Tag Archives: The Valley

Open Your Mouth And Say “Aaah”

Somehow, it’s the end of week three – and I’m still sort of standing!

I really thought I was doing well; I’ve been on top of my work, doing well on tests, even managing to get a decent amount of sleep. And then today, after my 6am wake up for my weekly four hour pharmacology lecture, I realized that I am actually feeling an overwhelming sense of exhaustion and the desire to sit in a cool, dark room for the entire weekend. (Not that that’s an option, what with all the studying I need to do.)

Has it really only been three weeks of class? Hasn’t it been more like three months?

I keep reminding myself that this summer is a sprint: intense and over before you know it. Truly, there are aspects of this program that I’m loving – why don’t I go ahead and write them down to keep myself from turning this post into an unsavory whinge-fest:

  1. For the most part, the standard of the teaching is very high. I have enormous respect for my professors and instructors, and am constantly concocting little reasons to schedule an office hours meeting with them, despite the fact that I don’t have any questions of an academic nature. Just so that I can hang out with them and ask them about their lives and careers.
  2. My classmates are excellent – sharp, engaged, compassionate, and with a dizzying variety of backgrounds and accomplishments. I’m glad to know them and proud to be counted among them.
  3. I’m loving learning how to conduct a full physical exam. During this summer we’re each paired with a classmate on whom we practice inspecting, palpating, percussing, and auscultating from head to toe; I swear it’s like being given the keys to a secret garden of weirdness. Did you know that your optic disc looks like the sun setting inside your eye? Or that your ear’s tympanic membrane looks like mother of pearl? Or that there’s actually a reason that they ask you to open your mouth and say “aaaah” at the doctor’s office, apart from making you look like an idiot? (It’s to visualize your pharynx and tonsils, as well as to ensure that your soft palate rises symmetrically while your uvula stays midline – indications that your cranial nerve X isn’t damaged.)

Interestingly, I’m feeling a little more tepid about the thing that other members of my class seem most excited about: the one day each week that we spend in a hospital unit learning how to be actual nurses. There’s nothing like suddenly being assigned to care for an ill stranger in a hospital to make you realize that you are ignorant in the most fundamental of ways: how should you speak to the patient? How should you touch them? How do you walk the fine line of providing care appropriate to the professional role of a nurse, without veering into non-professional areas like socializing with them or being their “fetcher?” (Hint: pouring water from a pitcher on the bedside for a shaky patient whose medications give them dry mouth is a-OK – fetching them (or their cousin) a Coke from the vending machine – NO A SPRITE! NO A GINGER ALE! – just because they want one, is not.)

This isn’t my first time interacting with people and providing them with intimate care in a hospital setting – but the last time I did anything like this, it was as a doula in China. And those women weren’t sick – they were just pregnant. True, they were sometimes in pain, but the pain of “back labor,” and how to manage it, isn’t the same as someone who has back pain following surgery for a herniated disc. Those women didn’t have open sores as a result of being bedbound in their homes; they didn’t have central lines that needed cleaning or tracheostomy tubes that needed suctioning. They were never so neurologically impaired that you couldn’t tell if their sudden grimacing was because you were hurting them or because some mental demon was flashing before their eyes.

Or perhaps it was something about the hospitals I visited in China made that those experiences so different from this one. The hospital to which I am currently assigned is such a nice institution: it’s recently built, it mostly serves the surrounding community (as opposed to being a magnet for transfers from other communities or hospitals), it isn’t a level I trauma center. It is well staffed, and mostly calm. They even have “quiet hours” during the day on the unit where I work in which the lights are dimmed and people speak in hushed tones to allow the patients to get rest during the day.

As much as this is all to promote a healing environment for those being treated there, it also creates an otherworldly atmosphere that I find unsettling. When I enter the hospital I feel as if I’m leaving the world of the living and entering a place of sterility and suspension – a place somewhere between this world and the next. No matter how nice you try to make it, a hospital is a place that serves as a land of limbo for the sick and dying; it makes my heart hurt to be in one.

I didn’t have this feeling in China, and perhaps, perversely, it has to do with the fact that the hospitals I was in were nowhere near as “nice” as the one I work in now – they were chaotic and dirty. Families wandered all over the place, carrying in food, clothes, and supplies for their loved ones (who are otherwise not provided with these things by the hospital itself). At the hospital that I visited in The Valley, a stray animal or two could often be seen roaming the halls.

While this made them much worse places from a clinical standpoint (my God, the rates of infection), they felt like places in which life was happening on a continuum with the outside world. I felt, oddly, more comfortable in them.

