Er, Doctor, would you wash your hands, please?

Global Handwashing Day was October 15, so, in keeping with the Southeast Asian time scheme, we celebrated it on October 21. Things are always a bit slower in this part of the world. Anyway, my health unit was asked to “participate” in a program sponsored by the consulate and our public affairs office. We were told there would be presentations to an audience of nursing students selected from various hospitals around the city.

The time was set for Friday morning and, since that is the time I routinely supervise vegetable sanitizing—not to mention that I don’t speak the local language—Mehroon, my Urdu-speaking colleague, volunteered to represent our office. We only heard about this event a week before it was scheduled and, three days before it was to happen, we were told the presentation—now singular—was us!

Mehroon and our computer-whiz administrative assistant put together an amazing PowerPoint presentation, complete with videos from Centers for Disease Control, to drive home the point that hands spread germs and germs make people ill. The presentation especially focused on hand washing prior to touching patients in the hospital and how microbes can be spread from one patient to the next by staff members who are not particular about hygiene.

Mehroon teaches proper handwashing technique.

Mehroon strongly encouraged the nursing students to remind family members, hospital staff and—gasp!— physicians to remember to wash hands or use hand sanitizer between patients. Evidently, there was a bit of worried discussion about the latter suggestion. Sure, it is reasonable to instruct families and other staff members might be amenable, but the physician? The students were absolutely sure that offering this suggestion to the physician would not be tolerated.

I’ve been in medicine for a long time, and I remember those days—not that they are completely gone—when physicians were at the top of the heap, and no one dared to suggest or question. Most of the docs I know now think that type of isolated existence is lonely and not very safe, and they welcome rapport with the health care team. It is a worthy concept, and I hope some of these nursing students take the dare and mention what they learned for Global Handwashing Day, maybe even to a physician.

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

Go fly, kite!

I grew up amongst seagulls; a noisy, messy bunch, but not at all threatening, even when they came in large groups searching for treats. Once I left Texas, I was largely removed from groups of flying critters, except for occasional swooping pigeons, but living overseas has changed all that.

In Africa, swarms of fruit bats filled the sky at dusk, darting in and out of the trees and, sometimes, flying so close to me as I walked I could hear the “swoosh” of their giant wings.

In Islamabad, we had crows. To discourage them from roosting, we hung fake owls in the trees—owls are evidently a natural enemy of crows—along with shiny strips of twirling metal. It didn’t work. The crows would foul the ground below the trees and make a terrible racket at both dawn and dusk. The worst was when they became infected with H1N5 (avian influenza). Dead birds, scattered by the dozens around the grounds of the embassy, caused a minor panic.

Karachi has kites, black kites to be exact. These large, rather intimidating birds soar and swoop in groups all day long, not unlike vultures waiting for carrion to appear.

Black kite

My apartment has a very nice balcony with some lovely teak furniture. It might be a nice place to sit and read a book. I say might because I will never know. The kites like to land on the balcony rail and sit on the arm of the teak chair, and they are aggressive. I got a good look at a kite perched outside my window, and that thick, curved beak and the menacing talons were enough for me. My balcony belongs to the kites. I will never venture there.

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

It's just my southern hospitality!

If you have had even a passing interest in world news, you know that the United States and Pakistan are in an ongoing spat, and a number of issues this past year have caused dissatisfaction on both sides. This past week, the most recent political upheaval inspired a peaceful protest march to the U.S. consulate in Karachi. The consulate was informed there would be a protest of possibly a few hundred people, but that the protesters would not be allowed to actually reach the compound.

I should explain that the consulate in Karachi is in a self-contained compound surrounded by a high wall and is under tight security. Our office building, where all the work takes place, is about 150 yards from the residential building, where we all live. Between the two is a totally open area of sidewalks and palm trees but, since the wall is so high, it is impossible to look into the compound from the street. Or so I thought.

As I was leaving the consulate, one of the security officers cautioned me to go straight to the residence as the protesters had been allowed, in spite of what we had been told, to move up the street outside the compound and they were gathering right then. I moved on through the entrance and began my walk to the residence. I was about a third of the way when I heard the music and shouting. It wasn’t threatening shouting, and it wasn’t cheering. It was just lots of noise coming from the area outside the wall and, when I looked in that direction, I was absolutely shocked to see people—lots and lots of people—standing above the level of the wall.

So there I am in the middle of the otherwise deserted area between the two buildings, looking at these folks who are looking right back at me. Many of them were waving their arms, and it seemed to me they were waving at me. I didn’t feel threatened at all, but it certainly ran through my mind that this was a situation I had not anticipated and with which I was not completely comfortable. While I saw no indication of hostility, I also know it only takes one person with ill intent to turn a situation violent.

I quickly considered my options. I didn’t want to turn around, as that would put my back to the crowd. Instead, I did what every good southern woman from the United States would do in that situation. I smiled my biggest smile, waved at the crowd and kept moving forward to the residence, reaching it without incident.

Later, I learned that the crowd came with buses and people had climbed on top of the buses to see into the compound, thus giving me the impression they were standing above the wall. And the initial estimate of several hundred turned out to be several thousand, though that was not obvious from the numbers I saw levitating above the wall.

