country with such worthless documentation, that she should be ashamed of boarding this bus to begin with, that he didn't care if even the president of Haiti himself had approved this paperwork; that this was the Dominican Republic, the child was Haitian, and she was entering the country in an illegal and unacceptable act. Et cetera. Et cetera. Et cetera.

Brown Haitian eyes nervously meet each others across the bus. The mother's welled with nervous tears. Mine meet those of my companions to my right.

This must be the drama that replaces the en-route movie, I imagined. Not really sure if I want to be a spectator at this event.

This bus trip is taking an infinity, I then note. I wonder if this baby was perhaps conceived and given birth to on this very bus. Is this, perhaps, why she has no passport?

Strangely, however, despite repeated immigration rants, neither mother nor child was ever actually asked to leave the bus. Were these men showing compassion to this baby's fate?



They had no problem throwing an elderly woman off the bus at one of the first rural stops due to insufficient paperwork. Her elderly eyes stared in horror at the bus's departing tail lights as she stood solo on a grassy roadside embankment. Her horrified family, inside the bus, pressed disconcerted hands against the glass from the inside. All eyes inside the bus, mine included, reflected her horror as we drove away from her bent elderly silhouette that became smaller and smaller in the distance as the bus slowly rumbled away.

Granny, it seems, was not immune to immigration's ire. So, what about baby?

Perhaps fearing a similar fate for the baby, with the setting of the sun and the arrival or rural darkness, repeated cajoling negotiations were audible from varied passengers with the arrival of the next impatient, gun-toting immigration official.

"It's nighttime," called one slightly sensual female Dominican passenger in Spanish, batting her eyelashes towards the bus door in the darkness as one of the gunmen stormed from the bus with the baby's insufficient paperwork. Immigration stop number eight, I believe. About six hours now from the border in the middle of rural farmland. Nine o'clock at night.

"Please, sir. Don't throw her off the bus. Have mercy, sir. She's poor. She has no money. No place to go. She has family in the capital city. You can't throw a newborn baby off the bus. She has nothing. She has no place to go. You don't need this burden. Please, sir."

Did the negotiation save the child the elderly woman's fate? Or was it a carefully slipped bribe? Or the very real perceived inconvenience, on the part of a rural immigration official, of the prospect of, "if I yank this Haitian child and mother off the bus, then I have to figure out what to do with them in the dark nothingness of this rural night." i.e. nocturnal bureaucratic laziness out-trumps immigration policy.

So, recurrent ranting immigration lectures about incomplete paperwork, all met with confused non-Spanish speaking tear-filled Haitian mother eyes, ultimately ended in... well, surprisingly... absolutely nothing. Except the recurrent departure of the random immigration official, the hydraulic hiss of the closing bus door, the grinding of gears, and the puzzled realization that we were once again departing with mother and baby intact and an immigration official glaring at the rear side of our departing bus.

I believe we were stopped 14 times on this nine-plus hour journey by various "immigration" officials as we made our way across the Dominican. Several times, in the pitch blackness of night, we were all commanded to "get up and disembark the bus", and stand uselessly at the side of the road for no apparent reason. After ten minutes in the roadside grass, during which apparently nothing happened, no passports checked, no bribes requested, we were told to board once again.

Some people have said that this is the nature of a Haitian bus entering the Dominican Republic. That such searches and repeated "immigration" boardings are commonplace. I don't really see the logic. As someone described it, a muscle flexing claim of Dominican authority. But, I suppose, if nothing else, it breaks up the monotony 0f a nine hour bus trip into perhaps more tolerable 30 minute segments.

By the 14th boarding by an immigration official, all passengers on the bus started to groan in impatience. Comments could be heard about "the baby girl" and repeated scathing looks from the passengers were directed to the seat in front of us. As the doors swung open to admit yet another immigration official, I glanced at my American companions.

Unable to tolerate one more rant at the mother and infant,we decided that if the baby started crying, then we would ALL start crying, as a means to distract the official from the child.

Maybe, if she holds the baby really low to the floor, we conspired, and we cry loudly enough, he might completely overlook her presence while instead glaring at the three crazy gringas.

If the immigration guy questions our sobbing, I told my companions, we'll just say, 'Hey, man, it's been a really long ride. We're tired and cranky and we just can't help it.'"

We made a few practice whimpers and cries. To my left, my anonymous Haitian companion, against whom I had been wordlessly crushed for eight hours, began to grin.

Obviously, he secretly understood English.

He finally turned and met my gaze. We exchanged a knowing glance.
"Good idea, no?" I said, nodding. "Go ahead. You can cry, too. You know you want to."

He looked away, straight ahead, not acknowledging me as he tried to suppress his smile.

The baby stayed silent. She attracted no attention. We all raised our passports in the air. Except, of course, for her...because in her rush for the bus, or perhaps because of her onboard conception and birth, she had obviously inconsiderately failed to bring hers along.

We settled back into our slots in our human matrix, suspended against each other in our giant organic cell wall. The disco/ immigration man with the bling and gun descended the bus stairs into the darkness. The door hissed shut. The lights dimmed. With my one remaining sensate leg pressed firmly against my smirking Haitian stranger, the bus gears rumbled harshly, propelling us the final leg of the journey from the Haitian frontier to the city of Santo Domingo.