For tincture of time, there's no copay.

If you follow this blog, you know I’ve been missing for a bit. I am thankful to my buddy, Betty Ulrich, who penned the last entry, and I couldn’t agree more with her description of medical facilities we see in various parts of the world and how fortunate we are to have U.S. medical care.

So where have I been? Well, I went home for a few weeks to see my family, and then I attended a medical conference before returning to Karachi. Since then, I’ve been in somewhat of a funk! Is that word still used, or am I dating myself?

This is a very common problem in the Foreign Service (FS). We call it “culture shock,” but I think the name is a bit misleading. There is a period of time, usually three to six months after transfer to a new post, when an individual feels somewhat disconnected to the new environment, perhaps longs for the city and friends he or she has left behind and experiences anxiety or doldrums. Clinically, people show up on my doorstep complaining of insomnia, gastric disturbances, lethargy or nervousness. Symptoms are nearly always nonspecific, and a treatment of benign neglect is all that is warranted. I advise a person to eat well, exercise, get a good night’s sleep, do something that interests them in off hours and, usually, that is all it takes. “Tincture of time,” we call it.

No one is immune, no matter how many times the moving process is experienced. Early in my FS career, I was sure I would reach a point when culture shock didn’t occur. I was wrong. It has manifested itself in very different ways, depending on the circumstances, but it has always happened.

When I left Ghana, I really missed the friendships I had created and the many local people I had grown to love. When I left Guinea, I pined for the islands offshore that were such a wonderful place of respite. When I left Afghanistan, I had a haunting feeling of things left undone. When I left Pakistan (the first time), I was plagued by concern for the colleagues that remained.

This time, I think the hardest thing is being away from my children and grandchildren, and this only became an issue with this latest visit home. My grandson Cade, the little guy who used to describe his grandmother as living in a box, because he most frequently saw me on the computer screen via Skype, has the part of Michael in the community theater’s presentation of Peter Pan. I won’t be there, and I’m still deciding if that is acceptable to my vision of who a Nana should be.

When I knew I wouldn’t have the mindset to blog for a while, I wrote to Jim Mattson, editor of Reflections on Nursing Leadership, the magazine for which I write this blog. I told him I was suffering from jet lag, a cold and a bad attitude, and we both agreed the first two would resolve quickly, but the last malady could present a problem. I think the cure is near.

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.

Pink backpacks in Kabul

I have been fortunate enough to serve in 14 embassies with the U.S. Department of State for periods of time ranging from one month to three years (Ghana, Guinea, Afghanistan, Nicaragua, Sierra Leone, Mexico, Uzbekistan, Hungary, Russia, Kosovo, Rwanda, Romania, Pakistan and Czech Republic). I am often asked which of these was my favorite posting, a question impossible to answer. In truth, each has given me memories I cherish, friendships I continue to enjoy and experiences I value. But, if pushed to name one post that was a pivotal experience for me, it would be Kabul, Afghanistan.

I spent 14 months in Kabul in 2003-04 and it was, I think, the best time to be there. The Afghan people were full of hope and promise, the Taliban were weakened and had retreated, and much needed money and skilled personnel were flowing into the country to rebuild the economy and improve living conditions. I was there when the girls were permitted to return to school. On the first day of the term, the streets were full of nicely groomed girls holding hands, smiling and walking briskly toward their classes. I remember a profusion of pink backpacks as I sat in the rear seat of the embassy vehicle, sobbing at the sight.

The city of Kabul was relatively safe then, and I was allowed to meet civilian medical colleagues from other missions and military medical colleagues from the International Security Assistance Forces (ISAF) and the North Atlantic Treaty Organization (NATO), both at secure locations and even at approved restaurants in town. Truly, one of the great delights of my career was the opportunity to collaborate with so many American and foreign military medical professionals. I came out of that experience with an unshakeable regard for the military and utmost respect for the sacrifices they make for us.

U.S. Aid for International Development (USAID) made a commitment to build primary care clinics throughout Afghanistan so that physicians, midwives and community health educators could begin to pull the health system up from the ruin that years of war had created. I was invited to attend the opening of the first such clinic at a village some distance from Kabul.

The citizens of the little village were proud of their new clinic and the medical personnel the government had sent to staff it. I was proud of the U.S. government for making this dream a reality, and honored to be there to witness the villagers’ delight.

After the dedication speeches, the village imam came to ask the USAID representative for another favor. “The children need a school,” he said, through an interpreter. “May we have a place for our children to learn and books to teach them?” I was really struck by this old man and his humble request. Isn’t that what we all want for our children—good health and a future? Is there really anything else that matters, regardless of where on earth you live?

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

When personal overlaps with professional

I suppose being in practice in the Foreign Service is akin to working in a small town—a very small town. While a few embassy populations are quite large, with more than a thousand staff members and families, most are well below the 500 mark. I am responsible for the occupational health needs of fewer than 200 people in Prague, plus another hundred local staff.

