Small miracle

The Western Hemisphere and most of Europe are gripped by the tragic events unfolding in Haiti. Modern media transports those of us who have televisions to the center of the misery and captures us with heartbreaking and touching stories.

I always considered myself a knowledgeable person, but it wasn’t until I joined the Foreign Service and traveled to the, shall we say, more unusual parts of the world, that I realized how little I really knew about life outside of my sphere. I understood American poverty and I understood the chasm that existed between those who have and those who don’t—in North America. After all, I grew up in south Texas and had visited our neighbors to the south many times. I thought I knew.

What I know now is that the events currently taking place in Haiti are occurring all over the world, on a smaller scale, daily. I don’t just mean earthquakes. I’m talking about desperate circumstances, poor nutrition, unsafe water, lack of shelter, and poor medical care. The World Health Organization estimates that one million African children die each year from malaria. That’s just one continent and one disease. To extrapolate is truly disturbing.

And while I now know, and have seen firsthand, some of the terrible conditions people survive, I have also seen small miracles occur, without international coverage or support, that make life better for these unfortunate people. I’ve already mentioned a few, but I want to tell you another.

When I worked in Conakry, Guinea, I was introduced to six nuns of the Missionary Sisters of Charity—the order started by Mother Teresa—who operated a clinic. I began assisting them in small ways. The clinic usually had a full load of 25 inpatients, mostly children 3 years and younger who had nutritional needs.

One day, I received a phone call asking me to come to the clinic to see a sick child but I was unprepared for what I found. A village woman had come to the clinic with a premature infant. She was the infant’s grandmother. The mother of the child needed to stay in the village with her other children. This baby weighed 1 kilogram. I had no experience with preemies and looking at this little boy was like looking at a tiny, skinny doll. I was afraid to touch him. In spite of his small size, he looked pretty good. He was alert, he was feeding well (breastfeeding mothers at the clinic were pitching in) and he had no respiratory problems. But he was only a few days old, and I couldn’t imagine he would survive. In a developed country, this child would be in the NICU for weeks with all sorts of advanced monitoring and treatments. This baby was in an open crib in a room full of sick children, with just a mosquito net between him and certain malaria. If he needed specialized care, it just wasn’t available. The clinic didn’t even have hot water.

I went to the clinic every other day and watched in amazement as this child survived, developed and eventually flourished. When he was 3 months old, he was a plump, smiling and cooing little boy, and his grandmother took him back to the village. I think of him often and wonder if his miracle continued. He would be 8 years old now. I hope he is.

For Reflections on Nursing Leadership, published by the Honor Society of Nursing, Sigma Theta Tau International.

Unpacking history

Today is moving-in day for me. I arrived in Prague in October but my HHE (household effects) were just delivered. I had a much smaller shipment that arrived from Islamabad in October, so I’ve been perfectly content living with what I have, and I have dreaded this day for several months now. I need to give you the background on the problem.

Allow me to introduce you to one of the oddities of Foreign Service life. We move—a lot! Our standard tours are one to three years, depending on the difficulty of the location. While our housing is provided, and almost always furnished, personal items, household goods, kitchenware, books, etc. move with us. Some posts are in areas where standard goods are difficult, if not downright impossible, to buy. If we are moving to one of those “hardship” posts, we are also granted a consumables allowance, which is an additional weight to use for products we will need while we are at that post and are not likely to find locally.

In 2001, I transferred to Conakry, Guinea in West Africa. Conakry is one of those “hardship” posts where a consumables allowance is essential. Guinea is a country incredibly rich in resources with a long-standing corrupt government that has kept the people in abject poverty. Fortunately, people don’t usually starve there because food grows abundantly, but the people are starved for everything else. As a result, goods and services are largely unavailable.

I was supposed to be in Conakry until 2004 and I brought with me ample goods to see me through. I’ve learned that I do quite well on local food, so most of my consumables are things such as paper products and cleaning supplies. One can really tell a lot about a person’s preferences from seeing what is chosen for consumables. Let your imagination be your guide: disposable diapers, wine and beer, ethnic foods, various canned goods, etc. For me, it is American paper products. They can’t be beat! If you have ever used non-American toilet paper, you know what I mean.

