Dispatch # 6 - Dhaka Airport
A few people have asked where they can make a donation to help the refugees.
The organization I am volunteering with is called MedGlobal. They are doing great work in the camp by providing top-notch medical care in an underserved area of the camp. They are also supporting the work of their local NGO partner, Prantic Unnayan, and the health initiatives of OBAT Helpers. They also run missions to Greece, Lebanon, Sierra Leone, and Venezuela.
If you want to donate to broader refugee relief efforts that address issues beyond healthcare, check out the International Rescue Committee (disclosure - my sister works for the IRC, great organization) or the UNHCR.
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Thirteen days, eleven shifts, and at least 300 patients. Thirteen breakfasts of rice and vegetable curry. At least 40 hours driving through the countryside to-from camp. A few tom-tom rides and three morning beach runs.
A few highlights
- The sounds of the camp. Very few cars or motors. Kids in schools reciting their lessons. The afternoon call to prayer echoing throughout the camp summoning us to leave clinic and head for the van. Kids poking their heads out of bamboo huts and running alongside our path shouting "bye-bye" whether we were coming or going.
- Getting to flex my MacGyver muscle. The clinic was well appointed but many times I had to jerry-rig an appliance to get it to do what I needed - fashioning nasal suction for an infant, connecting a catheter to a bag with random tubing that was the only thing available, using plastic cups for a spacer for an inhaler, doing skin exams outside because the light was better (okay, this last one was just common sense).
- The medicine is the same. Some illnesses show up that we don't usually see back home - Mumps, chicken pox, weird fungal skin infections - but looking over my patient list each day, most patients were there for colds, COPD, diabetes, heart failure, reflux, body aches. It reaffirms our common humanity and the similarities between all people. Eventually everyone's gotta die of something and the organs that can become sick are limited in number and the same for everyone.
- Kids love games. Driving home every afternoon from the camps, the recently harvested rice fields were teeming with kids. Kids chasing each other, kids playing cricket, badminton and soccer, kids flying kites, kids using a stick to roll a metal ring. In the camp, there was one area on the outskirts where kids played soccer but in the heart of the camp there are tons of badminton/volleyball nets where groups of 6-10 kids play a version of volleyball-soccer where you have to get the woven bamboo ball over the net without using your hands. No screen time, no social media. I am definitely romanticizing this childhood I see through the windows of a visiting NGO volunteer - there are countless injuries, broken bones, bullying, and real-life struggles. But it also reminds me of the childhoods many of us (falsely) recreate for ourselves that are closer to the stories told of our parents' memories of growing up in the 1960s than our actual childhoods filled with a combination of outdoor time, the advent of the internet, and afterschool programming with formal instruction.
- The beach is beautiful. It's not the cleanest water. And along the edge of the road there are heaps of trash. But in some areas, at low tide, it's more than 300 yards wide. With no one in sight. And maybe a beautiful moon boat bobbing on the waves in the distance.
- I've said it before but I was amazed by the engineering in the camp. It doesn't feel permanent but I describe it as modular and solid. Lots of reinforced earthen features - staircases built into hillsides with the steps reinforced with bamboo ledges and gutters alongside and sandbags packed with mud for the steps themselves. Pit latrines but with concrete siding for the pit and concrete covers for the waste holding tanks. Shelters made of bamboo and plastic tarps but the bamboo is woven into two layers of thatching that sandwich the tarp and keep dwellings dry from the typhoons. Houses that are in flood zones or landslide zones are clearly marked by the UN and it's clear their engineers have scoured the hillsides to study and document the current state of affairs.
Other random thoughts
- My two translators were fantastic. They speak English as well or better than I do. They translated some questions that were culturally insensitive but important for medical reasons (i.e. "Are you sexually active?" "But she said her husband died last year." "Yes, but that's not the question - are you sexually active?"). We spent 7+ hours a day together, joking, working, and sharing meals. I appreciated their strengths and weaknesses as I'm sure they did mine. And yet, few things make me more depressed than thinking about their future. Two guys, with newly broadened horizons - one of them says he reads Google News each morning on his phone - who are smart and driven - studying "Learn to Speak English Like an American" YouTube videos - and who are unable to apply for refugee status because they are stateless and thus can't be formal refugees. I heard about one's 3.5 year-old daughter and the other's mother who died one month ago in the camp. Being a translator is a relatively good job in the camp. As camp residents, they aren't allowed to be employed, but they can "volunteer" for NGOs that can reward their volunteering with "incentives" that pay $115/month (regulated by UNHCR and the local government). To put this pay in context, a doctor working at the public government hospital makes only $280/month. But they still aren't allowed to get a formal education, they are prohibited from learning Bengali, and there's no potential of working outside of the camp.
