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Alexandra Martin-Onraët Doctor Without Borders

The concept you have of medicine as a student, or at least the one I had, differs greatly from reality. Basic sciences are wonderful, but they are not medicine. When our patients don’t read our books, “science” becomes art, sometimes even with a touch of serendipity. Add the stress of treating people who might die and those who do; the frustration that arises when the disease wins; having to refer a patient due to lack of space, and having to deal with the limitations of a collapsing health system. We don’t learn that in the classroom. One learns to builds one’s shell, but with holes, to be able to feel a little.

05.Trabajando

Photographs by Alexandra Martin-Onraët & Marie Laure Batard
Visitors pass for the tuberculosis pavilion

In 2010, after finishing my residency in internal medicine, I felt the desire to participate in Doctors Without Borders (MSF, www.doctorswithoutborders.org), an international medical and humanitarian organization that assists populations in precarious situations. The selection process was not particularly difficult. The requirements are posted on their webpage and all compulsory documents are sent by mail. The difficult part, sometimes, is the waiting period; the organization’s first response is to schedule an interview and that might take weeks if not months. During the interview – as in any other – you bring your CV, you’re asked about your motivations, and they require you to speak at least two languages. There’s higher demand depending on the profession; according to the languages you speak, it is easier to go to certain countries.

00.entrada-del-hospital

Entrance to Homa Bay’s District Hospital

It is important to note that the missions are not exclusive to doctors. In fact, doctors are the minority in a mission: nurses, psychologists, engineers, administrators are also required. There are projects that focus on the construction of a hospital; others require fieldwork to explore social and cultural aspects to adapt to the local needs. Those are the projects where sociologists and anthropologists intervene. The logistics team is the backbone of the project: there has to be available transportation, enough fuel, food, water, etc. Certain missions take place in very isolated parts – usually refugee camps – where provisions are delivered by helicopter, and in those cases, it is essential to guarantee a solid communication network. For each one of these tasks, they hire specific people, hence all fields of study are welcome. To be assigned a destination as a volunteer, in the first interview, you are asked which places you would prefer to work in, what type of mission you’d like, and how long you would be willing to go for. They start off from the basis that whoever approaches the organization is a volunteer, and they try to adjust to their preferences. There are all kinds of projects; the emergency ones, such as epidemics, which require intense work because of the physical and mental exhaustion they implicate, usually last three months. These projects are created very quickly and thus require human resources from one day to another, which is also why they end just as fast as they began. Other projects last six months to a year, but the minimum time is three months. You can clarify, from the beginning, what countries you do not wish to go to (usually those at war or those a higher risk than the average countries at risk).

According to the conditions and availability of dates that one establishes, the organization proposes different countries. It is possible to turn down the proposed option, but you’ll have to wait until another vacancy opens in another place. That’s one of the disadvantages of accepting these missions: you have no control over your future for a brief couple of weeks before your departure. You wait until the day they announce you leave the following week and you have to be available on the spot, leaving everything behind.

01.centro-de-salud2

A health center near Homa Bay

I was in Doba for three moths, an oil city in the south of Chad, during a meningitis epidemic. I was there from March to May 2010, during the hottest time of the year in that region. My work consisted of getting to the most abandoned and forgotten health centers, deliver medicine and help wherever it was needed. We’d make eight-hour rounds on a 4-wheel drive, dodging potholes, sweating, stuck to the seats. We had to explore areas that reported new cases to set up epidemiological alerts, as well as helping another team in charge of the vaccination campaigns.

I then went to Homa Bay for sixth months, a town on the border of Lake Victoria, in Kenya; one of the hot spots in the country, where one in every four or five inhabitants had HIV and the majority of them belong to the Luo tribe. They called me Daktari Mzungu (white doctor). The project was more stable there; we worked jointly with the local health system in the General Hospital of the area, treating patients with HIV and tuberculosis in one of the areas with the highest resistance to medicine against tuberculosis. Some patients with tuberculosis could be hospitalized for months, receiving emetic treatments, trying to gain life in weight. There was another part of the program intended to adapt remote areas that dealt with a project of “decentralization” so people would not have to travel for hours and kilometers to be treated.

