Tuesday, April 12, 2016

The practice of reflection is integral to fully realize the experience.

I am a volunteer for 4 weeks with Project HOPE. All opinions expressed are my own and do not represent the positions, strategies, or opinions or Project HOPE.

The end of last week added some additional learning experiences on top of the work I have been doing at the hospital. Last post, I talked about how I have worked on teaching the internship students and medical students while at the hospital. After a day in the hospital, one of the internship students asked if I would like to go out and have a coffee or lunch somewhere in the city. It was a gorgeous sunny day and in the 70s (global warming…) and we went to a large national park within the city of Pristina called Germia. We took a bus which cost 0.40 euros to the park. At the park entrance was a bike rental, tennis courts, and an enormous outdoor swimming pool that is filled and opens in June. We walked through the park along a path that threaded through fields where children were playing soccer and on playground equipment. It was spring break here in Pristina, so the children and their families were taking advantage of the warm weather. On the other side of the path was a large hill with flowering trees and trees starting to bud. We walked along this path and stopped at a bench to enjoy the outdoor weather, drank at the fountain with reportedly some of the best water in Kosovo (at least in the city of Pristina!), and talked all along the way. Some teenagers that we passed shouted out a greeting and asked “Where do you come from?” I responded “New York.” He shouted back “I love America! I was just in New York.” We continued our walk to the end of the path where a large restaurant sits amidst the trees and the playgrounds and had a traditional local lunch of peppers in cream sauce with cornbread and garlic bread to dip as well as fresh salads of cucumbers, tomatoes, onions, olives, and cheese. My friend and I talked about everything - current TV shows and movies, hopes and plans for the future. I asked if she would mind telling me about her experience during the war. She said of course - it is one thing that friends don’t talk about much in Kosovo. Many people suffer from PTSD, and now that the war is over, want to put the past behind them. She says she knows everything about many of her friends, except where they were during the war. 

My friend was living in Pristina with her family. She was 11 when the NATO bombing started in 1999. They were initially told the bombing wouldn’t last for more than one week. After 10 days with no end in sight, her family fled south to Macedonia. They spent 5 days sleeping outside at the Macedonian border in a neutral zone then entered into a refugee camp inside Macedonia where they lived for 3 months before being able to return home. She remembers life in the camp to be well organized and structured. They did not worry for food or shelter. The biggest concern she remembers is that her sister was 5 months old at the time they fled Pristina and due to shortages of food, her parents were constantly worried that her sister would not survive. Her sister now has scholarships to study abroad in prestigious universities in the field of her choice. When they returned home, their house was still intact although there had been looting of some of their possessions. They had left everything behind except essential items and passports when they fled for the Macedonian border. I think about the current refugees and migrants sitting along the border in Greece where they are being sent in boats back to Turkey. So many people I have met who were in a similar crisis situation leaving their war-torn country only 17 years ago have been some of the most inspirational people I have met. They are people determined to advance their education and use that education to help improve this new independent nation that the war was fought in order to achieve. 

Later that evening I went to the local mall with one of my other friends. There is a 5-D “60’s” cinema that you can pick two short movies to watch. In addition to 3-D glasses, the chairs move so that you feel as though you are in the movie. When it rains in the movie, you get rained on in the theater. It was pretty entertaining. 

Due to some scheduling conflicts, plans to revisit the refugee transit center in Macedonia were postpones. Instead, my colleague and I decided to explore the immediate surrounding area of Pristina. We had a fantastic guide, Alban Rafuna (www.beinkosovo.com) who brought along his extraordinarily bright 7-year-old daughter Noliana with him. We visited the predominantly Serbian populated village of Gracanica where one of the best preserved Serbian Orthodox Churches/Monasteries is located. Like many Serbian churches, this one is surrounded by a high brick wall with barbed wire on top of it. The Monastery is still in active use by the Orthodox nuns and is beautifully preserved. We were not allowed to take pictures within the church, but the frescoes inside were breathtaking. It is hard to believe that they are the original frescoes from the 1300s when the church was build by the ruling leader of the time. After this, we headed to an archeological site, the old city of Ulpiana which dates back to the time of the Illyrians - the original predecessors of modern Albanians. Three areas have been excavated within a large area of farmland outside the city. It was picturesque with flowering apple tree orchards dotting the countryside around it. Here we met a beautiful stray dog who fed our scraps of food and spare water to. We traveled a bit father out in the countryside up to Novobrdo Fortress which is in process of renovation. The village below was filled with flowering trees surrounding an old mosque and the ruins of a church that have been many years without use. We had lunch at a restaurant atop an adjacent hill with views of cows and sheep grazing on the green grassland below. We took our leftovers from the meal and revisited the stray dog to feed her our scraps. 