- Working in resource-poor settings can lead to bad/risky decisions. It is easy to fall into the mindset, "if I don't do anything they'll die and there's no other option available." This may be wrong on both accounts. Simply "doing something" may actually cause harm; call it a sin of commission versus a sin of omission but basic medical ethics typically prefer the latter, except for emergency medicine which may lean towards sins of commission. And to say "there's no other option available" isn't totally true. We were able to transfer some patients. Some could go for a higher level of care, others could simply go to a facility that was open 24/7. But the lack of resources and the desperation of the situation definitely clouded my judgement 2-3 times where I still lay awake at night wondering if I made the right decision with those specific patients.
- Limited resources makes for painful decisions. For example, there are no AEDs or defibrillators in our clinic or really anywhere in the camp. The implication is that if someone has a cardiac arrest in the camp, it isn't worth it (purely from a resources and expected outcome standpoint) to resuscitate them. This ignores the 1-5 people who may be helped by having an AED around, who would magically be brought to a health clinic in time for something to be done, and who would then survive without needing further support or intervention. The odds are extremely low. But that's a decision that the NGO community has made and again, for the 1-5 people (remember population 1 million) who may fit the criteria, it sucks.
- It's currently illegal to test for HIV/AIDS. We had point-of-care HIV tests in our clinic but the Bengali government doesn't allow us to use them. According to our field coordinator, Bangladesh doesn't report HIV/AIDS statistics to the WHO. You can't have a problem if you don't measure it, right? Even if anti-retroviral therapy isn't widely available, I wish we could have tested pregnant mothers in order to prevent vertical transmission from mother to baby. FWIW, the minister of health is planning to allow 8-10 clinics to start testing for HIV in the camps within the next few weeks.
- Sounds like I got out just in time. Today (12/14), one of the volunteers who's still there said that the government is cracking down on NGO workers, refusing visas to those newly arriving at the airports, telling NGOs they won't be allowed into the camp all weekend, and stopping vans for "random" searches along the road. There is a general national election coming up on December 30, which may have something to do with it. For my last two days, we had to carry our passports with us at all times because more and more NGO vans were being stopped on the way to/from clinic for passport checks. Glad I went when I did and lucky I was able to get out.
I am now safely back in the US. I celebrated passing my EM boards with a burger and craft beer. And I can't wait to get home to my wife and dog.
"We don't sail because the sea is there. We sail because there's a harbor. We don't start by heading for distant shores. We seek protection first."
- From We, The Drowned by Carsten Jensen
The organization I am volunteering with is called MedGlobal. They are doing great work in the camp by providing top-notch medical care in an underserved area of the camp. They are also supporting the work of their local NGO partner, Prantic Unnayan, and the health initiatives of OBAT Helpers. They also run missions to Greece, Lebanon, Sierra Leone, and Venezuela.
If you want to donate to broader refugee relief efforts that address issues beyond healthcare, check out the International Rescue Committee (disclosure - my sister works for the IRC, great organization) or the UNHCR.
===============================================
Thirteen days, eleven shifts, and at least 300 patients. Thirteen breakfasts of rice and vegetable curry. At least 40 hours driving through the countryside to-from camp. A few tom-tom rides and three morning beach runs.
A few highlights
- The sounds of the camp. Very few cars or motors. Kids in schools reciting their lessons. The afternoon call to prayer echoing throughout the camp summoning us to leave clinic and head for the van. Kids poking their heads out of bamboo huts and running alongside our path shouting "bye-bye" whether we were coming or going.
- Getting to flex my MacGyver muscle. The clinic was well appointed but many times I had to jerry-rig an appliance to get it to do what I needed - fashioning nasal suction for an infant, connecting a catheter to a bag with random tubing that was the only thing available, using plastic cups for a spacer for an inhaler, doing skin exams outside because the light was better (okay, this last one was just common sense).
- The medicine is the same. Some illnesses show up that we don't usually see back home - Mumps, chicken pox, weird fungal skin infections - but looking over my patient list each day, most patients were there for colds, COPD, diabetes, heart failure, reflux, body aches. It reaffirms our common humanity and the similarities between all people. Eventually everyone's gotta die of something and the organs that can become sick are limited in number and the same for everyone.
- Kids love games. Driving home every afternoon from the camps, the recently harvested rice fields were teeming with kids. Kids chasing each other, kids playing cricket, badminton and soccer, kids flying kites, kids using a stick to roll a metal ring. In the camp, there was one area on the outskirts where kids played soccer but in the heart of the camp there are tons of badminton/volleyball nets where groups of 6-10 kids play a version of volleyball-soccer where you have to get the woven bamboo ball over the net without using your hands. No screen time, no social media. I am definitely romanticizing this childhood I see through the windows of a visiting NGO volunteer - there are countless injuries, broken bones, bullying, and real-life struggles. But it also reminds me of the childhoods many of us (falsely) recreate for ourselves that are closer to the stories told of our parents' memories of growing up in the 1960s than our actual childhoods filled with a combination of outdoor time, the advent of the internet, and afterschool programming with formal instruction.