My role is different now, of course. The expectations that my wonderful preceptor has for me and my classmates are high, which puts me in a state of mild terror every time I have to do something new – although I am pleased to say that I was able to rally my Spanish skills somehow to interact with the first patient for whom I was responsible, who did not speak any English at all.

I’m uneasy just at the moment. I hear that it passes.

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Experience Overload Part 4: Danger in the Valley, and Making it Out

Barbara and I made it out of the Valley without incident, which is certainly not always a given. Last time we made our 5am exit (I kind of love doing that – stealing away under cover of darkness!) there was a giant mudslide following a night of torrential rain, and it looked like we wouldn’t be able to leave at all.

Before going to the Valley I had never encountered a mudslide and didn’t understand what the big deal was. So it’s some mud, right? Can’t you just…go over it? No, it’s not just “some mud” – it’s like a giant flood of rocky pea soup, up to your knees, or waist, or higher. You do not just “go over it”. Earlier this year, farther up the Valley, there was a mudslide that killed 30 people when it submerged an entire village – so don’t mess around with mudslides.

Life is full of little horrors like that in the Valley. It is a deeply beautiful place, and one in which life has become easier for the Azu over the past couple decades as they have become wealthier. On this past trip, all of the fields were ripe and bursting with greenery – mostly corn and rice, but there are also little orchards of peaches and apples,  and fields of tea bushes.

The Valley in April, when the rice was just starting to come up.

But the beauty and increasing fortune of Valley life belie the many dangers of living there.

The River that cuts through the Valley is a beast – broad and muddy, swirling with rapids and hidden boulders. Every year some number of people are carried off in it and drowned, including a little boy this summer who was pulled out into the River and died, after playing alone on its shores. He had been living with his grandparents, his father having run off and his mother away in another province working as a migrant laborer. Local authorities called his mother back to the Valley, telling her that her own mother was very ill. They feared that if they told her what had actually happened she wouldn’t even be able to withstand the journey, and they were probably right; upon hearing the news that her only child was dead she seemed to lose her mind, and was closely watched in case she should try to commit suicide.

Any little incident can turn into an emergency in a place like the Valley; even those who live on the Valley floor near the main road, and who are likely better off financially, are hours away from a hospital that could deal with any remotely serious issue. This is to say nothing of the poorer people who live many hours up into the mountains, which can only be accessed by footpath. A minor injury from a fall goes untreated and becomes a lifelong limp; a small cut from a tool or animal bite becomes infected and festers, turning deadly.

One day we were in the Valley, Barbara and I were riding down the main road in a little motorized vehicle when we saw a teenage girl we know pass us on her bike. We called out a greeting to her and she smiled, disappearing over a dip in the road. Sixty seconds later I spotted her again, this time lying unconscious by the side of the road. Her arms were bloodied and she couldn’t move – fortunately this was temporary and she was only in shock, probably having had a moderate concussion (wearing a helmet, thank god).

But what if she hadn’t been wearing a helmet? What if she had broken her back instead of cutting up her arms? The hospital in the Valley doesn’t know how to treat head injuries or perform involved, emergency surgery.

We managed to get her home and she is perfectly fine now – but you see how fortunes can change in an instant in the Valley.

I don’t know when I’ll next be able to go back with Barbara; the next few months are full of plans made or half-made, and then RP and I may be going back to the US. I’m trying to savor the experience of having been there as if it will never happen again. There is no classroom that offers the education that going to a place like the Valley can, but I’m excited to return to the classroom nonetheless; these experiences show you all of the gaps in your abilities, and teach you how insufficiently educated and unprepared you are to help people in situations of real hardship.

Here’s hoping that one of these nurse-midwifery programs will take me!

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Experience Overload Part 3: Miracles and Meltdowns

Miriam (Barbara’s foreign nurse friend) runs a free clinic out of her home one day a week, so Barbara and I were able to go a couple times when we were in the Valley. The clinic is a pure act of charity; Miriam’s resources to treat the many people who sit on her front porch each week are limited, and people are often seeking help for complex illnesses and injuries. Sometimes frustration runs high because people are clearly looking for a miracle cure – but in order to know why this is reasonable, you have to understand the mysterious circumstances under which healthcare is sometimes provided here.

As in many places in China, tuberculosis is endemic to the Valley. Cases here are often allowed to progress to a stage rarely seen elsewhere; permanent lung damage, disabilities from TB that has spread to and destroyed skeletal joints, and deaths are not uncommon. The government, however, does provide a certain amount of TB medication for free if you test positive, and Miriam is often able to arrange for a patient to receive this treatment. That can, indeed, seem miraculous – one day you have a cough and a fever, the next day you’re diagnosed with TB, and then this foreign lady makes sure that you get free medication and home visits so that you’re not going to die! From that perspective, why shouldn’t people turn up expecting to be cured of all manner of diseases?

