at the risk of sounding too soft

In afternoon clinics I can find and pull medical records in our paper-based system; when required, I can check weights and test urine samples. I measure blood pressure and blood sugar; I write prescriptions. I am quick and efficient, even if I don’t always follow protocol. I think this is easier than asking other people to do their jobs.

Black girl childhood is a very specific and nuanced experience. The particular damage done to black girls often comes from our mothers who perpetuate patriarchal standards of respectability and people-pleasing. This is the legacy of girlhood, passed from womb to womb like the secrets of our bodily cycles. What starts as admonishments to keep the girlchild safe (don’t fight, dress modestly) twists to become the base on which our worth is judged. Good girl/Bad gyal. Prude/Slut.

By the time I hit puberty I had absorbed a constitution of rules about good behaviour and decided that being “good” meant being liked by other people. If I was not liked by other people, that meant I was “bad”. And a sure-fire way to be disliked was to get involved in conflict. As a child observing conflict at home, at school and in my community it was clear that nobody liked the angry person who made noise and upset other people. I developed a panic reaction to conflict and tension of any kind, and to this day whenever I perceive conflict my stomach clenches, my breath hitches, and I become acutely aware of my heartbeat. I became sensitive to the barest hint of discord and in anticipation of that physical reaction I avoid, avoid, avoid.

So at work when someone raises their voice, or grumbles under their breath or takes an inordinately long break time and cannot be found, I hesitate the next time I need to ask that person to do their job. My anxiety doesn’t care that it’s the job they’re being paid to do; my anxiety’s only concern is protecting me from a potentially stressful situation. This ingrained response has kept me alive and safe so far, but the work I do is so much bigger than my anxiety.

So I keep trying to grow beyond my survival mechanisms to a version of myself who can be brave. I find solidarity in the realm of social justice where there are plenty of loud angry women doing their best to dismantle systems that oppress and harm entire groups of people. But mostly I hold on to this lifeboat of questions.

Why is it important for me to stand my ground? 
Who suffers if I stay silent
How will things change if I don’t 
What kind of example am I setting?
So what if they don’t like me?

I don’t get it right all the time, and most of my progress comes in the tiniest of steps. But I’m here to take up space in this fight. And no matter how imperfectly I try I will continue to take up space and work toward the future I want to believe in: a future where little girls don’t get boxed into respectability. A future where women aren’t afraid of their voices.

A future where all of us are brave, and vulnerable and radically compassionate with the world, and with ourselves.

Desolate, yet all undaunted

There are days when I feel like a balm in Gilead and then there are days when I feel like a band-aid on a diabetic foot. On days like those, when my best intentions butt up against the machinery of social injustice like a very small recalcitrant cog in a very large and impersonal wheel, on those days I dream a little dream about the kind of system I want to work in, and the kind of care I want my patients to receive.

In my dream, healthcare is widely acknowledged as a fundamental right. Instead of flexing their defense budgets, countries flex their high life expectancy and superb quality of life. Within governments across the world, health and wellness ministries get the lion’s share of resources because without them people would literally die. This includes ministries responsible for food, housing, water and electricity so that people can eat with clean hands in safe dwellings and store food in healthy ways.

In my dream, we preach and practice the bio-psycho-social model of health by recruiting and training a large cadre of mental health and social health professionals, alongside nurses, doctors and pharmacists. Mental health isn’t stigmatized, it’s a routine part of formal education (along with gender and cultural studies) from the kindergarten level onward.

In my dream, no one struggles to pay for healthcare because there’s no such thing as ‘payment’ for a service that is essential to human well-being. Healthcare providers are treated with dignity and respect by their employers, who understand the traumatizing nature of the work they do and encourage them to take care of their own health. This way they do not fantasize about migrating with their expertise to work in more lucrative environments. We retain enough healthcare providers of various disciplines so there are no long waits for non-urgent care. We have enough equipment and people to maintain the equipment because management no longer believes in quick fixes and ignoring a problem until someone else has to deal with it.

Patients can wake up at a sensible hour and easily travel to their nearest health facility, because it is always less than an hour away. They can visit their provider, do their investigations and fill their prescriptions on the same day. Language interpreters are available, bathrooms are gender-inclusive and all facilities are accessible for persons with disabilities.