- The beach is beautiful. It's not the cleanest water. And along the edge of the road there are heaps of trash. But in some areas, at low tide, it's more than 300 yards wide. With no one in sight. And maybe a beautiful moon boat bobbing on the waves in the distance.
- I've said it before but I was amazed by the engineering in the camp. It doesn't feel permanent but I describe it as modular and solid. Lots of reinforced earthen features - staircases built into hillsides with the steps reinforced with bamboo ledges and gutters alongside and sandbags packed with mud for the steps themselves. Pit latrines but with concrete siding for the pit and concrete covers for the waste holding tanks. Shelters made of bamboo and plastic tarps but the bamboo is woven into two layers of thatching that sandwich the tarp and keep dwellings dry from the typhoons. Houses that are in flood zones or landslide zones are clearly marked by the UN and it's clear their engineers have scoured the hillsides to study and document the current state of affairs.
Other random thoughts
- My two translators were fantastic. They speak English as well or better than I do. They translated some questions that were culturally insensitive but important for medical reasons (i.e. "Are you sexually active?" "But she said her husband died last year." "Yes, but that's not the question - are you sexually active?"). We spent 7+ hours a day together, joking, working, and sharing meals. I appreciated their strengths and weaknesses as I'm sure they did mine. And yet, few things make me more depressed than thinking about their future. Two guys, with newly broadened horizons - one of them says he reads Google News each morning on his phone - who are smart and driven - studying "Learn to Speak English Like an American" YouTube videos - and who are unable to apply for refugee status because they are stateless and thus can't be formal refugees. I heard about one's 3.5 year-old daughter and the other's mother who died one month ago in the camp. Being a translator is a relatively good job in the camp. As camp residents, they aren't allowed to be employed, but they can "volunteer" for NGOs that can reward their volunteering with "incentives" that pay $115/month (regulated by UNHCR and the local government). To put this pay in context, a doctor working at the public government hospital makes only $280/month. But they still aren't allowed to get a formal education, they are prohibited from learning Bengali, and there's no potential of working outside of the camp.
- Working in resource-poor settings can lead to bad/risky decisions. It is easy to fall into the mindset, "if I don't do anything they'll die and there's no other option available." This may be wrong on both accounts. Simply "doing something" may actually cause harm; call it a sin of commission versus a sin of omission but basic medical ethics typically prefer the latter, except for emergency medicine which may lean towards sins of commission. And to say "there's no other option available" isn't totally true. We were able to transfer some patients. Some could go for a higher level of care, others could simply go to a facility that was open 24/7. But the lack of resources and the desperation of the situation definitely clouded my judgement 2-3 times where I still lay awake at night wondering if I made the right decision with those specific patients.
- Limited resources makes for painful decisions. For example, there are no AEDs or defibrillators in our clinic or really anywhere in the camp. The implication is that if someone has a cardiac arrest in the camp, it isn't worth it (purely from a resources and expected outcome standpoint) to resuscitate them. This ignores the 1-5 people who may be helped by having an AED around, who would magically be brought to a health clinic in time for something to be done, and who would then survive without needing further support or intervention. The odds are extremely low. But that's a decision that the NGO community has made and again, for the 1-5 people (remember population 1 million) who may fit the criteria, it sucks.
- It's currently illegal to test for HIV/AIDS. We had point-of-care HIV tests in our clinic but the Bengali government doesn't allow us to use them. According to our field coordinator, Bangladesh doesn't report HIV/AIDS statistics to the WHO. You can't have a problem if you don't measure it, right? Even if anti-retroviral therapy isn't widely available, I wish we could have tested pregnant mothers in order to prevent vertical transmission from mother to baby. FWIW, the minister of health is planning to allow 8-10 clinics to start testing for HIV in the camps within the next few weeks.
- Sounds like I got out just in time. Today (12/14), one of the volunteers who's still there said that the government is cracking down on NGO workers, refusing visas to those newly arriving at the airports, telling NGOs they won't be allowed into the camp all weekend, and stopping vans for "random" searches along the road. There is a general national election coming up on December 30, which may have something to do with it. For my last two days, we had to carry our passports with us at all times because more and more NGO vans were being stopped on the way to/from clinic for passport checks. Glad I went when I did and lucky I was able to get out.
I am now safely back in the US. I celebrated passing my EM boards with a burger and craft beer. And I can't wait to get home to my wife and dog.
"We don't sail because the sea is there. We sail because there's a harbor. We don't start by heading for distant shores. We seek protection first."
- From We, The Drowned by Carsten Jensen
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