Clinic days are long; the first patients have shown up by 8:30am, and we often weren’t finished until 5pm. At a desk job, that’s just a regular day – but when you’re seeing an endless stream of patients who often cannot be helped, you want to go home and go to bed without dinner at 6 o’clock.

What complicates matters is that many of the patients we saw had actually already been seen by a physician in one place or another – the Valley hospital or a village clinic – and simply did not like or did not understand the answers they received.

Some of these patients face deeply serious problems: one young mother brought her 2-month old baby girl to the clinic for intractable chest congestion. I have never seen a baby that looked like this before – she cried endlessly in a way that seemed to choke her every five minutes. She was clearly unable to breathe properly, and turned blue several times. At the Valley hospital the mother had been told that the baby did not have pneumonia, and they didn’t know what to do for her.

Fearing that perhaps the baby had cystic fibrosis, which would be tantamount to a quick death sentence in a place like the Valley, Barbara and Miriam advised the mother to take the baby immediately to the city hospital four hours away for further tests. Unfortunately, the young mother was living alone with the baby at home for the next few days, with her husband off working and in possession of all of the money. There was a discussion of scraping together enough money to lend her so that she could get to the city, but someone who spoke Azu and Mandarin would have to accompany her, since she did not speak Mandarin and the city hospital staff do not speak Azu. No such person could be found on such short notice.

Then there are other patients who have been told what to do to fix their health problems and are simply being stubborn about it. One amazingly wizened Azu woman presented herself on Miriam’s front porch complaining of eye troubles, eventually revealing that she had been diagnosed at the hospital with cataracts in both eyes. The woman was a serious character: at 75 years old, she stood perhaps two and half feet tall, a consequence of her dwarfism. She was dressed as if she had been plucked from her village and drafted into the Cultural Revolution-era military; she wore the traditional Azu women’s patterned skirt and embroidered vest, strung from neck to knees in beads and large shells, and had paired them with a camouflage green Mao hat and combat boots of the kind favored by the People’s Liberation Army.

Despite the fact that she had been correctly diagnosed, and that her problem was fixable with a very simple surgery that would be provided for free by a hospital right down the road, she refused to go, claiming that the doctors there would kill her. She quickly announced that she would only have her eyes operated on by a foreigner, and demanded to be sent to Kunming for said mythical foreigner to schedule her surgery.

We explained to her, in the nicest possible terms, that she was being a huge pain in the ass, and that if she wanted her sight back she should go get her free surgery down the road, where they were not going to kill her.

“You people aren’t helping me!” she companied, adding, “Plus my knees and hips are sore.”

Lady, you are a 75-year old with dwarfism who has done manual labor in the fields her whole life. My joints would hurt too.

*****

One of the strangest problems we’ve encountered at the clinic is infertility. Barbara and I were meant to be focusing on any OB/GYN patients, and apart from a few women with minor infections, they all seemed to be having trouble getting pregnant.

Infertility can be difficult to cure even if you have lots of money and all of the latest technology available to you. So what do you do when women show up at a free clinic halfway up a mountain side, with no lab technology, no samples of or understanding of any medications they’ve previously been given, and tell you that they can’t seem to get pregnant?

These are not 40-year old women who put off having children because they were busy with their careers or because they couldn’t find a suitable mate. Azu girls often start marrying by age 16, and everyone seems to be married by age 20. Marriage and childbearing and extremely culturally important, and therefore nearly universal. So again: what do you say to a 26-year old in seemingly good health, who had one still birth when she was 8 months pregnant seven years ago, who has been trying to get pregnant ever since, but who doesn’t quite understand the mechanics of how pregnancy actually happens?

Pesticide use on crops in the Valley is ubiquitous, and women often apply it with their bare hands – perhaps that’s the problem? Perhaps it’s their husbands who are infertile, having contracted sexually transmitted infections? Perhaps this incidence of infertility is no higher than normal in a population of this size, but because it’s so embarrassing for Azu women to discuss it they will only come to this free clinic, making it seem like we’re seeing unreasonably large numbers of infertile women? Who knows.

We drew lots of pictures, and explained in simple terms about the ovum traveling down the fallopian tube. We went over the possible causes of infertility, and even tried to explain how to monitor your temperature and other symptoms daily to determine whether or not ovulation is occurring. Even as I was explaining these things, I could see how hopeless the situation probably was for most of these women. They seemed to understand what we were saying, but were quiet; perhaps they knew how hopeless it was as well.

