Sunday, April 19, 2009

Partners in Health

I was looking at the monthly e-newletter from PIH, which is the organization founded by Paul Farmer, MD. The book MOUNTAINS BEYOND MOUNTAINS details the life and work of this extreaordinary physician, who is treating the poorest of the poor in Haiti, and in many other places now as well. He has tremendously changed the way international health programs deal with Tuberculosis and HIV/AIDS. The article which caught my attention is by a midwife who is volunteering in Haiti, and was answering a question-- "what is women's health?" She answers that when women are coming in for screening for cervical cancer (Pap smears), they ask questions about their children, and their children's health, and also about sexuality, relationships with spouse or significant other, contraception and family planning, domestic violence, how to increase the family income so their children can have a better future, nutrition and self-care, among other things.
These are the same sorts of concerns women have here, and yet we are supposed to code the visits only around issues of a "gynecologic finding or disease". I am sick of this myopic set of rules, with built-in non-rewards for trying to meet the needs of patients one-on-one, in the issues of their lives. I am sick of the insurance companies knowing what I talk with my patients about, because I don't think it is their business, and it removes privacy from the patients. The whole stupid morass we got into with HIPPA was to help with privacy, but it is a freeway of information to the insurance company while there is a stranglehold on being able to give family members relevant information to help them deal with the illnesses of their loved ones.
Anyway, I really love the work that PIH is doing in Haiti and in other places, and one of the most valuable things is to give each patient an accompanying person, as an advocate who helps keep them coming for their appointments, and who makes sure they are eating and sleeping, and taking their medicines. Small stipends are given to the starving patients with Tuberculosis, to make sure they get enough to eat. Traditionally, Tuberculosis is a disease of poverty, and when people can't eat well, they are so tired and listless that they end up dying of this disease. They NEED to eat, to be able to keep their immune function strong. Same with HIV/AIDS. SO the idea of the "accompagnateur" is vital.
What is also a big piece of the puzzle for countries with very high amounts of poverty-stricken people is that there are not enough resources for public health. This includes the money for securing a safe water supply-- putting in wells and pipes and plumbing for towns; and keeping the latrines away from the water sources. In Paraguay, most of the children were severely anemic, because they walked barefoot, and hookworms would enter their feet from the grass. The hookworms have a fecal pathway, and if the rains washed contaminated waste matter into the grasses and fields, the next cycle would begin again. We were able to reduce the childhood anemia and infestation rates tremendously once we started helping each family to get a concrete floor for the latrines, and to help them choose a site for it where the water supply would not be endangered in the flooding rains.
I hope you will take a look at the PIH website, and maybe become a donor. The work they are doing is so important!

Saturday, April 18, 2009


Those of you watching my blog for awhile know that I am totally inspired by the work of Thomas Ball, the filmmaker. He has now introduced me over the internet to the work of a marvelous Italian photographer, Luca Campigotto. I tried to paste the website onto this site, but am not sure you can see it, so I am adding this note. Here it is:
His work is really interesting, and he has photos from all over the world. I love the ones of Anchor Watt. Crumbling Buddha heads. Also there is a hauntingly lovely one of the ancient coliseum, curved walls of arches. Many marvelous ones of Venice, and the large boats, and the equipment of massive movement of things onto and off of boats. Check it out!!
Also, if you have never looked at the Venetian Red website, the current show being discussed by the author, Liz Hager, is a lovely mobile by an Indian lady artist. It is birdlike, and interesting.

Wednesday, April 15, 2009

Spring: thoughts on women's needs

Actually I wrote this in 2007 in the Spring, for a Christian website.

I realize that it has been about a month since my patient with ovarian (or actually primary peritoneal) cancer has gone home. This is a lovely thing. She has been keeping in touch with her oncologist; and calls me once a week, to go over how she's doing. I am so happy that she is still eating a little, and not in pain, although her belly is swelling again. She knows the path ahead is narrowing. But she is able to be at home with her family; and her husband is very dear, and the children come round and help, and make her special foods, of which she eats a little.

