Period of Complete Adjustment

21-August-2011, 1725

The end of August is coming up very quickly and my excitement can’t be contained since yours truly will be heading back to the playground down south.  I decided to just go back to Cairns, Australia on my 60-day PNG visa restriction because that will be the shortest trip.  The thought of going to Singapore, Fiji, Brisbane, Sydney, or New Zealand crossed my mind many times, but since time is of the essence, I decided not to as I really didn’t want to be spending precious play time on midair.  I booked a nice and decent hotel right at the heart of the Esplanade, close to the shopping centers and the Casino.  Maybe this time, I will try my luck and my itchy hand at the Caribbean Stud Poker.  I am really looking forward to this nice break again, and this is going to be the very last one as well.

I suppose I can say that my mindset has now completely adjusted to all things PNG.  I honestly admit that I had a very hard time psychologically adjusting in the beginning.  But around the middle of the assignment, ever since my entire focus shifted to work and objectives that I set for myself in this Fellowship, my appreciation of the whole experience itself turned around.  One of my saving grace is the Alcoholics Anonymous prayer line—“GOD, grant me the serenity to accept the things that I cannot change, courage to change the things that I can, and wisdom to know the difference”.  I framed this on a PPT slide, printed it, and tacked it at my desk wall so that every morning and every time I sit behind my desk, I am reminded of the true purpose and objective of me being here.  I understand that I will not be able to change everything or most of the things that I identified and outlined that needs changing or modifying.  Even if I am just able to bring about change in practice in one or maybe two items that I identified, I will be able to say that I made a difference in PNG and that I had done my job as a Global Health Fellow. 

Having said that, I immerse myself at work and spend my time working with PNG folks at the clinics.  They enjoy my company when I am working side by side with them at the VCT counselors’ room, at the treatment room, at the STI examination room, even at the reception area.  Patients and clients shake my hands as the nurses introduce me.  Last week, I tried to comfort a patient who will be receiving her second IM shot of Benzathine Penicillin G 2.4 million Units for primary syphilis infection.  Matt, the male STI nurse was a bit apprehensive because the client was a female.  He described to me the procedure he’s just about to do.  He will be giving the 10 ml IM injection once at the dorsogluteal site.  I learned quickly that PNG nurses have never been taught or heard of the ventrogluteal site.  A quick demonstration and teaching soon followed as I gave him the evidenced-based rationale on why VG site is more superior to DG site.  We both identified landmarks after obtaining informed consent.  I described to Matt the Z-Track technique.  We had to divide the shots into two this time since it was 10 ml.  I gave the first, he gave the second.  The patient actually did verbalize less pain compared to last week’s shot.  After my quick IM session with Matt, I went outside of the clinic to visit the tent where the Case Management Team is holding counseling sessions.  When I went back inside the clinic, almost all the nurses and Community Health Workers (akin to LPNs in US) asked me if I could hold a training session on intramuscular injections.  Matt supposedly told the folks about the new technique he just learned from me.  I now have an additional training session that I will be doing in September. 

Two weeks ago, the clinic physician asked for my professional opinion on a case of a 35 y/o cachexic and HIV+ male who has been having progressive further weight loss and productive cough.  Acid fast bacilli on the sputum were negative X 3.  Thank goodness I always bring a handkerchief with me.  Quite subtle pulmonary changes and infiltrates were evident at the most recent CXR.  Both the physician and I were thinking of either pneumocystis carinii or jejuvecter pneumonia.  He will have a return visit the following month for a repeat CXR and AFB test, then will be decided to start on quadruple anti-tuberculous medications—INH, Ethambutol, Pyrazinamide, and Rifampicin. 