I have caught a lot of ribbing from my colleagues for waving at the protesters, and more than a few have suggested that the “waving” I perceived was, perhaps, less than friendly. I choose to remember my version of the event. It is the southern way.

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

Food for thought

One of the things I love most about working in the U.S. Foreign Service is the variety of health issues I have to deal with. Each new post brings a fresh challenge, a new opportunity to learn and, frankly, a different way to make changes that have a lasting influence. Most of us choose a nursing career to have a positive impact on the lives of others, and my job offers very creative ways to fill that need.

I am the first Foreign Service medical officer to be assigned to Karachi. There is a wonderful RN who has been here for years and has done an amazing job of getting the needed accomplished but, as a sole practitioner, she was limited in the projects she could attack. I am now in the office, as well as an administrative assistant, and we are on the prowl to stamp out common health problems.

One of the major issues at this post has been food-borne illness. Kitchen checks and food-handler classes failed to make a significant dent in the number of people with GI complaints. For the past six weeks, a small part of my day—each day—is looking at food safety issues. This is not new. Almost every Foreign Service medical officer has responsibility for food safety at his or her post, but the depth of responsibility differs vastly, depending on the post’s location and size.

I have five commercial-style kitchens to evaluate and approximately 30 food workers spread among them. Despite my previous experience, which I considered advanced, I’ve turned over a whole new leaf in food safety, pun intended! There is a mantra that Foreign Service people recite: Wash it, peel it, cook it or don’t eat it. And that is good advice, but not the whole picture. I bet most people have never thought of the many opportunities food has to make a person ill.

I have to consider where the food comes from and how it has been handled prior to purchase. If the meat is fresh, there is possible contamination, such as salmonella for chicken and eggs, E. coli for beef and vegetables or, more commonly, vegetables contaminated with the protozoa Giardia.

Once the food is purchased, our kitchens are expected to clean it with the intent to rid the food of harmful organisms. In this part of the world, this is usually done with salted water, but our standards do not accept that as sufficient, so cultural sensitivity is required when asking our cooks to do something different than they do in their own homes.

The food is now properly cleaned. Are we done? Not on your life, pun intended. Now it has to be stored at the proper temperature. That means assuring freezers register no more than 4 degrees Fahrenheit and refrigerators no more than 38 F. But what about a place where the electricity is unstable and power fluctuates between the grid and a generator, sometimes multiple times a day. This is murder to a motor and the fridge that was functioning properly yesterday may be at 60 degrees today. We require cooks to record the temperature of these units daily, but think of how difficult it is to understand the concept of proper cold storage when you don’t have cold storage in your home? I recently found a freezer where the worker had dutifully recorded the temperature of 27 degrees for three days running but didn’t understand the significance of this “danger zone” temperature and hadn’t notified Maintenance of the problem.

OK, so we have properly functioning storage and now the food is prepared into meals. Am I twiddling my thumbs at this point? No, I’m out there with my handy-dandy, infrared thermometer, truly one of the coolest inventions on earth, checking to be sure the salads are being served cold and the hot foods are hot. So now, sigh, my job is finally done!

Hmm, what about the flies? What about the hygiene of the dinnerware, glassware, tableware? What about the hands of the servers? Are any of the staff workers ill with a communicable disease? Is the lassi (a lovely local drink) really made with pasteurized yogurt, or did some raw tuberculosis-tainted yogurt sneak in?

I’m sure I have colleagues who would say they did not go into medicine to focus on food safety issues, and I never imagined this as part of my forte, either. We really take this for granted in the Western world. But I don’t live and work in the Western world, and I have to tell you, I am struttin’ my stuff right now. I haven’t had a bad belly come through my health unit door in about 10 days, and my staff and I are kings of the consulate! No pun intended!

But, dengue fever is on the rise, up 15 percent over last week in the city. That will be another story.

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

Almost like coming home

I’m here—back in Pakistan—and it is almost as if I never left. There is so much that is familiar about Karachi: food, crowded streets, tuk-tuks, sounds and smells. The past two years in Prague have started fading away, which is sort of sad, as I enjoyed them so much. But I find I am glad to be back; almost like coming home.

I joined the U.S. Foreign Service with the intent to live and work in places I would never visit as a tourist. My goal was to really get to know people and cultures that were different from the life I had always known, and I have been true to that goal. Even living in Prague, in the Czech Republic, which is in many ways similar to the United States, was very different from my pre-Foreign Service life in the American South. Americans and Europeans are pretty savvy about health and wellness issues. At least, they know a good deal about it, even if they don’t follow good health practices. But Southeast Asians are often not well educated about safety and health issues. Many of the home remedies and first aid applied in this region are traditions passed down from one generation to another, and they are not always effective traditions.

For instance, during my previous tour in Pakistan, one of our gardeners sustained a deep gash on his lower leg from a chainsaw accident. In an effort to stop the bleeding, his co-worker doused him with the gasoline mixed with oil that was used to power the chainsaw. We rushed him to the hospital for definitive care and, after the surgery, the surgeon called me to ask what that oily substance was in the wound that required such pains to debride?