There is an article in the Nation this week about the problems of the women who are the caretakers in our society. I would say it is also a problem for the husbands, such as the husband of my patient I am telling you about. But women especially need to have social laws which support the caregiving functions. Our laws unlike most of the civilized world, equal Lesotho and Swaziland in absence of paid maternal leave; and almost no progress has been made in helping women to bear the double burden of working outside the home and caretaking within it, since the 70s. Most women need to work outside the home just to help pay the bills. We need guaranteed health care, paid parental leave, high quality child-care, a living wage, job training and education, flexible work hours, more opportunities for part-time employment, community solutions for mass transit and housing, It is interesting to think that if we could put all these structures into place, to help women be better caregivers to meet family needs, that we might be a shining light for other nations in how to do so. We just might break the back of the problems of sexism, and lack of opportunity to shine for half the human race. I just read an article in the New Yorker that said 1 million children worldwide per year are engaged in child prostitution. We have all the problems of women dying of childbirth, and insufficient health care in countries like Afghanistan, where a repressive religionist group is holding women hostage. There was an article in Glamour, of all magazines, which said that 60-80% of women in Afghanistan are "married" off to an older man to pay off a family debt; many are treated like slaves, with abuses: and there has been a terrible escalation of deaths of young women from self-immolation with cooking oil.
In America, 21 million women live below the poverty line. We need so much to help get women stabilized, so the children can be raised in better environments. I personally believe that this sort of governmental policy work will help stabilize marriages. When women are overworked and exhausted, and there is no end in sight, they start feeling it is the fault of their husbands. If we could give families a break, helping mothers to be able to get more rest and "down-time," we would help reduce some of this desperation and inability to bear the daily life "sturm und drang" of modern life.
I was listening to the tapes from my recent retreat with Father Allender, on transcending anger. He says this wonderful line about how scary it is for young couples getting married, to enter a situation that has a greater than 50% failure rate. It carries so much intrinsic stress now; and we have not generally seen that changing the social and legal rules about "the common good" could help to shore up this fragile structure. I see it every day, as women hit the wall, trying to do everything, and suddenly the body is just unable to cope with it all. About the 7th month of pregnancy, women feel like they are running a marathon, and they have the last 3 miles to go. It would be so great if I could say "honey, you go home and put your feet up, and have a cup of tea. Your disability check will help pay the rent until you are up and functioning, a few months after you have your baby, and your milk is coming in, and you are back on your feet again. Just don't worry about it now." I could drop the cortisol levels in my patients so much, if I could say that line. Rich or poor, good job or bad, they all hit that wall. I feel if I could just reach the husbands and fathers, we could have a change of governmental policy-- because as they look at the women they love, they can see this is true.
Well, here's to you. Happy spring again, love, martina

"History may not repeat itself, but it definitely rhymes"
Mark Twain

Monday, April 13, 2009

An apocalyptic vision

I was driving down through the green hills and valleys of California to see my mom for Easter, and a lovely vision came to me, which seemed like a potentially possible future; no less potential than the Book of Revelations' vision of all the events of the hallucinatory "rapture". The vision unfolded quite fully in my mind, and a rosy picture it was, which made me smile; and if it comes to pass when I am alive and still able to get up and dance, I will dance, like David danced with the Ark of the Covenant!