Pulmonary tuberculosis is one of the prominent problems in PNG aside from STIs and HIV, there’s no doubt about it.  With the case I just described above, and many others similar to this one, the clinics and the community have a weak knowledge on the disease process, pathophysiology, treatment, prevention, and protection.   I developed a simplified training program on pulmonary tuberculosis for the community outreach volunteers, clearly identifying the statistics of TB in PNG from World Health Organization.  Then, we talked about Standard Precautions, Transmission-Based Precautions, and Airborne Transmission.  I strengthened the notion of physical barrier (mask, handkerchief) and handwashing.  Every single one of the OVs and Field Support Supervisors were so interested that we exceeded the time limit again.  Many questions and comments came afterwards.  At the very end of it, they wanted me to facilitate another training program, this time on HIV. 

So, it has been a very busy past two weeks and I am happy that its weekend.  I need to catch up on laundry and ironing.  I am really starting to become a master of this ironing craft since I’ve been in PNG.  Yesterday, I took an afternoon nap and was woken up by loud voices yelling and screaming.  Then I hear footsteps running on the street.  Tom and I went to the verandah and we both witnessed a very up close inter-tribal warfare between CHIMBU and TARIMA tribes.  The fight supposedly started with just two men drinking.  A disagreement happened, and the next thing you know, the whole tribe on each opposing ends of the street became engaged in the fight.  It was an all-out brawl needless to say as the men and adolescent young men started bringing out the machetes, axes, bows and arrows, and galvanized iron roof for shields.  The other guys were throwing and hurling rocks, bottles, and bricks in every single direction.  Most of all, the two tribes now engaged in an all-out fight started doing their war chants and cries.  We were just watching in our terrace as it was really a scene to be had.  If this would have happened in May or June, I would have freaked out and said “I’m going back to the States, the heck with this stuff!”.  But I am more sensitized now, it’s as if another event happened in PNG, the land of the unexpected.  I actually found myself saying “Yeah, so what else is new?”

Mid-Assignment Deliverables Getting Done

07-Aug-2011

          It is now August and the days are passing by with a few major deliverables for the GHF program getting done and over with.   Measurable results from the training sessions and formal presentations I did most recently are yet to be seen.  Most of the reviews and comments are glowing however, with most of the staff thanking yours truly for bringing the topics and co-facilitating the training.  To recap, there was the 2-day training on Occupational Health and Safety, Infection Control and Standard Precautions, Bloodborne Pathogens, Waste Management, and Environmental Health.  A week after, a training program was also given for the Community Outreach Volunteers and Field Support Officers on HIV Post-Exposure Prophylaxis as well as a simplified and “toned-down” version of Infection Control in the Community.  Last week, we did another 2-day program for the clinicians, case management team, and FSOs.  This time, we facilitated training sessions on Family Planning, Contraception, and Prevention of Mother to Child Transmission of HIV. 

          The last bit was specifically challenging since contraception and family planning are not really my strongest points in healthcare.  I can stand my ground on the most basic premise of condom use, lubricants, and biological sterilization.  Needless to say, I also had to re-learn and browse up again on the principles of contraception, from anatomy/physiology, down to intended target population, mechanisms of action, how to’s, and contraindications.  In the beginning of the training session, I told the participants the disclaimer that we are all learning in the actual program.  I surely did mention that I will be relying on the expertise and inputs of the clinicians who have a greater deal of experience in the topics for the greater benefit of the group.  Thankfully, we had two physicians and a nurse midwife in our midst.  But, fairly speaking, I was able to re-learn the various methods in time and thus hold my ground on the training sessions.  In fact, I was able to share with the group some literature review tidbits concerning pregnancy in HIV serodiscordant and seroconcordant couples.  I learned that most of the contraception methods that are routinely available in the West are only beginning to gain popularity and acceptance in PNG.  There are the oral contraceptive pills, IUDs, implants, and even female condoms.  Choices such as Mirena, Nuva-Ring, and Ortho-Evra patch are still foreign and alien.  Without a doubt, the most common, widely accepted, and ever popular latex male condom is still the prevalent choice for many.  Having said that, I capitalize on the important message that condoms “kills two birds in one stone” and offers a dual protection and advantage: preventing unintended pregnancy as well as preventing sexually transmitted infections and diseases. 