Because providers take the time to explain complex treatment regimens with patience and empathy, patients take an active role in their healthcare and don’t only worry about their health when they get sick. Because there is close communication between primary and secondary healthcare providers, treatment interventions are oriented around the patient, their family and community, instead of a rigid hierarchy. We change our model of medical education to prioritize prevention, primary care and public health instead of obscure diagnoses and competitive sub-specializations, recognizing that these are necessary things but the vast majority of medical graduates will not become pediatric neuro-oncologists.

I dream a dream where even in the tiniest clinic in the furthest district beyond the last streetlight a midwife or a health inspector or a community aide has the power to change a system that perpetuates the very conditions we try so hard to treat. Instead of feeling like a useless band-aid, doomed to watch the wound fester and never heal, I hope we can reach for the idea that there is a better way.

When we feel like things can change,
we might actually
try
to
change
them.

And then, who knows what might happen? This is the part where I always wake up, shake the sleep from my eyes and get back in the arena to fight. Another day of being balm and band-aid, the believer and the battle cry. Another day to dream and press on, to make the dream come true.

.

Featured Photo credit: Luis Villasmil on Unsplash

on Universal Healthcare

I believe that healthcare is a human right. No one should have to suffer from a treatable disease because they cannot afford to access treatment, and no one should end up in debt after surviving illness. Jamaica is one of the few countries in the world that offers universal healthcare: Jamaican citizens pay no user fees when they access healthcare in public facilities. We also have the advantage of an extensive primary care network of health centres (clinics) that can be easily accessed by most communities.

There are many people for whom this type of healthcare is the only option. And there are many people for whom this type of healthcare is a last, last resort. Because I spend most of my time working closely with the former group, the disdain of the latter group always takes me by surprise.

I enjoy my work. I and humbled and gratified to watch people come into clinic worried or in pain and leave feeling calm and pain-free. I am delighted to complete an application form to the National Health Fund (NHF) so that my patients with chronic illnesses can access much-needed medication for a fraction of the cost. I am happy to sit and listen to the hard stories of their life, knowing they don’t often get the kindness of a friendly ear. I am excited to teach them about nutrition and how their medications work – even better when they actually heed my advice.

But there is still so much more that can be done, and that is why Jamaicans who can afford to will always choose private healthcare.

After I see a three-year old with an ear infection and write a prescription for antibiotics, the nearest public pharmacy is too far away for the parent to consider making the trip. In Hanover where I work, there is only one public pharmacy in the capital town of Lucea. Not to mention, the NHF only covers drugs for chronic conditions like diabetes, hypertension and asthma. Antibiotics and painkillers, which cost thousands of dollars, are not included. Private health insurance is not a feasible option for most of my patients either. If it was, I’m certain they wouldn’t be lining up in the clinic.

Another issue is the wait time. It’s a running joke, a widely known fact and a painful embarrassment that the waiting time in public health facilities is really, really long. Visiting the health centre for a routine visit can take hours, if not all day. Getting an appointment at the specialist clinic in our nearest tertiary hospital takes months. Waiting on an elective operation like a hernia repair can take years. Then after waiting for so long to have their concern dealt with, patients often encounter burnt out and unsympathetic health care providers who are tired and stressed from seeing too many patients with too few resources.

When it comes to diagnosing diseases the wait time gets even more sinister. Waiting for a Pap smear result in the public system takes anywhere from three to nine months, if it ever comes back at all. Privately? That takes two weeks. Screening mammograms (recommended annually) aren’t offered in the public system in Western Jamaica any at all. Biopsies (for example, when we’re suspecting cancer) in the public system have to be expedited by paying for them, otherwise the result could take months to return.

Photo by Nikko Tan on Pexels.com

Contrast the crowded, hot waiting area of a public health centre with the air-conditioned insularity of a private office. A doctor or nurse who smiles with you instead of frowning at the added workload at the end of an already long day. The appeal of private healthcare goes beyond shorter wait times to the perception that having to pay for something automatically means it is higher in quality. But that’s a discussion for another day.

Today I only want to wonder what public healthcare would look like if it received the lion’s share of resources. What if we had enough space in our waiting areas so that people didn’t have to sit outside? What if we had enough staff so that essential tasks didn’t have to be neglected? What if we had enough vital, essential and necessary drugs so that people didn’t have to choose between buying food and buying their medication? What if we injected resources into preventative services (health education, screening programmes, behaviour change) so that we could ease the burden on our hospitals? What if our policies ensured that staff could take proper vacation leave (not this minuscule two weeks a year that most people save up to take two months at once)? What if we had enough money to pay people so they wouldn’t need to add second and third jobs to try and make ends meet, further contributing to their burnout?