The newspapers and magazine articles' story goes like this:
The first woman elected to the papacy by the college of Cardinals in Rome has taken the name Pope Mary Magdalene I. She was highly favored to be a winner, but after 2,000 plus years of male-only papacies, it seemed almost inconceivable that she would actually be voted into office. Her closest friends in the college of cardinals, known affectionately as the "Tres Teresas" or the 3Ts, Terese of Lisieux, the French-speaking cardinal of Singapore, Teresa of Avila, cardinal from Southern Argentina, and Teresa Benedicta of the Cross, cardinal from Northern Germany had spoken very highly of her administrative skills, communication skills, and holiness.
"She is a very charismatic person", Teresa Bendedicta said, and "will be a great asset in helping to form more cohesive Catholic communities around the world."
Pope Mary Magdalene I has said that she will continue to wear the habit of her order, the Daughters of Charity formed by Mother Teresa of Calcutta, with the wide blue band along the rim of the white veil and sari-gown. She will walk barefoot to the throne of Peter, as a reminder of the vows of poverty taken by the sisters in her order.
One of the male cardinals who was said to be very much in opposition to the election of a woman, however holy, to the papacy, has said that he now will attend the consecration and Mass, because it came to him in a dream that "divine love conquers all". Most of the male cardinals seemed genuinely gracious and pleased, as they believe the election of a woman is a long-awaited fulfillment of the Gospel promise that we are all children of the living God, and brothers and sisters in Christ. Cardinal Bernard of Clairvaux, the head of the Benedictine order, was especially clear that this follows what St. Paul said in the epistle to the Galatians, that we were baptised into Christ, and "there is neither Jew nor Greek, slave nor free person, male nor female, for we are all one in Christ".
Both the Italian Cardinals, Ignatius and Dominic were won over by the sensible and kind behavior of the new pope. They were both impressed with her preaching, and her life of service to the poor.
The first promulgation from Pope Mary Magdalene was to ask each archdiocese to have a local site for pilgrimages within each archdiocese, where a representation of "the empty tomb" should be displayed. "Every Catholic Christian should have an opportunity to make a pilgrimage to a place which reminds us of this fundamental miracle of our faith; and of the importance of Easter, which makes us people of the Resurrection" she said.
She has also asked the College of Cardinals to promote ways to be better stewards of the earth as part of the duty of Christians, and to make plans to increase the ecologically sound practices of growing vegetables and fruits within each archdiocese especially for the needs of the poor and the sick; and wherever feasible to convert the church buildings to wind- and water- and solar-powered energy sources.
Sister Misericordia of the Franciscan Sisters of the Poor in South China was in enthusiastic admiration of the idea of growing food within the purview of the church properties-- as this gives a good role model for secular organizations to follow.
All over the world, women rejoiced, as this brings a new feeling of equality and shared stewardship in God's creation and in the full expression of holiness within the lives of women. The "Tres Teresas" have also said that this will help ensure the full protection of children within the offices and functions of the Catholic church, as Pope MMI is dedicated to protecting all children from abuse and exploitation through better policies and enforcement of existing regulations.

Wednesday, April 8, 2009

"Bread for the Stardust Pilgrims"

My third book of poems is at the printers's. This is the title. The first poem is called "I am from California" (see below). I am very excited to have the new book coming out. If you want one, send me $8.00 (includes shipping and handling) to the address posted here. If you want it inscribed, please let me know. I feel like this was the best gift I was supposed to exercise in my life, and I have managed to put these poems into books, and now here comes the third book! It feels like blowing kisses to God!
It is very hard to find a market for poems. So I finally realized that instead of spending a small fortune entering contests, and sending poems "cold turkey" to small literary magazines, in the hopes of having them accepted for publication, I should just produce the books. As it turns out, several small presses have accepted poems for publication, and I am grateful that my "babies" have moved out into a life of their own-- and in such very fine company! The first publication that accepted my work was the Nimrod Journal from Oklahoma. I believe the most elegant is called Chrysalis. The one I was delighted to be accepted by for this year is called Bitter Oleander. My work has also appeared in The Bilingual Review, The Griffin, The Healing Muse, The Meridian Anthology of Contemporary Poetry, North Dakota Quarterly, Phoebe, The Pikeville Review, Westview, Wisconsin Review, and Zillah, a Poetry Journal. Last week I got an acceptance from the Minnetonka Review. So it is a nice thing to have blown these dandelion seeds to the winds, and I hope the poems live beyond me!
I also am going to have the "Rose Windows in the Cathedral of Mary" printed this year. So there will be four books in print. I will still honor the offer I made when I started this blog, that if you buy 3 books for $24.00, you get the fourth book for free. I do hope that people will take comfort in them, and enjoy them as a sort of bread, made for pilgrims made of stardust in this amazing universe!

" I am from California"


I am from light on the water,
And the shimmering leaves of live oaks in summer.
I am from the Camino Real
And the California missions;
I am from the Pacific ocean in all seasons,
From the Big Sur to Mexico:
Flying buttresses of sandstone and the jade ponies
Dancing and prancing to shore with foaming manes,
From sage and chaparral,
Here where the stardust lands with the moonshadows
On the great golden hills.

I am from the summer tamales and ripe avocados,
The women in red satin on white horses; from
Ave Maria, and Carmelita, and Tio Juan, and Pancho,
From Soledad and Dolores.
I am from the high highs, and low lows,
The laughter and melancholy;
The puns and nicknames and poems,
the hysteria and grief,
From Cinderella's slippers, and Rumpelstiltskin's threats;
I am from the stations of the cross and the rosary,
And the hunger for the bread of angels.