          These past few weeks have been extremely busy in terms of work.  There were a couple of days when I actually brought work home.  Back in the States, I usually do this anyway, so it is nothing new for me.  I also am aware that this habit is discouraged since it disrupts the work-life balance.  In essence work stuff should be left at work and never be brought back home.  I tried to instill and live by this notion ever since I came to PNG.  Other than the occasional reading of flyers and pamphlets on service delivery programs, I generally leave the bulk of work related stuff at the office.  Only of late did I actually do some training programs and presentations in the comfort of my apartment.  It is such a relief to finish the second training session on Friday.  I have a bit of a breather now and some time to do my mid-assignment report to be submitted back to the company.  

"Breakfast at Tiffany's"

24-July-2011 - 14:47

This weekend has been just like the others, with the prospect of having to face the daunting task of laundry and ironing clothes and filling in the time with something that hopefully will somehow prove to be amusing.  It’s a good thing that Remembrance Day in PNG this year falls on a Monday so we have a three day weekend to enjoy however we like.  I slept in Saturday morning and got up at 0900 and really took my time to do my household chores.  Today, Sunday, Thomas and I decided to splurge a little bit by going to Airways Hotel for a good and hearty breakfast.  The hotel is very posh and Western by all standards, from the pristine white china, to the pure white linen tablecloths and napkins.  Even the coffee/tea cups are petite; it sure reminded me of Rose in the Titanic, sipping tea with lemon quite prim and proper and placing the linen napkins on the lap ever so carefully.  Meanwhile, I also thought that I was back in Cairns Australia once again as I sat down at the familiar tropical rattan chairs underneath wooden ceiling fans and fixtures.  The restaurant is nicely situated with most of the seating arrangement out in the open air facing Jackson International Airport.  I asked Tom if we were still in PNG and he just laughed at me.  He of course understood that I meant the stark contrast of the environment from where we just came from versus where we were at that moment—it was really, quite frankly, palpably different.  100% of the customers and hotel guests were expatriates busily crunching numbers in their IPhones, Ipads, and Blackberries, or reading the business section of the local niuspepa (newspaper).  We both watched as Air Niugini and Airlines PNG domestic and international flights taxied off the runway before lifting for takeoff.  There were some Qantas flights as well, probably heading to Brisbane or Cairns.  I immediately thought that I will be in one of those flights again soon.  September 4^th marks the 60^th day again of my second entry here and therefore I have to leave the country once again and come back.  I am still deciding as to where I will be going this time: Cairns Oz (again), Brisbane or Sydney Oz (though it’s winter in there at this time, and it will be cold), New Zealand (winter also), Nadi, Fiji (hmmm, nice tropicality in here but I only have two to three days to enjoy and I will be spending half of that time in the air), Singapore, Vanuatu, or Solomon Islands.  Most likely it will be Cairns again—one and a half hour flight and I will be in the playground once more.  We’ll see…  Also, there are a couple of days in September when there will be no work because of PNG Independence Day—9/16 to 9/19—and I am also thinking about having a mini getaway once more.  Still prematurely thinking of it at this time, not sure yet, but it would be nice to go somewhere to relax and enjoy. 