As a result of that incident, a program was created to train some of the local employees to teach all of the other local employees, in their language and on a regular basis, about basic first aid. I’m pleased to say that the program is still ongoing in Karachi and is taken quite seriously by the workers. I am hearing stories of how family members and neighbors have been helped through the program.

Sharing information about health and safety practices to poorly served populations around the world is one of the most important things we can do. It follows the “teach a man to fish” philosophy, and small successes are really great triumphs.

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

I’m ba-a-ck ... I think

I hurt all over! No, it isn’t flu, it is “crash and bang!” There are several postings around the world where U.S. Foreign Service personnel are at an increased risk for things, such as mob mentality, kidnapping or targeted terrorism. If we are assigned to such a post, we are tasked to complete a defensive driving course, the idea being that we out-drive the threat and get to safety. My Pakistan assignment requires me to take this course.

We are taken to a racetrack in the boonies to drive worn-out police cars way too fast. I probably wouldn’t complain if it was just speeding, though I am truly a granny driver. No, we have to drive through water so we can skid and try to stop the inevitable donut-spin that comes if you don’t brake absolutely correctly! We must ram an almost done-for vehicle into the front, then the back, of a totally done-for vehicle, to move the thing out of our path.

Then there is the exercise of driving forward at about 40 mph, stopping as quickly as possible, backing up using mirrors and doing a rapid Y-turn so you are going back the way you came. I don’t get motion sickness easily, and I’m not a whiney person, but I am sure whining over this experience.

The requirement is 100 percent participation, so when I place my hand over my stomach and turn my green face toward the instructor, he simply asks, “Do you need to hurl before we continue?” Considering that my abdominal contents are unsure which way to face forward and that’s it’s 100 degrees,, yes, that is exactly what I must do.

My three days of vehicular terror are over. I had such a nice weekend planned, but now it consists of moving from the tub of hot water, where my very sore muscles are trying to un-spasm, to the couch, where I lay quietly, trying to convince my stomach that life is back to normal. Before this experience, people would tell me “crash and bang” was great fun. Just goes to prove, once again, one size does not fit all!

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

Karachi, here I come

Four young, beefy guys just left my apartment and, while I know this must sound intriguing, there is a simple explanation: They are movers. Once again, it is time to pull up stakes and move somewhere else in the world. For my next adventure, I’m going to Karachi, the largest city in Pakistan and the main seaport on the Arabian Sea.

If you have followed this blog, you know I previously spent three years in Islamabad, the capital of Pakistan, located 710 miles north of Karachi. There is a complex reason why I chose Karachi as my final post, but one important element is that I honestly like the people.

This usually comes as a shock to people who have never been there, especially Americans who interpret the troubled relationship between the United States and Pakistan as anti-Americanism of the Pakistani populace. I’m not a political person, despite the fact I am employed as a diplomat, but I can say with certainty that the problem between the average American and the average Pakistani is that they each know the same thing about the other, which is to say almost nothing. Both groups have formed opinions based on rumors and sensationalized news stories, and the reality is far different from the perception.

Please note I did say average Pakistani, because there is no denying there are radical factions at work in Pakistan, as in many countries. Fortunately, I need only interact with people who are just trying to get through another day, as am I, with no ill will toward anyone else. I can honestly say that, in my previous three years in Pakistan, I never met a single person who was anything less than welcoming and friendly to me. I hope I never do.

This moving ritual that we Foreign Service employees participate in always brings up the question of “Which post did you like best?” I can never really answer that question, because I’ve found something to like about all of them and comparison between embassies is very much an apples-and-oranges dilemma. But I can say what I liked best about each post:

Accra, Ghana was my first taste of Africa, as well as my introduction to Foreign Service life. It was an excellent beginning, as Accra has a vibrant culture, the provincial travel possibilities were marvelous and I developed friendships that are still important to me.

Conakry, Guinea is the place people mean when they say “the end of the earth!” In spite of the poverty and lack of opportunity for the citizens, I met some of the kindest people I have ever known in Conakry.

Kabul, Afghanistan is the zenith of my Foreign Service experiences. I’ve explained why in previous blogs. To summarize, it is where I experienced great professional purpose and enormous pride in American assistance to others in need.

A two-year “roving” tour that took me to nine different countries over four continents during which I learned a person can live for an extended period of time with only two suitcases of material goods. I also had one of the most amazing experiences of my life in Rwanda, as I climbed through a bamboo forest to watch mountain gorillas in their habitat.

I appreciate Islamabad, Pakistan for the art, food and generous hospitality of the people. I also have to say the work-team environment was as close to perfect as I will ever have.

Prague, Czech Republic is a gift of beauty at the foot of Cinderella’s castle. It is almost a fantasy to walk down these cobblestone streets and enjoy the spectacular architecture. I’ve been on a two-year vacation, but shhhh, don’t tell my bosses, okay?

I will depart Prague this week, and I have several weeks of vacation and a couple of weeks of training before I report to Karachi. Please be patient while I take a break. I will be back.

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