I am from California, in the eighth generation,
Only loosely tied to America the beautiful.
I carry a green strand from Ireland,
Where the FitzGerald cattle walk home
On the shingle of the western shore;
We eat enchiladas with green chiles for St. Patrick's day.
I carry the songs of my grandmother,
Who sang like the swallows coming home
To Capistrano;
And from my father at the piano
Holding every melody in the warbling songs.
I am from the 40 boxes of Dad's slides and photos,
The paintings on the walls,
The portraits of my sisters,
The house like a living museum,
The Spanish silk shawls on the balcony,
The cut glass vases,
The bowers of roses,
The music box with the gilded cherubs, the dappled light on the patio in summer,
The red geraniums in the terra cotta planters.
I am from California,
From light on the water,
Where the stardust lands with the moonshadows
On the great golden hills.


By Martina Nicholson MD
Peace Corps, 1972-74

The almost dead woman came from seven leagues away, on an oxcart, on a Sunday afternoon. Dr. Orihuela came to our house to find me, to ask for my assistance, as all of the nurses were home with their families at farms outside of town that day. He told me she was in obstructed labor for 4 days, and that the baby had died inside, and that she was moribund. He said maybe a cesarean section would save her life; he wasn’t sure. It might be just too late. Still, the family had brought her, and he thought he should try. Of course I said I would help, but since I never had seen or assisted at surgery before, that he would have to tell me what to do. We went to the Centro de Salud, stopping to get the dentista on the way; this fellow had learned the art of dripping ether onto a gauze-covered strainer over the patient’s face— and thus was our anesthesiologist.
Dr. Orihuela had been trained at the Adventist hospital in the capitol, and he had meticulously taught some willing young women to be nurses, and to sterilize and keep the OR things ready for surgery. We had the pink alcohol which was used for lighting lamps, and yards of muslin bandages. All of the instruments were sterilized in an antique but functioning sterilizer. The OR was lit with sunlight, and one bare bulb.
We carried the moaning and glazed-eyed woman into the OR and put her on the table. The anesthesiologist put some ether over her mask. I was told to be careful not to breathe too closely to it. I remember how hard it was to get the uterus clean from the thick pea-soup meconium. The dead baby was removed. I realize now it was a classical uterine incision. Vertically cut into the muscle, at the top the uterus is so thick that it is very difficult to stitch together again, even in healthy tissue. This tissue was inflamed and wooden. The stitches kept tearing through. Dr. Orihuela worked carefully and as quickly as possible. When the anesthesia became too light, I would lean my arm against the patient’s thighs to keep her from writhing off the table. When she fell too deeply asleep, Dr. Orihuela would tell the anesthesiologist to take the mask off and let her breathe for a while, real air. Finally, all the layers were done, the skin was closed and bandaged. Beads of sweat were on my forehead, and my nose itched through the surgical mask. I helped lift the patient and carry her to the post-partum bed. Her urine was red as cranberry juice, and the doctor thought she was going to die of kidney failure or possibly lack-of-blood-clotting problems.
I could not sleep all night; I prayed she would live. The doctor’s wife, Na Irma, told me that one problem is that the patients would wait too long to come; and if they died, other people would believe the hospital was a place for dying, not a place to be saved and to become healthy. They would blame the doctor, instead of understanding that the disease was too advanced. She told me that when a patient is cured, people always thank God; but when a patient dies, they blame the doctor.
I paced in my room, and before dawn, I walked back to the Centro de Salud. The woman had a catheter, and the bag for urine was now full of pale yellow liquid instead of red wine-colored urine. The doctor came in early, too. She was very pale, but he said she would live. He took her in the VW van to the capitol, to get a blood transfusion. He said it would help her not to get a puerperal infection.
Two weeks later, I was giving my morning charla to the waiting patients at the Centro de Salud. A rosy-cheeked young woman walked up to me and said “Hello, doctora Martina!” and looked expectantly at me. I looked blankly, trying to recall ever seeing her before. “Don’t you remember me?” she queried, “I’m the patient whose life you saved! I will never forget you.
Twenty three years later, I am an Ob-Gyn. I have done many cesarean sections since, but none with a clearer sense of its life-saving potential. My desire to become an Obstetrician was born that day, and I have told this story many times to explain why I became a doctor. I have never regretted the long path it took to get me to where I could be able to perform such a service. I have also never forgotten how Dr. Orihuela had diligently and quietly prepared for that day. Without his foresight, there would have been no sterile equipment, no clean and functioning OR, no electrical generator and running water in the Centro de Salud. Almost alone among Peace Corps Volunteers, I was working for a physician who cared deeply about public health and was doing the best he could to be like the Johns Hopkins missionary physician who trained him. One looks back with gratitude to mentors who were truly men of great stature, and I will always be grateful that I worked in Ybycu’i under Dr. Orhuela’s great example.