03.sala-de-espera-TB

The waiting room of the tuberculosis medical office is always located outside, in order to be well ventilated and prevent transmission between patients

Pulmonary tuberculosis is highly contagious which is why they also carried out environmental control, which consisted in adapting the homes of patients with tuberculosis: make windows, build separate rooms for the coughers, and try to beak with the transmission cycle of the infection. The program had many lines of work, such as nutrition, psychology, contraception, which implied the collaboration of many diverse specialists.

August 20, 2010

«Here in Homa Bay, the majority of the people are Luo, a tribe dedicated to fishing and livestock. The Luo each have three names. The first name is Christian, which was added in the last two generations. It is followed by the nickname Luo, which describes the circumstance of birth, and the third name is inherited from the father’s nickname. In addition, men’s names begin with an O and women’s with an A. Therefore, if you were born at dawn and you’re a woman, your second name will be Amondi; Omondi if you’re a man. The name usually describes the moment of day when you were born: Omondi (born at night), but sometimes it describes the context, many times related to the harvests; for example, Okech (born during famine), Okeyo (born during harvest time), or the weather: Oluoch (born during heavy mist). Thus, you can tell if the boy was born after his father died, simply from his name (Ochola), or if he was born “mysteriously,” when his mother, after a previous pregnancy, had not recovered her period (OkumuI), or had it outside the house, fortuitously (Ooko). You’ll know if the mother had twins, and who was born first (Opiyo: born first of a twin pair; Odongo: born second). It tends to get confusing at times when you have a cubicle full of Otienos in the hospital.

I am Adhiambo, born in the afternoon, because, according to Kenyans, the daktari needed a local name.»

04.pabellones

The waiting room of the tuberculosis medical office is always located outside, in order to be well ventilated and prevent transmission between patients

During this first period, I faced various difficulties in different aspects of my life. At a professional level, for example, it was very hard to face the lack of resources, medicines, and physical spaces to treat patients; including the lack of water and the high mortality. I remember one day, we got to the health center where there were no patients with meningitis, but there was a woman, probably younger than she looked, with grey hair and weather-beaten skin that had arrived with diarrhea. She was severely dehydrated and about to die because they could not giver her something as simple as serum. There were days in Chad where we’d get to the health center and find patients outside, passed out on the grass, on their looms, sweating profusely under the shade of a mango tree. In Kenya, the rounds could be surreal; sometimes there’d be two patients per bed, lying like dominoes, coughing on one another, with no control whatsoever. And you had to maintain your composure and go from bed to bed, trying to carry out a positive intervention…

August 23, 2010

«I close my eyes and move forward. Next patient. I’m hoping that we’ll be able to do something for this one, at least have the feeling that tomorrow he’ll still be alive. I try to concentrate on the medical record that the student dictates to me, trying to avoid the neighbor’s dying unprotected breath, and a mix of odors I will not describe. Young mother with HIV and neurological disorders. Another one. This one has confirmed criptococcosis and we have treatment; there’s hope. Next to her: a recently diagnosed young man with HIV with cough and expectoration. Start on anti Tuberculosis. Oh! And move him to the isolated room! And close the f… door! Currently, in the resistant tuberculosis ward, my two hospitalized patients are stable, tolerating the therapeutic bomb. Naftaly, who had escaped two weeks ago, came back today, wanting to take pills.

Naftaly was infected with multi-drug resistant tuberculosis by his sister, and blames her for it. Him and his sister, 24 and 22 years old respectively, live 200 km from Homa Bay, and the only option they have to get their treatment is to be hospitalized or rent a house in the city, because, until recently, there were no resistant tuberculosis programs outside of Homa Bay. Their mother accepted to pay the rent of a house for the two of them, but they can’t stand each other and therefore cannot live together, so Naftaly had to be hospitalized. He is in the intensive phase of the treatment. He’s escaped many times; we try to convince him and his mother to seek help from the psychologist, to stay with his sister until he finishes the treatment. I am sure half of the information they receive is lost when the nurse translates but, in a nutshell, the mother has given up on her two children, she has others at home she has to take care of and of course! she’s not willing to pay a second house for her willful son. On the other hand, Eunice, only 10, co-infected with HIV and resistant tuberculosis, is in her tenth month of ambulatory treatment, and shows an exemplary loyalty to the HIV as well as the tuberculosis treatment, and wants to be a doctor when she grows up.»