What if there was no one who benefits from an arrangement that strips the powerless and poor of their dignity while literally condemning them to die?

Universal healthcare implies some kind of equity, but there are too many gaps in our system that people can fall through. The burden of filling these cracks is carried by people who are already struggling under a system that does harm to their well-being. Perhaps when we emerge from this public health crisis, the government will finally recognize the undervalued role of public health and primary care and make meaningful efforts to improve the quality of health we offer our people.

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If you’re interested in more readings like this, check out my post on The Case for Primary Healthcare. For a more poetic take on this rural doc life, you can read Why Hanover.

Is your DIY face mask working?

Since the onset of the COVID-19 pandemic, face masks have become the accessory du jour. Because of the increased demand for masks and other types of personal protective equipment we are on the brink of a global shortage where we may not even have enough supplies for frontline health care workers.

Some savvy individuals have started making their own reusable cloth masks out of various fabrics such as cotton or scuba. Available in a variety of patterns, they’re stylish and cost-effective. But do they work?

People seem to think they do. I had to visit the Emergency Department recently and saw the majority of doctors and nurses wearing brightly coloured, simply designed reusable masks. They were made by a local dressmaker who was selling three masks for $1000 JMD. The purpose of buying three was to interchange the masks, ostensibly to minimize soiling. Still, members of staff wore these masks for hours, whether or not they were directly interacting with a coughing patient.

My gut instinct says they’re probably not as effective as a disposable medical mask, but what does the literature say?

The first thing I learnt is that there is limited research on the efficiency of reusable fabric masks. Cloth masks have been studied from as far back as 1905 and as recent as 2017, with ambiguous conclusions.

In 2013, this article in the Journal of Infection Control acknowledged the historical use of cloth masks in protecting healthcare workers from respiratory illnesses1, and highlighted the lack of evidence around the efficiency of cloth masks, calling for further research. They argued that in an outbreak developing countries would not be able to consistently afford disposable surgical masks and respirators, but policy guidelines made no reference to the use of cloth masks, possibly because there wasn’t enough evidence.

The authors go a step further and tease out recommendations to improve the efficiency of reusable cloth masks (higher thread count, more layers and muslin instead of gauze), but they point out that most of their evidence comes from studies conducted in labs with mannequins as opposed to actual healthcare settings.

A 2015 randomised trial of cloth masks compared to surgical masks in Vietnam compared the outcome of clinical respiratory illness, influenza like illness (ILI) and lab-confirmed viral illness between clusters wearing disposable surgical masks and reusable face masks2. They found that the rate of all infections was highest for persons wearing cloth masks, particularly the rate of ILI and lab-confirmed infection.

(This is the only randomized control trial of cloth masks. )

A 2017 study in the Journal of exposure science evaluated the efficiency of three types of cloth masks and one type of surgical mask commonly used in developing countries in reducing exposure to particulate matter3. The study compared the filtration efficiency of each mask to the gold standard – N95 respirators. They concluded that:

Compared with cloth masks, surgical masks are more effective in reducing particulate exposure

And finally, The Lancet recently published an article discussing the “Rational use of face masks in the COVID-19 pandemic”4. The authors compared the policies of eight different health authorities on the use of face masks. Notably, China was the only country that explicitly recommended cloth masks or ‘non-medical masks’, and the recommendation was for persons at ‘very low risk’ of infection (those who mostly stay at home or in well-ventilated areas).

One interesting observation is that none of the studies I found examined whether wearing cloth masks was harmful i.e. associated with increased risk of infection compared to no mask at all. Theoretical discussions suggest that wearing a mask without a medical indication could increase your risk of infection if the mask is used improperly or for long periods or if you develop a false sense of security and forego other preventative measures such as hand washing. But before the advent of mass produced disposable masks, cloth masks were our best protection against infection. Can they help us still?

There is a plethora of emerging research on all things related to COVID-19, an outbreak which has been described as the greatest clinical challenge of our generation. Now is the time to explore and evaluate cost-effective resources for health, especially as the pandemic threatens the health of the most vulnerable among us.