Saturday, April 4, 2009

Women who write

I am finishing the 3rd book of poems, and working hard on the figuring out of the title. I will post it as soon as I am sure of it. Today's Writer's Almanac says that men like women who write. It is probably not true in my case. My husband is not glad that I say anything to anyone about him. He believes in privacy and anonymity, and considers me like a leaky faucet in his life. He is not happy about it, but he has continued to let me live, while he grumbles.
In my AlAnon group, once after a meeting, several women were visiting together. One woman said that she has known married men to "hit on" women in the group, even when it is inappropriate. I said that it is good that we have been sort of encouraged to have same-sex sponsors, so that it will help us to maintain healthy boundaries, when we have not been good at boundary-setting before. I admit, I have been an amoeba to other people's needs. After the conversation, I went on thinking about this issue. I think the men in the group are very privileged to hear women's inner thoughts. We don't talk back, or "cross-talk" or counsel. We simply listen. So some women, working on an issue inside their own minds, are laying out their thinking in a "safe place" for the first time. Many women came from homes with a tremendous amount of emotional abuse, and were completely shut down and unable to allow themselves to communicate beyond a bare survival level. We see this all the time in the places where life is more primitive, and the gender roles more restrictive. The way we have structured the 12 Step meetings, people are encouraged to share their experience, strength and hope. This allows everyone access to our insides. Which is a sort of emotional penetration, which others in the group are privy to, without having to know the person well, or do any connecting work. I realize that there is still some "weight" attached to the issue of gender. The other day we were talking after surgery with some nurses who are like me, with grey hair and a couple of decades of "health care" experiences. I was remembering how it felt to walk into the surgical lounge during the Anita Hill/Clarence Thomas hearings. The guys were incredulous that this should be happening on tv, to someone who was being vetted for the Supreme Court. We still had a few guys who were up until that time telling off-color jokes, or teasing nurses, or flirting a bit too outrageously. That was the beginning of the wake-up call, I think, for a lot of the guys to watch what they were doing, and be more respectful in their manners and speech. Most of the men I have known have been respectful in their thinking, but some of their behavior was a bit rough; and they have learned the necessary lessons for acting more professional and reasonable and respectful in the workplace.
Now, we also have a lot of women writing, and "spilling their guts" in various formats. So it is an interesting thing to think about the question of whether men love women who write, or are alarmed, or just entertained by it. It certainly is a way to talk about the emotional contents of our thoughts, and we are able to give someone an extensive insider's tour of our minds, without having to face us across the breakfast table, or discuss the household tasks, or to undress or touch in any physical way. So there will be voyeurs, and there will be some interested bystanders who go home and understand their own wives and daughters better, and some for whom this is a major form of learning about human nature.
I was thinking about Chekhov. He has always been a wonderful model of a physician to me, although most people think of him as a writer. He is so thoroughly looking at the patient, and the forces acting on the patient, and the milieu in which the patient exists, that one can practically name all the medical diagnoses in the people of his stories. Once I read a fascinating article about writers who are so graphic at describing reality that even a disease which was not yet known at the time of the writing can be inferred from a description by one of these writers.
It remains interesting to me that most of the male writers write about men with more clarity than they do about women. Women are often written more as an "object of affection" or interest, rather than from the inside, in novels from the previous centuries. And also, women had the handicap of less education, so often their thoughts could not be as complex as the thoughts of men, and be believable. It remains to be seen whether there will be a new sort of gain from the women writing now, into the interiors of women's minds, not just as romantic partners, but as independent thinkers and interesting people to know. And sort of a side issue, is whether this "window into the interiors of the womens' minds" will yield a new level of friendship and integration of self and other, and interactions with both men and women.