My emotional distress was essentially translated into handling frustration, trying to understand the limitations of the place, the poor efficiency in the treatments, and the little impact it could have on the patients; knowing that somewhere else, with the minimum resources, that patient could survive. One has to accept the injustice implied in coming from a place with no name but never assume that it isn’t worth trying to make each one of them an exception. Lastly, at the physical level, one had to get used to 45 degrees in the shade, to the lack of wind, rain; to the smell of fried fish of doubtful origin, to flies in the milk replacer, to repetitive meals, to the boiling mattress, to the amoebas… However, living in these extremes allowed me to be happy at three in the morning when it was 30 degrees centigrade outside, to crave the first day of the rainy season to smell the aroma of the wet soil. I also learned to appreciate the smell of fried fish; I even appreciated the call to prayer at four in the morning in Chad… I learned to keep a water bottle cool (lukewarm) after having had enough of drinking hot water, wrapping it in damp cloths that absorbed the heat despite the temperatures of more than 40 degrees outside.

I learned from the women who walk carrying twenty kilos of mangoes on their heads daily, from their towns to the market, and then return, carrying water, to prepare the meal after grinding the grain, without complaining.

06.Mercado

Homa Bay market

I learned to respect death, to see it in the eyes of many; I understood their way of expressing sadness through screams, the spontaneity of their comments. What were the satisfactions? The children yelling and waving on the edge of the highway, their colorful braids and their white smiles; the fresh mango from the tree, the sunsets with freshly squeezed passion fruit juice by the edge of the lake, inhabited by long and bald birds; the patients’ outbursts of laughter when I would greet them in the morning, as I walked by the waiting room, with my Mexican accent, “¡Oyaoré! ¡Habari!”

07.children-party

New Year’s party for the children in the clinic, the worker’s children and others

Now I work in the National Institute of Cancer. You often find yourself in between in Mexico. The scale is different, but there are also people who go back home with leukemia, without chemotherapy because they couldn’t pay for it. There are people who go from one hospital to the next, until they find a stretcher where they can be treated. The patients here don’t lie under the mango tree, but they’re stacked in the hallways. Perhaps people don’t walk three hours to the health center, but – if all goes well – it takes them eight hours to get there on a bus. Primary health care is limited, people get to the hospitals every day, victims of the lack of prevention and information: there is no health education. People learn about the disease once they suffer it and the demand for medical attention clearly exceeds the resources. The greatest challenge is to never stop believing that every day, things can be done to better the system. One must never give up or justify unfavorable results due to unfavorable conditions. I don’t think one needs to go all the way to Africa to find desfavorecidos places that require the implementation of health care, like the ones MSF provides in their missions. It happens in many areas of Mexico and the health conditions in this country coincide with those of some of the white countries of the MSF where core changes are required to better education, primary health care and work on prevention. But Mexico doesn’t require substitutions or patches: MSF is an organization that tries to adapt to the local situation, but its role, in general, is to fill holes.

02.el-equipo-MDR

The patients and team of the Multidrug-resistant tuberculosis clinic

MSF works as a temporary solution, it looks for “the lack of,” and works through substitution in countries so poor or in such fragile sociopolitical conditions, that it cannot wait for the local government to solve the growing health problems that turn into deaths. Originally, it focused only on emergencies, natural catastrophes, epidemics, but, little by little, they’ve adopted extended programs. However, politics usually establish that the intervention cannot be for an indefinite period of time, since training programs are laid out to leave the programs operating in the long run, at a national level.

08.atardecer-

Sunset from the peninsula, opposite Homa Bay. It is the time of day that the ibis return to the trees.

Alex Martin-Onraët was born in Rueil-Malmaison, France. When she was eight, she moved to Mexico, where she lives until now. She studied medicine in the UNAM, as she planned since she was nine years old. She followed the expected path: after general medicine followed internal medicine; in 2010 she decided to do something crazy and go to Africa, inspired by the memories of a childhood trip to Kenya, her father’s fantastic stories, and the adventure it implied, to discover a new culture as well as the need to get out of the bubble that had been her professional training. Upon her return from Africa, she completed her studies in infectology for two years and now works in the National Institute of Cancer (Instituto Nacional de Cancerología).

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