This means my patients are also my colleagues and friends. It is not uncommon for me to have lunch or dinner with someone I treat in the clinic the same week. Rarely are we in a situation where we provide care for people we don’t see frequently outside of the health unit, even if it is just passing in a hallway.

I have always had mixed feelings about this unusual practice environment, as having such a close relationship with one’s patients has both advantages and disadvantages. Under this system, my feeling of responsibility for a patient’s medical outcome is both professional and personal. My medical colleagues and I have to maintain clinical objectivity at the same time we have a very special interest in the people we are treating.

Recently, one of my patients has been very ill and has required advanced medical care within the Czech health system. I am thankful there is such competent care available in Prague, but the length and severity of the illness has cost me many tossing-and-turning nights. I worry and wonder if all the people making decisions in this case—myself included—are making the right decisions. From the beginning, there has been a high chance of complications, and I am acutely aware that, if things don’t go well, my embassy colleagues might look at me with a critical eye. But that isn’t the cause of my fidgety sleep. I have tremendous regard and respect for my patient, and it is that personal connection that causes the angst!

At my first post—Accra, Ghana—I was forced to hospitalize a septic 3-year old. The parents were on their initial overseas assignment and had been in country for exactly one month. The mom was a lovely young lady who stood about 5 foot 2. After admitting the baby to the hospital and initiating IV infusion of the drugs that were going to save her, the mom turned to me, literally grabbed me by the shirt and pulled my face down to hers. “Don’t let my baby die!” she cried.

That was the first time I felt the full force of the responsibility this practice can bring. Unfortunately, it hasn’t been the last time but, in that case, the child did well and left the hospital in less than a week, her mother having never left her side.

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.

Prologue to my blog

The advertisement in the nursing journal said, “Deliver primary care to U.S. government employees working in embassies overseas.” That was enough to catch my attention! I was a 40-something single mother with a great nurse practitioner job in Biloxi, Mississippi, but I had a nagging suspicion that there was more to be had if I looked for it. Soon, I was going through the long and frustrating process of applying for the position of foreign-service health practitioner with the U.S. Department of State.

That was 10 years ago and, in subsequent years, I have enjoyed long assignments in Ghana, Guinea, Afghanistan and Pakistan with shorter tours to Mexico, Russia, Hungary, Uzbekistan, Rwanda, Kosovo and Honduras. I am assigned—with consideration of my preference—to a U.S. embassy community to deliver patient care in the medical unit, usually as the sole provider, but sometimes with a State Department physician. The patient load is the run-of-the-mill primary care stuff with some interesting twists along the way. Some are location-specific, such as parasites, malaria, or “acid” bug burns. Some are scary acute-care problems (MIs, cancers and orthopedic nightmares) that my clinic diagnoses, stabilizes—using local resources, when available—and transfers to a medevac center or to tertiary care in the United States.

It isn’t all direct patient care. I am responsible for testing embassy water quality, evaluating food sanitation practices of embassy kitchens, scrutinizing local public health issues that might affect our embassy population, emergency preparedness, health education of the embassy staff and a variety of issues that are in some way related to the health and well being of embassy personnel. It is never boring and I marvel at the range of knowledge I have acquired since taking this job.

The off-work possibilities are boundless. I’ve spent New Year’s Eve in Red Square, ridden horseback to Egypt’s Great Pyramids, climbed through a bamboo forest to photograph mountain gorillas and been a lazy bum on some of the most beautiful, and isolated, beaches in the world.

I’ve met amazing people at every location and learned that, no matter the region or the language, we are all more alike than we are different. I have also seen the poverty, lack of education and poor health care the majority of the world suffers. It devastates me, but I have been able to offer small assistance by volunteering at a children’s center or supporting a local hospice.

Of course, there are some negatives to this employment. While I have attended the major events in my grown children’s lives, such as weddings, I’ve missed just about all of the daily life events. Webcams and Skype phone calls help my seven grandsons remember my face and voice between visits home, but I miss not being with them more often. My youngest daughter traveled with me until 2003, when she returned to the United States for university. Now, I live and travel unaccompanied and sometimes feel out of touch with the U.S. culture, and my family and friends. Still, I know how truly fortunate I have been to reside and work in the world at-large. It isn’t for everyone but it has been a dream-come-true for me.

I recently completed a three-year assignment in Pakistan, an amazing experience. After returning to Washington, D.C. for two months of language training, I’ve now moved to my new assignment, Prague, the capital of the Czech Republic. The past 10 years have taken me to mostly rough, medically underserved locations. For the next three years, I will be in the heart of Europe, and I wonder what that assignment will hold for me. In this blog, I will share my discoveries and adventures and reflect on past ones. I hope you’ll join me.

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