Sadly, one of many stray animals in Kosovo

Prizren at night
That evening on a whim, I went on a drive back to Prizren with some friends in order to see the city at night from the top of the fortress. I hadn’t been feeling all that well the past few days after eating far too much of a milk cake that I think was likely going bad (unfortunately discovered post-consumption in the GI ailment that followed and persisted for days). But, sick or not, I did not want to miss this opportunity! I was not disappointed. The city of Prizren is even more magical at night. 

Friday brought along with it another enriching encounter with an inspiring Kosovar who is the executive director of an NGO called Action for Mothers and Children (www.amchealth.org). I was connected with the director through one of the internship students I met who was on the previous rotation through labor and delivery. This foundation has connections to Dartmouth in the US and she connected with them while spending 3 months studying electronic medical record systems at Dartmouth as part of an exchange program. AMC was originally founded in 2009 in conjunction with USAID with grant money. In 2012, that grant money ran out, but determined to continue the work of the foundation, it became a locally run NGO. Its emphasis is on women’s and children’s health with the original mission to reduce maternal and child mortality rates in Kosovo which was one of the highest in Europe. The statistics are mostly unofficial as there is not a system in place for keeping track. They have multiple projects with the primary aim of education. There are 5 educational resource centers throughout Kosovo which offer classes to women and their partners. Most of the classes are aimed to prepare women for labor and delivery and in prenatal care (nutrition, smoking and alcohol cessation). They also have classes on newborn care. Currently, they are working to establish a national screening program for cervical cancer and to create a national transportation system for babies to be transferred to the only Level III NICU in the country in Pristina when a higher level of care is required (currently, the babies are transported privately by car). The aim of AMC is to provide research and evidence-based information to the people of Kosovo and also to use that information to advocate for policy changes. Some of the advocacy is being done for the health insurance system in development to ensure that prenatal care is included as part of the health insurance package. Prior to AMC’s lobbying efforts, this was not included in the original plans. The main office has 5 employees who all take on a number of projects. They are a group of highly motivated people dedicated to the improvement of health outcomes for the people of their country. 

Thursday, April 7, 2016

Finding my niche

I am a volunteer for 4 weeks with Project HOPE. All opinions expressed are my own and do not represent the positions, strategies, or opinions or Project HOPE.

This past weekend, my fiancé Michael came to visit me from Germany. It was his first time in Kosovo. Unfortunately, he started not feeling well the day he left and continued to not feel well the whole weekend. Despite having to take it easy and not being as ambitious in our plans as we had hoped, we still had a great weekend!

Stone Bridge of Prizren
On Saturday, we took the bus to the city of Prizren. Prizren was the original capital city of the region in the era of the Ottoman Turks. It is strategically placed along a river and within a valley of beautiful mountains. In Kosovo, it is one of the areas where Turkish heritage is best preserved - Turkish is still taught in a lot of the schools and the local cuisine tends to have more Turkish influence than in other parts of Kosovo. The bus ride took approximately two hours and en route, Michael slept and I read about the city and formulated a plan for the day of things we may want to try and see while there. We took a walking tour along the river up to a fortress dating back as early as the 6th century overlooking the city. En route up the steep hill to the fortress, we passed by the ruins of a Serbian Orthodox Church - St. Savior. It is completely enclosed within a metal gate topped with barbed wire and is watched over by a caretaker. This Church was destroyed during riots in March 2004 and is in process of restoration. The church itself was built in the 1300s and some of the frescoes on the wall can still be made out - those that weren’t destroyed in 2004. While wandering through the inside of the now open air church, one can imagine the beauty of it when it was complete. Continuing up the steep hill, we reached the fortress and the view was spectacular. We could see the entire city below and the surrounding mountains. Standing on top, we stood quietly and listened as the call to prayer rang out across the mosques in the city below. We grabbed lunch at a place along the river specializing in Albanian cuisine and happened to be present when a large entourage of political figures came to dine at the same restaurant. The roads were blocked off by police cars. After lunch, we continued our walk through the city. We walked past many of the city’s highlights including the League of Prizren which is considered the original group advocating a nationalist movement for Albanians in Kosovo since the middle ages. We saw multiple mosques and another Serbian Orthodox church destroyed in 2004 and now in process of restoration. Sunday, we took a walking tour of Pristina before Michael headed back to Germany.