Tom and I, the voracious omnivores that we are, both ordered the Combination Breakfast, which is one order of a hot breakfast meal—usually 2 eggs whichever way, bacon, hashbrown, and grilled tomato—and an open continental breakfast bar—pastries galore, fruit juice, fruit bar, dry cereal, antipasti bar, etc.  The traditional egg omelette with onions and tomatoes was dashed gracefully and generously with a little too much salt.  There was one leaf of parsley to add and contrast the color, which I thought was a nice touch.  The hashbrown was the size of a silver dollar.  The grilled tomato was, well, one solitary cherry tomato, which was really cute!  In order to restore the balance and equilibrium as well as the Na+/K+ pump, I also feasted on generous servings of papayas, cantaloupes, honeydews, bananas, and grapefruit slices.  While I was enjoying the fruits of the season, especially the grapefruit, all of a sudden, the thought of hepatic inhibition/induction through the elaborate and confusing cytochrome P450 system emerged in the firing synapses of my neuronal connections.  I thought “Oh my goodness, here goes my fish oil and Diltiazem interactions…”  But in the end, I ate the whole plate of fruits anyway, figuring that I should and would be ok since I only had about three wedges of the citrus grande full of furanocoumarin.    Overall, Airways Hotel restaurant is Grade B+ for service, B+ for food, and B+ for the price.  Like all else in PNG, combination breakfast at Airways Hotel was priced a bit much for what it actually offers.  Not that I am complaining, for I really did enjoy the change of scenery and the experience of having to dine in while watching the airplanes fly.  I suppose the criticisms are objectively stated.

                It was calm and peaceful high noon as Tom drove us back home using the scenic back roads lined with ubiquitous mango trees.  It will be mango season soon enough as evidenced by the densely fruitful trees.  I remember my Mom dearly because it’s her favorite fruit of all.  The mangos that we have in the US I believe are imported from Florida, Costa Rica, or somewhere in South America, and though its good, it absolutely cannot compare to the mangos here in the Pacific.  The aroma alone of the fruit stimulates the senses and induces appetite for it.  Well, there are no mangos yet in the market, and as soon as it hits, I will be having a bounty, take pictures, and post it here. 

3rd Month Into the Fellowship – Bit Busy!!!

Each time I describe all of the activities and undertakings that I do in PNG, there are times when I can’t myself help but feel that I am part of the little circle of friends that include Frodo and the Hobbits, Gandalf Greyhame, Aragorn the Dunedain, Gimli son of Gloin, Boromir son of Denethor, and Legolas of the Woodland Realm.  For those of you who do not know, these characters are from the movie The Lord of the Rings, and are the members of the Fellowship of the Ring, set on a quest and mission on track to Mordor to destroy the Dark Lord Sauron’s “one ring that rules them all”.  I suppose it is because of my repeated use of the term ‘Fellowship” that I have always associated it with my favorite movie series of all time.  One will probably think of me as a nerd or a geek, but there is parallelism that I can totally relate.  No, my quest is not to reach the summit of Mt. Hagen or Mt. Williams in the highland province of Goroka, nor am I set to destroy any piece of jewelry, apparel, or trinket.  My mission is simple yet complex, easy but hard, fun and anxiety provoking all at the same time, but nevertheless an unprecedented adventure that is slated to become an experience I will never forget.  The juxtaposition is so surreal and visceral especially since I am still here and living the experience day in and day out.  The third month is halfway through now and it will soon come to an end again to signal the 6-month Fellowship being halfway done.  It will also herald the start of the 4^th month and the start of the second half of the experience.  I equate it to the trials and tribulations that the young Hobbit from Hobbiton experienced as he and Samwise Gamgee, together with their pots and pans and rock salt from the Shire, journeyed until the end to find themselves triumphant.  I admit that I still have some time to go and deliverables to do so it is still premature to call this journey of mine a winner.  After all, I am still plagued with the stings of isolation and loneliness at times, but thanks to my family, friends, colleagues, and professors from back home for reaching out and checking in on me every so once in a while to say hello.  E-mails like these lifts my spirits up, inspires, and gets me going again.  I suppose it is fair to say that I am now in the process of slow adaptation here and getting used to my daily PNG life.  So, why don’t I give you guys a snapshot of the things at work that are keeping me busy these days…