References

1 Chughtai AA, Seale H, MacIntyre CR. Use of cloth masks in the practice of infection control – evidence and policy gaps. Int J Infec Control 2013 9(3). doi:10.3396/IJIC.v9i3.020.13

2 MacIntyre CR, Seale H, Dung TC, et al. A cluster randomised trial of cloth masks compared with medical masks in healthcare workers. BMJ Open 2015;5:e006577. doi: 10.1136/bmjopen-2014-006577

3 Shakya, K., Noyes, A., Kallin, R. et al. Evaluating the efficacy of cloth facemasks in reducing particulate matter exposure. J Expo Sci Environ Epidemiol 27, 352–357 (2017). https://doi.org/10.1038/jes.2016.42

4 Feng, S., Shen, C., Xia, N., Song, W., Fan, M., & Cowling, B. J. (2020). Rational use of face masks in the COVID-19 pandemic. The Lancet Respiratory Medicine. doi: 10.1016/s2213-2600(20)30134-x

in 2020 (on Progress)

You ever see something ridiculous and think ‘Really? Is this still happening in 2020?’. Like, men still can’t say the word ‘two’. . . in 2020? Hanover still doesn’t have a Burger King. . . in 2020? Jamaica still doesn’t have a sexual harassment bill. . . in 2020? We still gonna argue about climate change. . . in 2020?

Jamaica is light years behind the rest of the Western world when it comes to LGBTQ+ rights and inclusivity. The closest we get is when the national HIV programme focuses on sexual risk reduction among key populations (as determined by international donors) like men who have sex with men and transwomen. In the past the government hasn’t put much effort put into understanding the lives of these individuals beyond getting them tested at workshops and lymes and ensuring they took their meds if diagnosed positive. This service gap encouraged the development of civil society groups like Equality Jamaica and Transwave, which advocate for the rights of LGBTQ-identifying folks in a holistic way, not just zooming in on their sexual practices.

The habit of defining people by their sexual practices has always rubbed me the wrong way. The intellectual defense put forward by many in my field is that not every man who has sex with men identifies as gay or bisexual. Which, fine, I understand that, but many more of them do identify that way. Or are afraid to identify as gay/bisexual because of the possible repercussions. And that’s important to acknowledge too. It is awkward as hell to have a conversation about sexuality with someone you’ve just met, and for most patients the revelation happens after building the therapeutic relationship, if it happens at all. But regardless of who my patients choose to have sex with, I try to create a space where they can feel accepted.

I’ve always taken the position of affirming people’s identities and respecting their life choices, while the rest of my colleagues politely tolerate the ‘alternative lifestyles’ of the people we work with. Do I wish we could all be a little more open-minded and accepting? Yes, but I’m also grateful that I haven’t heard any complaints from patients (yet) about being treated poorly by staff members based on their perceived sexual orientation. For the most part health care workers are getting better at customer service and professional behaviour, whatever their personal beliefs. And that’s major progress.

There’s still much more work to be done in erasing stigma and discrimination due to homophobia. A lot of it is systemic, related to our laws and policies. But so much more of it is cultural and community based. Recently my supervisor exhorted the team to see MSM as individuals, not just patients with high risk behaviours. At first I was annoyed because, Obviously. They. Are. People. That’s what I’ve been saying this whole time! But then I was grateful. Because this was the same supervisor who two years ago had advised me to refuse care to a transman seeking advice on transitioning. And if that isn’t progress I don’t know what is.

Our healthcare system has a lot of catching up to do. When I look at models of healthcare in other countries, I recognize the outdated practices and policies that are holding us back. Some of it is a broader cultural mindset of paternalism and individualism but who is to say which came first? What I hope for is a cultural and psychological revolution, what I work toward is effecting a little change every day in my circle of influence. The progress is heartening, a reassurance that we are moving in the right direction, however slowly. Huge changes don’t happen overnight, but they happen. Through the dedicated effort of committed people, change starts somewhere and then spreads across the world.

Why Hanover

From time to time I get quizzical looks when I tell people that I work in primary care (aka clinic) in Hanover, one of Jamaica’s most rural parishes. The eyebrows climb even higher when I further explain that no, I don’t have a private office somewhere.

Fellow doctors wonder how I survive on the salary (and compared to my hospital colleagues it is meagre). Patients who connect with me are disappointed that I only work in hot, overcrowded government facilities and not some low-traffic office with an air-conditioned waiting room. Would-be mentors are perhaps bemused by my preference for this rural space that offers little in the way of career advancement.