Serbian Orthodox Church - St. Savior. Destroyed in 2004.
I feel as though I am getting into my niche at the hospital. I have had multiple students, residents, and specialists ask me if I have done any deliveries/episiotomies/c-sections and I said, no, but that wasn’t really my primary focus for being here. This is true, and I really do feel like I have an alternate purpose in being at the University Hospital. As I mentioned in a previous post, I am working towards providing educational resources for the faculty (residents, students, midwives, nurses, specialists - whomever!) to have on hand on labor and delivery so that when there is some down time, they can look at evidence-based guidelines and try to make the University Hospital up to international standards of care. I have emailed some PDF files to one of the residents and provided the residents with a brief textbook of Ob/Gyn so that there is at least something to start from.

Kids playing outside in a public fountain on a warm spring day in downtown Pristina
I have discovered two additional roles for myself that have certainly provided me with a sense of purpose, and I hope have contributed positively to the experience of the others I am with on a daily basis. There are many medical students that rotate through labor and delivery. Medical education is difficult. There are many more students than there are positions available to them after the finish their studies. If you are not at the top of the class, the chances you will find a residency program and especially a program that will pay is limited. After completing 6 years of medical studies (this is a bachelors/masters degree), they do a 6 month internship. Afterwards, they must work for 1-2 years as a general practitioner and then can apply to residency. The number of spots are limited within specialties so there is a chance that the specialty one is interested in may not have an available spot at the time you are ready to start residency. A choice is made to start residency in another specialty or to wait. Residency positions within the university or public hospital system are paid but not a living wage (I’ve hear anywhere between 500-700 euros per year) and private residency training is not only unpaid, but requires the resident to pay for the job and training. For Ob/Gyn, residency is 5 years. After that, many physicians do not make a living wage working in the public hospital system and so have private practices on the side. Because of these limited opportunities in training, many students and residents will leave to complete or do further training abroad, many with plans to not return to Kosovo given the limited opportunities here for work. If such highly educated people are not paid a living wage for their work, I worry that an educational drain will exist in Kosovo whereby everyone who can leave, will leave. 

Medical students very much take on the role of observer when doing their practical part of training (during medical school and during the internship). They are sometimes engaged by the specialists but there is not a lot of teaching that happens at the bedside. Some of the this is the hierarchical culture of the training system but some is just a lack of time - with 10,000-12,000 deliveries per year, there is not a lot of down time on labor and delivery for teaching. I have tried to personally fill in this gap by engaging the medical students and trying to teach things that are applicable to the clinical situation they are observing or to answer any other Ob/Gyn related questions. This is one role I have been trained to do as both a medical student and a resident and I am happy to be able to fill the role of a teacher while I am here.

The other role I have made for myself is being the support person for the woman in labor. Since family members are not allowed on labor and delivery, the first time moms seem the most nervous and unsure. Although I do not speak Albanian, the effect of holding a hand or rubbing someone’s shoulder, head or back when they are in pain gives the support I am unable to provide with words. In my normal day-to-day residency work, I often have too much to do to be able to provide this one-on-one support for the patient in labor. In the US, many of them have family members or friends who come to support them and also have awesome labor nurses who are their support people. It has been nice to take that place for the women who deliver at the University Hospital in Kosovo. For me, this role as part of the care of the patient has been invaluable, and I think more meaningful for the patient than if I were the one sitting on the other side delivering the baby. 

Monday, April 4, 2016

The Halfway Mark

I am a volunteer for 4 weeks in Pristina, Kosovo with Project HOPE. All opinions are my own and do not represent the positions, strategies, or opinions of Project HOPE.