If we could help everyone who came to the clinic, the days would simply have been exhausting. But because we couldn’t help many of them, the days were not only physically tiring but full of anguish. Azu people are often happy to explain their health problems in front of other Azu, presumably because they are used to the very public nature of village life – so when one 36-year old woman approached me speaking so quietly that she was almost inaudible, I knew her problem must be very serious. Barbara and I took her into an inside room, where she presented us with a CT scan of her uterus. I don’t have any training in reading CT films, but even I could see that her uterus had some sort of mass in it, and what looked like only one fallopian tube. She said she had been trying to get pregnant for six years, and then dissolved into sobbing. She lifted her shirt to show the thick, dark scars lacing her abdomen from previous gynecological surgeries.

It was certainly not my place to give this woman a possibly faulty reading of her CT films, nor to pretend to understand how much pressure she must be receiving from her family to have a child at age 36. What was clear was that no one had ever sat with her for half an hour and allowed her to say how scared and upset she was about her infertility. We gave her advice as best we could, and she cried, “It’s hopeless, isn’t it? Isn’t it hopeless?”

It’s at times like these that I find myself wishing away the next few years, so that I can be done with my nurse-midwifery training and actually help a woman like this. Did we do anything to help any of these women in the Valley? Did we offer them hope, simply with our presence, that we then dashed by being unable to fix their problems?

How do you know when you’ve done a good enough job?

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Experience Overload Part 2: Hospital Regulars

We visited the hospital several times this week, checking up on the women who were of particular concern to Barbara. Their outcomes ran the gamut:

  • The woman with the seizures and infection had been doing better, but then her infection returned and she seemed to be retaining fluid at an undiminished rate. They had transferred her to a hospital in a city four hours away.
  • The woman who had had a cesarean after her labor stopped was much improved and, by our visit yesterday, had gone home with a healthy baby.
  • The woman with uterine cancer was gone from her bed, the sheets neatly folded. I assumed she had died, but was later told by a nurse that they had sent her home to die there – nothing more they could do for her at the hospital anyway, and they needed the bed.

For the record, I think this last outcome is probably a good thing. Just as a system in which hospital births are the norm for all women leads to lots of money being spent in achieving relatively poor outcomes, I think the same may be true of a system of hospitalized death.

In death, of course, unlike birth, the outcome is eventually the same for everyone. On the other hand, hospitalized birth and death have much in common: enormous potential for trauma; unnecessary and invasive procedures being performed, often without consent being given; massive quantities of money spent on these procedures; the transformation of a private, family affair into a sterile, clinical one. I’m still formulating my thoughts about this, and, in truth, have seen a dead body but have never actually seen someone die. Still, I think that establishing a system in which the beginning of life and the end of life generally occur out of the clutches of hospitals will be one in which more people have a good birth and a good death, instead of the undignified medical disasters so common now.

One of the nursing schools that I’m applying to has a minor in Palliative and End of Life Care; perhaps I’ll be their first midwifery student to take it up!

*****

One of the days we were at the hospital, Miriam (a foreign nurse friend of Barbara’s who has lived in the Valley for years) came by for a prenatal check up and ultrasound. The hospital staff were perfectly happy to lend Barbara a spare bed to perform the prenatal check up herself. Having seen Barbara do a few prenatal check ups, I knew that she would begin by asking a series of questions about Miriam’s general health and comfort, anything unusual during the pregnancy (Miriam has a number of children already, so she is very familiar with her pregnant body), and fetal movement. She then performs a Leopold maneuver, which is the process of manually palpating the woman’s belly to determine fetal position. Miriam said it would be fine if I wanted to palpate her belly as well – and judging from how exciting I thought this was, I can already tell what a geeky midwifery student I’m going to be.

Let me tell you: feeling the position of the fetus is not as easy as it looks. You think that if you palpate a pregnant woman’s belly you’ll be able to feel something concrete in there, but Miriam is around 7.5 months pregnant, so the fetus still has plenty of fluid around it. For the first few moments I couldn’t feel anything at all – just a dense orb of fluid, like a medicine ball. But then I felt a solid, unbroken line between her belly button and left flank – the fetal spine! – and followed it down to the head above the pubic bone. Her baby has been moving around a lot, but for now it’s in the perfect position for birth.

After using a Doppler fetal monitor to listen for the heartbeat (again, not as easy as it looks to get the fetal heart beat instead of the mother’s), we went with Miriam to another hospital building to get an ultrasound. I’ve only ever seen fetal ultrasounds done in China, so my experience is limited to what they do here, but so far I can’t tell a damn thing from looking at an ultrasound screen. It occurs to me that they may intentionally do them very quickly here, avoiding prolonged views of things you might recognize like the fetal torso, because ultrasound technicians are forbidden from revealing the baby’s sex. This is because one well-documented side effect of China’s “Family Planning Policy”, as it is known here, has been an exacerbation of the population’s lopsided male-female sex ratio, and a high prevalence of sex-selective abortion.