But I continue to choose Hanover year after year, even though my feet itch with wanderlust and three years is the longest time I’ve stayed in one place since high school.

But why?

Well, the parish is beautiful. Lucea overlooks a picturesque bay of rolling blue sea. Cascade overlooks lush green hills of swaying bamboo. For almost the entire length of the highway that passes through Hanover the sea is a few scant feet away from the road, replete with stunning sunsets and the cool calm breeze of true island living. But that isn’t it.

I stay in Hanover because I believe there is so much good I can do here.

Whether it’s running the parish’s first treatment clinic for persons living with HIV, or saying yes to every single patient that turns up at clinic in the hills no matter how full we already are, or spending the extra time to listen to an old man reminisce about his favourite son – there is so much good I have done, and so much that I can still do.

Clinics have a bad rap among patients. Somehow people developed the idea that hospital doctors are better (this is laughable because Hanover is so tiny that the same clinic doctors often also work at the hospital) and that clinics are not worth their time. But in the time that I’ve been working in Hanover (did I mention it’s been three years?) I’ve been so lucky to work alongside doctors and nurses who care passionately about the overall well-being of their patients, not only about their blood pressure or HbA1c.

The magic of primary care is really how one doctor or one nurse or one community health aide can make a dramatic difference in the outcome of a person’s health. The beauty and the privilege of my job is watching people not just improve their condition, but thrive with care and support.

The fulfillment that I get from my daily work reminds me why people look at medicine as a calling and not just a job. And while I won’t always work at the level of individual patient care, the purpose of my duties will always remain the same: to bring quality healthcare to the people who truly need it. They say you never forget your first love; and wherever I work in the world whether elsewhere in Jamaica or further abroad it is and always will be Hanover that has my heart.

Trigger Warnings & Trauma-Informed Care

trigger warning (n): a statement at the start of a piece of writing, video, etc. alerting the reader or viewer to the fact that it contains potentially distressing material

Back when I worked in an urban clinic there one doctor would be rostered to cover ‘police cases’ i.e. cases of sexual assault. I dreaded this duty. We all have our weak spots, and sexual assault is one of those scenarios where it’s impossible for me to maintain professional detachment. But it was part of the job at that clinic, and it didn’t seem like an opt-out deal.

I wondered, what if I was a survivor of sexual assault? I was already so uncomfortable, how would I have managed if this was actually a trigger for me? Do our supervisors check to make sure we’re psychologically prepared for this kind of duty? Or is graduation from medical school supposed to guarantee a certain level of psychological fitness?

Recently I participated in a training session for healthcare workers on mental health. The group was discussing self-harm and suicide, a topic that was bound to come up in any kind of training around mental health. But the attitude of a few group members caught me off guard; they were dismissive and flippant. When someone used the phrase “attention-seeking” I had to step outside.

The debate around trigger warnings has gained in velocity and vitriol in recent years. Opponents of trigger warnings label and shame people with mental illnesses as weak. Social media has watered down the phrase so that it’s become a joke, a meme or a gif. Still survivors and their supporters try to carve out safe spaces, where people coping with trauma and depression can exist without sudden and painful reminders.

Should work be a safe space?

For healthcare workers, that would be impossible. We can’t predict what issues the next person will have. The patient is our first priority and we create safe spaces for them.

But what if we could create a work environment that protected the mental health of patients and staff too? What if we went to work acknowledging that other people might be dealing with trauma? What if we recognized the impact of trauma and proactively tried to reduce harm?

I don’t think trigger warnings are the best way forward. Jamaican society exists in a constant state of high tension, repeated trauma and triggers. Trigger warnings at work would be undermined by newspaper headlines, radio talk shows and social media. The added stigma against mental health would make the suggestion laughable at best and condemned at worst. But there might be a middle ground.

The mental health training session wrapped up with an introduction to trauma-informed care, a novel approach that will hopefully change the way we do things. Trauma-informed care emphasizes psychological and emotional safety for providers and survivors. A trauma-informed system realizes the widespread impact of trauma, recognizes signs and symptoms of trauma in patients, families, staff; integrates knowledge about trauma into policies, procedures and practices and avoids re-traumatization.

In a world besieged by natural disasters, civil wars and states of emergency, we need healthcare that is attuned to the realities of our experiences. If we are traumatized as a society we need a system that supports everyone, patients and providers, in achieving good health. Ensuring our organizations are trauma-informed is the best way forward.