Unexpectedly, I was offered a move to Kabul, Afghanistan for the spring of 2003, more than a year before I was supposed to leave Guinea. I jumped at the opportunity and began the preparation of moving. But there was a catch. Housing in Kabul consisted of a 17-foot by 8-foot metal shipping container, and I was only allowed to ship 500 pounds of goods and bring two suitcases. So everything I had in Guinea that was non-perishable was put into storage for me by the Department of State.

My plan was to do the one-year tour in Kabul and then go to another regular post, but again I was offered my dream job—worldwide rover. My things stayed in storage for the second and third year while I worked temporarily in nine different locations, filling in staffing gaps. In fact, the things I had shipped to Kabul were now in storage, too, as I was down to two suitcases—period!

As providence would have it, for my next posting I chose Islamabad, again one of those limited-household-effects posts, and all I was able to move was the stored goods from Kabul. I stayed in that one-year post for three years! This brings me to today. This morning the belongings that have been stored since 2003 were delivered to my apartment.

I have been opening boxes all day, discarding things I wondered why I packed at all, trying to find a place in my limited storage space for other things I know I don’t need. I’m even getting nostalgic over a few items. When I opened a box filled with dinnerware my son gave me years ago, I choked up. And when I came across a couple of items that had belonged to my daughter, I sat down for a good cry. Perhaps nearly seven years of not having my real life with me was too long. I need reminders of my history to reassure me and help me remember who I really am and where I came from, not just things that chronicle where I’ve been.

Some of the boxes have been real surprises with contents I actually don’t remember at all. Several times today I have said, to no one present, “Where did this come from?” Fortunately, I like most of what I’ve found.

And then I came upon the consumables. I won’t bore you with the details, but I will tell you this. For the rest of my life, I will never again have to buy paper towels.

For Reflections on Nursing Leadership, published by the Honor Society of Nursing, Sigma Theta Tau International.

Culture shock

Culture shock is a well-known, expected phenomenon in the Foreign Service community. It doesn’t happen to every person with every transfer, and there are degrees of effect, but it is something we warn our patients about whenever they relocate. I am in culture shock.

There are phases to culture shock. The first is the honeymoon, where the new location is pleasing and exciting. Prague is certainly beautiful—amazingly beautiful—but the aspect of Prague that impressed me most in the weeks after I arrived was my ability to walk through the city and have no one pay attention to me. My last three years were in Islamabad, Pakistan. It was too dangerous to freely walk around the city and, in those few places we were allowed to go, a tall, gray-haired (head uncovered), fair-skinned woman walking about was always met with curiosity. Everyone stared! So, for the first six weeks in Prague, I walked for a couple of hours after work—more on the weekends—just because I could and no one would care. It was absolutely liberating.

The second phase of culture shock is negotiation. That's where I am. In this phase, the new living circumstances may cause frustration, anxiety and even anger over differences in language, cultural ethics and available food choices. This is a time of comparison between what was one’s life in contrast to what is one’s life and may lead to mood disturbance or even depression, in extreme cases.

Life in Pakistan was life on the edge, especially the last two years. Somehow, being in the middle of it conferred a sense of control. Now that I have moved on, I am beset by concern for those I left behind, especially my Pakistani friends who are less protected than the diplomatic residents. I feel helpless to do anything but worry, so I worry. I watch the news. I fret when a new incident happens. Recently, the Navy Yard gate in Islamabad was attacked and people were killed. The Navy Yard was one of my favorite places to shop and I felt safe there. In Prague, I feel safe everywhere. That is a very good thing, but now I also feel guilty for enjoying this safety and freedom in Prague when my former colleagues don’t share it.

The final phase is adjustment. When I get to that phase, life in Prague will feel normal to me and Pakistan will be a memory. It isn’t that I will lose my concern for my colleagues who remain in Islamabad, but I will accept that my focus is my life and work in the Czech Republic.

Foreign Service employees may also suffer reverse culture shock when they reenter the United States for a long visit or for a work tour. Returning to the U.S., especially from a country that is very different, can be mind-boggling.

Many years ago, I came home for the birth of my first grandson. I was living in Ghana at the time and, while it is a pleasant country and I enjoyed living there, food choices were quite limited. On my first day back in Mississippi, my daughter sent me to the grocery store with a list that included corn flakes. I stood in the aisle at Kroger looking at what seemed to be dozens of choices of corn flakes—different brands additives and sizes. I simply could not choose because I had grown accustomed to buying the one option available to me, if there was any available at all. Having so many choices was overwhelming! I was forced to call my daughter and request that she name a particular corn flakes item so I could continue shopping. And, yes, she thought I was completely wacky!