Supposedly, ultrasound technicians can lose their jobs if anyone finds out that they revealed the baby’s sex to the parents. However, I have also heard that bribing the technicians is common, and that technicians sometimes drop hints to eager parents – saying “Congratulations!” if it’s a boy but nothing if it’s a girl, for example. At the end of Miriam’s ultrasound, she and the technician exchanged a few words:

“It doesn’t matter to us what the sex is, since we’re definitely keeping the baby.”

“It may be a boy. We’re not allowed to give you any information because of the Family Planning Policy.”

Perhaps that was a hint, or perhaps they just say that to everyone.

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Experience Overload Part 1: Training Day

I don’t think I have it in me to put up a post every day, but I really ought to. Each day in the Valley reminds me of the summer that I took intensive Spanish (bear with me on this analogy) – one day was equivalent to a week, one week to a month, one month to a semester. If I let too many days pile up without ordering it all into neat paragraphs it seems impossible to process. We’re heading out of the Valley tomorrow at 5am after almost two weeks here, so it’s time for some wrap-up. So as not to tax your patience, I’ll put this up in pieces over the next few days…

Training Day

Barbara and I started off Monday by meeting with two Azu women to prepare our training for the next day. The training was to be for some 20 Azu village women, on a topic related to maternal and infant health. We are using the American College of Nurse Midwives’ Home-based Life Saving Skills manuals, which contain very basic, picture-based instructions on how to deal with life-threatening situations that can arise during pregnancy, birth and the postpartum period. They’ve been used all over the developing world, particularly in rural areas like the Valley, and are easily adapted because the pictures and text are so simple.

(Dear visiting Singaporean medical students who were bored and translated the text into Mandarin for fun: PLEASE STOP. I know you are all bursting at the seams with your newly acquired medical educations, but endlessly crossing out the ACNM’s text and replacing it with complex instructions that women who are barely Chinese-literate will be unable to follow is counterproductive. AHEM.)

The two women we met with decided that “Bleeding During Pregnancy” would be a good topic for the training, as this is something that they’ve encountered in their villages over and over. There ensued a flurry of translation into Azu (seeing Azu being typed out on a computer is supercool), cutting and pasting and photocopying, and BAM! Azu handouts on what to do in case of bleeding during pregnancy.

The training itself went very well, and that was not at all a given. Part of the issue in running such trainings is that any Azu woman will tell you that their main characteristic is haixiu – shyness. Azu culture is highly conservative and thick with taboos around issues of health and the body. It’s not at all certain that you’ll be able to get a bunch of women together and convince them to mime such things as urination over a plastic bucket and getting a friend or family member to keep track of how much blood they’re losing.

During the training there was much discussion of Azu women being haixiu and, given that, what people might actually be willing to do in case of bleeding. They agreed that urination would be ok because they can go off alone for that, but determined that they would keep track of their own bleeding, thankyouverymuch, unless they bled so much that they passed out – in which case someone else could take over.

Fair enough.

Haixiu aside, there are other, equally fundamental issues with running such a training – for one thing, it turns out that many Azu women have no idea what their internal anatomy looks like. If I said to you, “The egg travels through the fallopian tube to the uterus”, it’s likely that a little picture would pop into your head that originally came out of a biology textbook, or Our Bodies, Ourselves. These woman are largely extrapolating visuals from their experience slaughtering livestock, which can actually be useful if they’ve been butchering pigs, but not so much if it’s just been chickens. (I will leave it to you to Google appropriately.)

They are also hungry for information, which makes keeping the trainings on track a real challenge. When presented with a highly experienced and foreign-trained nurse-midwife like Barbara, every question they’ve ever wanted to ask comes forward. What do I do in case of a breech birth?…Why do they happen?…Why does the placenta sometimes not come out? It’s too much for a two-hour training – plus, we’ve got to come with better visual aids showing HUMAN anatomy next time.

One thing that doing such trainings teaches you is that just because people are shy, it doesn’t mean they have nothing to say. This is especially important to understand in the context of hospital care in the Valley, as whenever we’ve gone to the hospital, Azu women and their families are essentially silent in front of the Chinese staff.

We started off the training by having one woman tell the story of a girl in her village who bled seriously during the 4th month of her pregnancy, and miscarried. It was as if she had cracked opened the floodgates – out came the other women’s stories, slowly at first, then faster and faster until they were literally shouting each other down with their tales of pregnancies lost and saved, labors endless and precipitous, babies born alive and dead.