Those who know me well know that I tend to operate a little more on the glass half empty side of things. When I find that the glass is half full, it is positive; whereas, if my expectations are met, I am no worse for wear. 

Kosovar medical students and me after a rousing game of Uno
I would like to approach this moment in my time in Kosovo as a glass half full. Of course, I am amazed that already two weeks have gone by that I have been here, but I am pleased to still have two more weeks to take part as a visiting member of this lovely society in Kosovo. My colleague and I have some working plans for Project HOPE and are looking forward to the implementation phase of our plans. I am getting more comfortable in my physical environment. For example, when I first arrived, the overhead light in the bedroom of the apartment did not work. It still doesn’t work. However, there was a lamp on the desk that does work. The problem is with having enough outlets to charge my electronics. I have a computer that needs charging every night, my personal USA cell phone that I use when I am in a WiFi network that needs charging, my local phone that needs charging, and occasionally a camera battery, iPad, Kindle, portable bluetooth speaker, or iPod. (I realize I’m a bit of an electronics junkie although I will not claim to be an aficionado in anything electronic). When I wanted to go to bed and read, there was no light to use if I wanted my phone to charge, so I read with the backlight of my kindle which often made me very tired and prone to falling asleep prior to 9PM when I first arrived. After a few days in one of the desk drawers, I found an American power strip. This helped the charging problem for all of my electronics except my local phone (which has a European plug) and the lamp. So I could either have a working local phone, or light when it became dark outside. Finally, after two weeks of living here, I happened to wander past and notice the European power strips at the supermarket! So now, I have light AND a charging phone. It’s the small things that can create a lot of joy.

Albanian Flag outside the League of Prizren Museum
The other issue I have had living physically in the hospital at the end of a patient ward is entering the building and getting to my apartment. I am on the fourth floor at the end of the postpartum unit. There is no way for me to enter or exit the building without going through a patient ward. This isn’t so much the problem as the fact that the front doors of the building are locked sometime between 7-8PM and you have to go through a side entrance. This is also not so much of a problem except for the past two weeks, I have had to literally break into the hospital in order to get to the area to go up the four flights of stairs to get to the postpartum unit and walk through that and show my badge and get to my room at the end of the unit. There is a set of double doors and U-shaped iron bar is placed over the handles to create a lock. With some of the doors, you can open them wide enough to squeeze a small hand through and remove this bar. In one of the sets of doors, this is not possible and I had to knock and wake a sleeping patient or visitor (not sure which) that was lying on the bench on the inside and have her open the door for me so I could enter. Well, when I got back tonight (at 8:40 PM) from dinner with friends, I went through the side entrance, through the doors that miraculously did not have the U lock on them, but found that the other set of doors that I was unable to open wide enough to remove the U lock had the lock on. I happened to see that another visitor who I noticed enter the building behind me entered through a corridor that opened into the main area of the hospital. So I backtracked and discovered this open corridor. My life in the evening has just become 1000x easier. Let me tell you, I have so much more appreciation for freedom of movement in so many aspects of life then I did before. From the limited movement available to Kosovaars with the Visa Problem to my difficulties getting to my apartment where I live, I have a new appreciation for the freedom I have in my life to move from one place to another and would number that as something that should be considered a human right. 

Outside the Parliament Building in Pristina
I have thought about this a lot as I have read about the history of the region - I read a book by Robert Kaplan called Balkan Ghosts that discusses the entire Balkan region and its utterly fascinating history filled with conflict and various authoritarian powers and limits placed on the movement of people within the region. It is also something that was in the forefront of my experience visiting the refugee transit center. The whole reason for its existence being limitations of the freedom of movement. It is something I have only given thought to in passing such as thinking about my most important physical possession - which for me is my passport because it allows me the freedom of movement. All of our human ancestors dating back to the start of the species were nomadic - prior to the advent of agriculture, we all came from hunter/gatherer societies that depended on the freedom of movement for survival. Limitations in the freedom of movement has impacted survival.

Speaking of movement, Michael was visiting this weekend and we went on a day trip to Prizren, Kosovo. Unfortunately, he was feeling quite sick after he got here so our trip was not as full as either one of us had hoped it would be, but we still had a great time visiting a new place.