For Reflections on Nursing Leadership, published by the Honor Society of Nursing, Sigma Theta Tau International.

Win-win

It has been the holiday season in Prague and, as in most northern European cities, numerous small log-cabin-type buildings have been erected at most major plazas, and merchants have been selling crafts and Christmas goods. Originally, I thought this was the purpose of the markets, but I now know better. The real reason for the markets is to drink beer, grog and mulled wine and to eat pastries and sausage. The shopping is just for entertainment during eating and drinking rest breaks.

Recently, I visited an interesting specialty hospital in Prague. This hospital specializes in adult cardiac, neurosurgical and planned abdominal, vascular, orthopedic and GYN surgery. They have no conventional emergency department and they don’t accept trauma cases. The hospital is also heavily involved in surgical research.

My intent was to quickly view the outpatient diagnostic departments and perhaps see a med/surg floor, but the executive office, which had advance notice of my visit, arranged a presentation in the cardiac catheterization lab. Specifically, I was ushered into the electrophysiology lab, where a patient was undergoing right-atrial mapping for prospective ablation therapy.

I had atrial ablation in 2005, so I was interested in comparing the facility in Prague with the U.S. facility that treated me. The Prague lab is super high-tech with robotics and a magnetic catheter-guidance system that has just become available in the United States. I do believe my electrophysiologist in Memphis would be drooling over this lab set up.

The opposite end of this scale would be the National Cardiothoracic Centre in Accra, Ghana. It was my privilege to meet the founder of this, the first cardiac surgery program in all of West Africa, while I was posted to Ghana. Frimpong Boateng, MD, left his native Ghana in the 1970s to study surgery in Germany. After 10 years abroad, he returned to his home country to offer life-saving cardiac surgery where there had been none and, in 1989, with considerable support from members of the German medical establishment, opened the National Cardiothoracic Centre in Accra. For 20 years, he has struggled to keep his life’s work moving forward and has survived insufficient facilities, a dearth of funding and even occasional loss of electrical backup during surgery. The center regularly accepts patients from neighboring countries and primarily repairs valvular and congenital heart disorders for persons who would have no options if the center didn’t exist.

I have not been to this hospital in many years but I am confident that Boateng and his group of dedicated colleagues continue to provide valuable health care under the most difficult of circumstances and without all the fancy bells and whistles I saw this week. Don’t misunderstand. I am as impressed by the potential of the high-tech interventions and the practitioners who advance our knowledge through research as I am by the surgeon who is saving lives under stringent circumstances. Ultimately, in both cases, the practice of medicine benefits and lives are bettered. I think we call this win-win.


For Reflections on Nursing Leadership, published by the Honor Society of Nursing, Sigma Theta Tau International.

H1N1

H1N1 has arrived in the Czech Republic. This is a bit more complicated for my clinic than for a clinic in the United States. For one thing, I don’t have H1N1 vaccines. They were ordered months ago for the Foreign Service, but only a tiny fraction has actually been delivered to the Department of State for its overseas staff. I have 20 people who fall into the CDC’s high-risk group and should be vaccinated; some of them are anxious because the vaccine is not available.

The Czech Republic has vaccine only for a limited number of their residents, and they have purchased Pandemrix, which is not FDA approved, so I wouldn’t be able to use it anyway. I do have Tamiflu and Relenza and use them when appropriate. Although we have had employees diagnosed with H1N1, so far, none have been serious, and we are doing our best to keep it that way.

We’ve been busy educating all staff members at the embassy, including local employees who fall under the Czech health system. I’ve tried to impress on everyone that this is a public health issue and not just a private health concern. I’ve delivered information in e-mails, handouts and personal group sessions with the different offices, but the most successful campaign has been the use of a video prepared by the Virginia Department of Health. Whoever thought this up is a genius!

In 2007, when “bird flu” was all the rage, the U.S. Embassy in Islamabad, Pakistan was seeing a large bird die-off on the embassy compound. My clinic arranged for some of these birds—all crows—to be evaluated at a poultry lab and, sure enough, they died of H5N1. At that time, there had been no animal-to-person transmission of avian influenza in Pakistan, but having these multitudes of bird carcasses around the compound was unsettling to people, and a minor crisis was evolving.