I started bleeding at three months and eventually the fetus came out, the size of a plum…I started bleeding at six months and the twins were born dead – they were girls, I could tell by then…My relative bled all the way from two to seven months, but her mother-in-law prayed every day and the baby was born healthy…A woman in my village had bleeding, so we killed a chicken, stir-fried its innards and made a soup – it saved the pregnancy…A woman I know started to bleed, but she carried to term and even had the strength to pinch and bite her husband during her labor shouting, “This is your fault! You did this to me!!”

I don’t think the staff at the hospital know (or care) what a fine line they are walking with the village women, what a slim margin of error they are being given. For women who are resentful that they have to go to the hospital at all, bad outcomes that happen there are not forgiven. One woman relayed the story of what sounded like a placental abruption and/or uterine rupture – either way, there was massive hemorrhaging. The woman survived, minus her uterus, but the baby died shortly after birth. I have no idea whether or not this was the fault of anything the hospital did, but the conclusion offered by the storyteller was clear: people in her village do not like the hospital any more.

I may be justifying my own ignorance, but with topics like these it strikes me that it may be a good thing that Barbara and I don’t speak Azu. She guides the training in English, I translate English-Mandarin, and another woman translates Mandarin-Azu – which means that these village women are free to say whatever they want, knowing that by the time it gets back to me and then to Barbara, the essential facts are getting through but the nuance is long gone.

In the end, they’re not really telling their secrets to us – and that is a good thing.

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Back to the Hospital, and Shabbes in the Valley

Home

I’ve parked myself with a can of beer in front of my room’s electric fan, vainly hoping that either will do something to cut through the humidity that has settled into the Valley over the past few days. Barbara and I just came back from dinner at the house of a foreign friend who lives near by; after dinner we sat with the lights off in the living room, eating a mountain of lychees to keep cool. I complimented her on her beautiful Peruvian wall tapestries, and was then distracted by the concept of a place as inconceivably distant from the Valley as Peru – it might as well be a fairy tale. I spent the rest of the evening staring out the window of her home, overlooking the skeleton of a small, ruined power station in which villagers now grow corn in tight rows.

Tomorrow morning we meet with two local women to prepare a training for village women on life-saving skills relating to pregnancy, the postpartum period, and newborn health. One of the women only speaks the local language – let’s call it Azu – and the other speaks Azu and Mandarin. I’ll translate from Mandarin to English for Barbara, and the whole thing will be a little round-robin of translation and take three times as long as it should, but as we say in Mandarin: mei banfa.

One of the ways I know that my Mandarin skills have improved since we moved to China is that the prospect of this kind of activity only makes me a little nervous, as opposed to paralyzingly nervous in a manner that requires closed eyes and deep breathing. Now I always do pretty well in these situations, if I do say so myself. It’s tomorrow afternoon’s plan, returning to the hospital, that’s got me a little worried.

Back at the Hospital

On Friday we stopped by to see the Matron, and when she wasn’t in that day we casually made rounds, mostly to check on the woman who had had the emergency cesarean and severe infection. She seemed to have improved somewhat from the day before, but as we stood by her bedside I looked at the woman lying in the bed next to her – and then I looked again.

I recognized the face peeking out from underneath heavy blankets, her eyes just showing beneath her “new mother’s” head scarf. When we had visited the day before, she had just arrived at the hospital in labor, with her water already broken. She didn’t seem to be in heavy labor yet, and when Barbara examined her she noted that the baby was posterior, its head wasn’t engaged in the pelvis, and there was very little amniotic fluid remaining. A posterior baby (“sunnyside up”) is often more painful to deliver, but will usually come out on its own with a little maneuvering. One whose head isn’t sufficiently engaged in the pelvis might not come out at all, necessitating a c-section.

There are ways to encourage the baby to move down, but the hospital doesn’t favor any of them. They don’t like the women to move around in general, and particularly not after the water has broken because they fear cord prolapse (that the cord will slip out before the baby, which can be fatal as it cuts off the baby’s oxygen supply). This is not a well-founded fear when there is very little amniotic fluid, so Barbara encouraged this woman to walk the hospital corridor and to stay well hydrated.

The whole thing was hopeless. Let me explain the issues.

The Problems of Hospital Birth for Azu Women

1) This woman had been hooked up to an IV of oxytocin, to make her contractions stronger – this IV bag hangs from a runner attached to the ceiling. It is not mobile. So if she wants to walk the halls (which the staff do not want her to do anyway), they have to unhook the IV from the ceiling and someone in her family has to trail around behind her, holding the bag over their head. This gets tiring, so they do it for 5 minutes, drop their arm, and then the staff tell her to get back in bed.