Workdays are from 8 to 5, M to F.  I go to bed between 830 – 930 PM and I get up at 6 AM to start the day.  Two weeks ago, I started to roll out one of my major deliverables for the Fellowship (there it is again) and that is to train a group of unlicensed assistive personnel at the clinics on how to obtain vital signs correctly and properly.  See, one of my objectives is to improve the client flow in the two busy clinics I am working with.  It sounds so simple, doesn’t it?  Initially, I thought it was going to be a rather easy undertaking but now that I am implementing and taking action on it, I find it not so simple as I thought, matter of fact, it is rather complex, at least in the logistical sense.  The idea is to train this group of individuals so as to actively take part in patient care.  In so doing, all patients will have their vital signs taken and the flow of patients will be a bit faster since the licensed clinicians will go directly into assessment, treatment, and prescriptions.  You are wise if you had figured out that not all clients in the clinics have their vital signs obtained.  As a matter of fact, majority of them don’t.  This is the primary reason why I made it one of my major objectives to deliver.  In my mental image, the unlicensed assistive personnel will be obtaining the vital signs before they get seen and it will be most prudent for the clinicians to glance at the vital signs results first when they get the medical chart and identify any questionable results before they proceed with their job.  Now, as I mentioned, it is a bit complex because trying to coordinate a schedule that everyone can agree on is a bit taxing.  Some of the staff in the training comes from the other clinic which is about 15 to 20 minutes away depending on traffic.  In addition, it takes a bit of ingenuity to gauge learning and understanding.  I learned not to rely on PNG folks answering “Yes” all the time even though there are many who still have multitudes of questions, misunderstanding, and totally missing the concept.  In essence, some of the “students” in the class are nodding their heads and answering “yes” even if they don’t get some of the stuff that I am trying to teach.  I am not sure if there is such a term for this complex of “trying to please the master/instructor/teacher”, and this is exactly what has been transpiring.  Picture this, I am in the middle of class explaining the differences between oral, axillary, tympanic, and rectal temperatures; radial, brachial, carotid, and pedal pulses; and all of the background information concerning the topic and I have been getting robust “yes” from everyone.  During our next class, I asked a few questions for review and the whole class reverted to the classic “avoid the gaze”, “look down”, or “pretend I’m writing” mode.  I should know since I was once a student not so long ago and I admit that I also used the maneuver one too many times.  Last week, I devised a plan to work with them individually within the group setting.  Review classes are becoming more common.   I am now thinking that this is going to be a real challenge and I am just hoping that this plan will work so as to attain a win-win situation (for them and for me that is).  I am determined to make this class succeed.  For those of you who know me very well, I consider training someone and imparting the things that I know a personal project and objective.  If the person satisfactorily performs the job well, then I have done my job.  On the other hand, if the person performs less than satisfactory, then I have failed.  This last notion might be arguable to some since everyone’s learning curve is a bit different.  I can’t help myself but to think that the student’s performance reflects on the teacher’s deliverance. 

Another one of my key deliverables is co-facilitating an Infection Control Refresher program.  I developed and delivered a two-day training program on Standard Precautions, Transmission Based Precautions, Personal Protective Equipment, Handwashing, Bloodborne and Airborne Pathogenic Microorganisms, and Occupational Health and General Work Safety Overview.  My other comrade who co-facilitated with me developed a training program on Environmental Health and Hygiene and Medical Waste Management.  Some practices and activities that are considered routine in US, like handwashing, are sometimes viewed as something optional in patient care and not necessarily mandatory.  Needless to say, I spent a good time deliberating on handwashing alone, from the science behind it, to techniques in properly and accurately doing it.  The best part of the handwashing session is the surprised faces I saw from everyone when I told them that Pseudomonas aeurigonosa like to thrive underneath the fingernails and nail polish acts as a catalytic converter that arms and protects them.  The entire two days’ worth of training proved to be a busy but yet productive work because we had a good and robust interactive turn-up of attendees.  My slight worry concerning this training surfaced this weekend when I was correcting the post-test exams.  Descriptive statistics indicate the mean, median, and mode of the test scores is around 73.  Highest grade was 97 and the lowest was 44.  But despite this, I am glad that we had a good attendance rate for the training and that participation was at an all-time high.  We employed PPT presentations, group discussions, group work, role playing, and demonstrations.  And, I have pictures!!!