Our facilities manager called me one afternoon to announce that a sick hawk was on the compound and asked me what to do. “Leave it alone,” was my sage advice. For the next three hours, I received update calls as this poor bird experienced his death throes! When he finally did expire, he was refrigerated and sent to the poultry lab for diagnosis. He tested negative for H5N1, so they performed an autopsy! Cause of death: pathogenic E-coli. If Mr. Hawk had come to the health unit for his check-in orientation, he would have known to boil it, cook it, peel it or leave it, essential food sanitation advice in Pakistan, and he might still be soaring in the skies!

For Reflections on Nursing Leadership, published by the Honor Society of Nursing, Sigma Theta Tau International.

We got something right!

One of my responsibilities, when moving to a new post, is to assess local medical resources. Most cultures are more formal than the American culture, so there are official introductions, sometimes the exchange of small gifts, often tea or coffee, and polite chatting before we get down to the business of me asking, “What can you do for the official Americans in your country?” Not in those words, of course, but that is the real purpose. I will visit the hospital or clinic and ask nosey questions to determine if the facility is acceptable to me, and those I serve.

I continue to be surprised by the hidden jewels I find in the most unexpected of places around the world. I remember the husband-wife MD team—Harvard residencies—working in a truly backwater clinic in Rwanda and, in Guinea, the tropical disease expert from Germany. I have never served anywhere that I couldn’t find at least a few excellent physicians.

Nursing is another matter. Frankly, most of the countries in which I have worked undervalue the nursing discipline, and a few—Guinea and Afghanistan come to mind—don’t recognize the discipline at all. Nursing in these places is an OJT technician job with little formal training and no respect. In more modern countries, nursing usually requires formal education but falls short of the critical thinking required in countries with the highest standards of nursing care.

I recently had dinner with a German nurse who was lamenting that nurses in her country, while highly educated, were underutilized as integral members of the health care team. She was intrigued by advanced practice nursing and commented on the ways in which the German system could benefit from such a program. Finally, she said, “You Americans have really got it right!” Now, there’s a comment I never hear. I usually have to listen to all the things we Americans have wrong.

For Reflections on Nursing Leadership, published by the Honor Society of Nursing, Sigma Theta Tau International.

Assimilation in progress!

Encountering a different culture as a tourist doesn’t require true commitment to adaptation. A person on vacation eats in foreigner-friendly places, shops for souvenirs in stores where staff do not view the customer as a “bother,” and learns polite words (please, thank you, etc.) in the language of the country visited, but little else.

Not so for the expatriate who has come to a foreign country to live and work. We are more than guests of our new home country and are expected to assimilate as much as possible. In some countries, going to the grocery store is often more of a nightmare than an adventure. When I was in Russia, where I had no prior language training, I would only purchase things that were visible in the package or that had a picture I recognized. The writing was not only Russian, but in the Cyrillic alphabet, and completely unintelligible to me.

Once, an American co-worker, also a non-Russian speaker, and I decided to lunch in a particular restaurant because they had an English menu. Most restaurants will have a line item in the local language followed by a translation immediately below it in other languages. This establishment, however, had two separate menus, one in Russian and one in English. Our server spoke no English, so my friend and I found what we wanted on the English menu and then located items in the same positions on the Russian menu and pointed out our choices. Ah, you see what’s coming, don’t you? It’s true; the meals we ordered were not at all what we were served. It never occurred to us that the two menus, other than being in different languages, would not be exact duplicates of each other.

I’ve been in the Czech Republic for five weeks now and I’m learning to assimilate. At least the Czech language uses the Roman alphabet and I had seven weeks of language training to give me the bare necessities of communication.

I was in the butcher shop a few days ago and asked, in Czech, for the items I wanted. The lady behind the counter understood me and began preparing my order. I burst with pride when the woman standing next to me turned and said something in a long Czech sentence that I did not understand, but I knew she spoke to me because she thought I could understand. I smiled and nodded, to what I do not know, and she was satisfied.

For Reflections on Nursing Leadership, published by the Honor Society of Nursing, Sigma Theta Tau International.