2) The woman was thirsty, but refused to drink water. She refused to drink not because she’s a fool, but because the maternity ward has no bathroom – so if she wants to use a bathroom she has to go at least downstairs to another ward, or to an outhouse outside the hospital, which is not all that appealing when you’re in labor. The maternity ward does encourage women to use bedpans, but they had run out of bedpans by the time this particular woman arrived. Even if they had given her one, the women don’t tend to use them because they are in open wards, with no curtains separating the beds, so they would have to use them in front of other women’s husbands and relatives. Not gonna happen if they can help it – so they drink as little as possible.

3) By the time this woman arrived, her water had already been broken for two days. She had waited so long to come in for numerous reasons, including: a) Azu women tend to minimize their pregnancies and labors as long as possible. There are taboos surrounding pregnancy and birth that mean such things are rarely spoken of; b) Many Azu women, including this one, live a tremendous distance from the two-street town center where the hospital is located – they don’t want to walk hours and hours down a mountain if they’re not sure whether or not they’re really in labor; and c) Azu women don’t really like the hospital. The care is free, and they’re even given a cash incentive to show up and give birth there, but they still often prefer to stay in their villages. The local government has made that a moot point by recently passing a law requiring them to come to the hospital, but many are still unhappy about it; they have a hard time communicating with the Chinese staff, many of whom don’t speak Azu at all. They feel looked down upon and condescended to by these more affluent “city folk”, who look different, speak differently, dress differently.

4) And then there are all of the larger reasons that any Azu woman here is disadvantaged giving birth; their diets tend to consist of only a few vitamin-poor staple foods at any given time (potatoes, cabbage, hominy). They generally receive no prenatal care, meaning that any problems tend to become emergencies, usually at the time of birth.

This particular woman finally received a cesarean several hours before we arrived at the hospital. In light of the other woman with the severe infection, seizures and emergency cesarean, the hospital staff had gotten too nervous to wait any longer – her labor had stopped, they told me.

And now here she was, under blankets, her baby in some distant part of the hospital. She was mumbling, delirious with pain, unable to open her eyes. I knelt down beside her and squeezed her hand – what else is there to do? – and tears began to stream from her eyes, forming a little reservoir where they reached her nose. She squeezed my hand back and began to sob and shake – I worried that I was making it worse.

I noticed a young man and an old couple nervously hovering against one wall of the room and asked if they were her family – yes, they said. Because the hospital has no chairs or stools for anyone to sit on, they didn’t know where to be. I managed to scrounge a stool from a closet so that her husband could sit next to her, so that at least she would know he was there. When I walked past the room later on, I saw him spooning soup into her mouth.

We’ll see if she’s doing any better tomorrow.

Shabbes in the Valley

I did not grow up an observant Jew, but I’ve been experimenting with a few things lately, trying them on to see how they fit. Last month I decided to start lighting candles on Friday nights, for Shabbes – I cover my head, I light the handles, I wave the flames toward me and cover my eyes, I say the prayers. When I’m done feeling like I’m playing dress up, the whole thing feels pretty good. The first prayer I should say, of course, is  to Adonai, Eloheinu, creator of the fruits of the internet – because seriously, I wouldn’t know how to do any of this stuff otherwise.

Shabbes is always supposed to be a welcome event in the week, but after Friday at the hospital it seemed particularly necessary to light the candles, to go through the steps, to create a break with what had happened before.

I hadn’t brought anything to the Valley with which to cover my head, so I went out and bought the first head scarf I could find, which is one traditionally worn by older Azu women. Barbara was suitably impressed, so she took this photo of me (in which I realize that the shirt-scarf combination is sort of a horrifying optical illusion of plaid – apologies).


On Saturday night, I lit an improvised Havdalah candle for the first time in my life, accompanied not by wine but by Coke Zero, which, unlike wine, is available all over the Valley. I liked Havdalah – maybe this coming week I’ll even spring for some fruit juice.

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And Now For Something Completely Different

It’s nighttime in the Valley, a remote, rural part of China to which I’ve travelled from Kunming. As soon as the sun drops below the mountains, the clouds that had burned off during the day return, hastening the darkness.

Those of you who have read other parts of this blog may know that I am a birth doula and aspiring midwife, not a tech blogger. Since midwifery is an even more marginalized and beleaguered profession in China than in the US (and that’s saying something) it was through sheer luck that last year I happened to meet Barbara, an American midwife in Kunming, that she took me under her wing, and that we have been able to travel to this corner of China together. Barbara would call it providence.

We first came here several months ago, invited by the local hospital to conduct a series of trainings in midwifery skills that could help the staff deal non-surgically with the problems they most often see in birthing and postpartum women. The maternity ward of this hospital, a series of adjoined, muddy, concrete boxes, has at most 15 beds in its four rooms to serve a population of some 100,000 predominantly ethnic minority people. The hospital staff, of course, are mostly Han Chinese.

Occasionally the ward is very quiet, with one or two postpartum women lying silently, their new babies beside them bound up in blankets and string like pork roasts. But today was a full house – every bed containing a laboring woman or a new mother and her tiny child, the space in between the beds filled up with husbands and female relatives, small bundles of clothes, food that the families must bring themselves. Last night had been sleepless, a nurse told me, with four women giving birth before dawn. Women, like many mammals, birth more easily during the night, when quiet and darkness leave them less disturbed and more able to concentrate.

When we arrived on the ward this morning, we picked our way among the families and laboring women, searching for a nurse or doctor to recognize and welcome us – as foreigners who drop by only periodically, we are never sure what the reception from the staff will be, despite their having invited us to come. In my peripheral vision I saw a nurse dash from one room across the hall to another and spied a doctor filling syringes in an office at the end of the corridor, but no one looked familiar to me. Was it because all of the staff we had previously met were working a different shift, or because they had all left and been replaced? People change jobs so often and casually here that it was hard to know.

I peered into the staff lounge – really just a cramped patient room, with two beds, that the staff have commandeered – and saw the figure of the ward Matron standing in the window. The Matron is a saucy old broad, unflappable. A head shorter than I am, her face is perfectly round and beginning to be weathered by middle age. If you encounter her outside the hospital, she will be wearing acid washed, appliquéd jeans and a frilly top in the fashionable local manner, her pixie cut moussed into a small bouffant. In the hospital, she wears baby pink from head to toe – nurse’s cap; button-down, short-sleeved scrub dress falling to her knees; spongy, orthopedic shoes. She looks not unlike a waitress at a roadside diner.

Removing the cigarette hanging precariously from her bottom lip, and stubbing it into a wet sponge on the window sill, she called out to me by my Chinese name. “You’re back!” Her voice was croaky as always. “Where is Barbara? We’ll go see the patients.”

Barbara had already installed herself at a patient’s bedside, and was inspecting a slightly jaundiced newborn. The Matron approached her and they made exaggerated, noisy greetings in each others’ directions – the Matron speaks no English, and Barbara speaks no Mandarin. I’m the translator.

The three of us headed over to the far side of the small room to meet a postpartum woman who had been hospitalized for 10 days. She had arrived in labor, with her water broken and a severe infection setting in. She had first visited a village clinic half an hour away up a mountainside – when she had a seizure there, they had made her leave for the hospital. After another seizure at the hospital, she was taken for an emergency cesarean, during which they drained liters of fluid from her abdomen, later inserting catheters to continuously drain the fluid from her body, still accumulating mixed with blood as she lay in front of us.

I pride myself on being known for my toughness and I am embarrassed to admit that my biggest concern about entering nurse-midwifery school is that I will vomit or cry in front of a patient. The wound that a cesarean leaves is always barbaric looking at first – either sewn or stapled shut, I have yet to see a fresh incision that did not look to me like some form of torture. This woman’s wound was no different, regardless of the fact that the surgery had almost certainly saved her life and that of her baby.

Barbara and the Matron variously commented on how well the woman was doing – her infection was clearing, her incision healing, her fever had broken. But this woman was panting, subtly shaking, her face rigid; it seems that people here do not like to discuss their pain, and this woman was palsied with her attempts to hide it. I did not cry, but I wanted to. If someone could let me know why Chinese hospitals so rarely give medication for pain, I’d appreciate it.

We made our rounds of the other patients, all healthy if immobile, discouraged from leaving their beds. The laboring women lay on their sides, IVs tethering them to the wall. The new mothers drank chicken soup and ate hard-boiled eggs, their heads wrapped tightly in scarves to keep the “cold air” from getting to them, according to traditional Chinese medical practice.

We were finally taken to a room that previously I had seen used only for storage, but that was being used today to hold two patients. Dim and airless, the room stank of sickness. The entire maternity ward carries a foul smell, the stench of years of disinfectant fluid spreading dirt evenly across the floor mixed with the stale odor of clothes and bed linens too infrequently washed. The dogs that wander the halls and patient rooms don’t help. The hospital has no janitorial staff, so it is the responsibility of unenthusiastic doctors, nurses and patients’ families to clean the place. This room seemed to be the one that was cleaned least frequently, and I caught myself holding my breath.

What brought these women to the hospital, however, was not contagious. On one bed lay a woman about to give birth, and on the other a woman condemned to death by tumors. Shrunken and white-haired, her abdomen was distended with metastasized uterine cancer. Unable to eat or drink, she periodically spit up clear fluid and blood into the tissues held out by the attentive younger women of her family. Looking over one of their shoulders, I saw the woman’s face tighten and contort. I thought she was seized by pain, but I saw her lips move and understood then that she was praying.

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