There seems to be an ideological constant in this country and that is the notion of “PNG time”.  Whenever an activity (meeting, presentation, appointment, etc.) is planned at a certain time, chances are that activity is not going to take place at the exact appointed time.  For instance, the 2 days training in Infection Control was slotted to begin at 830 AM.  The first day, we did not started the training until about 945 am because half the class was late.  There was a slight improvement on the second day because we started at 9 AM, which was still a little late, but nevertheless earlier than the day before.  It’s the same with meetings and appointments.  Somehow, it is somewhat expected and customary to be around 30 minutes late.  The normalcy of this ideology in PNG is quite an eye opener and, quite frankly, very hard to get used to.  My driver—Gary—and I sometimes get into a respectful discussion about the issue because even he sometimes picks me up a bit late in the morning.  The worst part of it is his lack of judgment to notify me.  We had an agreement that he should notify me immediately should he become unavailable for a ride so that I can arrange for an alternative means of transportation in time.  I think as time goes on, Gary is starting to get to know me and all my “American” ways.  He means well and I recognize it.  There are times when I just reflect back and tell myself that I really should be the one adapting and getting used to the ways around here.  I really am in no position to impose my ways and mentalities that I am accustomed to.  After all, I am the expatriate, the visitor, and the foreigner in this land.  Sure, I can respectfully ask, but by no means should expect.  I am only human, and like I mentioned before, it is quite hard to get used to this mentality.  It is a lost cause to try and change this ideology because it is so pervasive and deeply ingrained.  For someone to set an example by being on time or even a bit early on meeting appointments, conferences, or presentations will probably impress a few on that one day only, but it is highly unlikely that the impression will last so as to induce change.  It is what it is.  During these times, I find solace and answer on the famous prayer line: “God, grant me the serenity to accept the things that I cannot change”. 

Snapshots at Cairns, Australia - Part I

 The American Chinese food cuisine made it to Australia as well.  It was a welcoming sight and smell - I recognized General T'sos right away. 

                                               Tiramisu and Cappuccino - elegantly delectable!

                                                      The Blue Lagoon at the Esplanade. 

                                                         Boy, was I happy to see this...

                      One of the perfromers on the street...called himself "Fireboy" and rightfully so...

                                          Cruise ship to Green Island.  Forgot my Promethazine...

Cairns, Australia Trip

July 10, 2011, 1331 pm

My sheer excitement and happiness was so palpable during the last week of June knowing that I will be leaving for Australia on Friday, July 1^st.  I went to the barber shop on Thursday for a haircut.  The Filipino barber asked “Boss, what type of haircut?  Do you want regular men’s haircut or something special, something stylish”?  I responded by saying “No, nothing stylish, but not regular men’s either.  US Navy cut, 0 on the side, 1 inch up”.  And that he did!  I was happy, and so ready to fly out!  My youngest brother saw the haircut when I sent him pictures from the trip.  He said it was nice, but also noted that I am sporting a light mustache and asked me why.  Why?  I really have no idea why – maybe just a change, that’s all!

So this Cairns Australia trip was actually a necessary one for me, albeit not being part of the Fellowship experience itself.  My PNG visa is a Short-Term, Multiple Entry, Business Visa, where maximum stays of up to 60 days are allowed per visit.  On or before the 60^th day, the visa holder must get out of the country and re-enter again if needed.  The NGO paid for my flight and one night worth of stay in a hotel.  I paid for the second night myself plus all of the incidentals during the trip.

The hotel I reserved is on the outskirts of the touristy area of Cairns and is serviced intermittently by a shuttle bus to pick up and drop off patrons to the area attractions.  I thought this will be the best case scenario since it will still be quiet and peaceful at night.

Friday – July 1^st:  I woke up early so I can pack my luggage.  Nothing too extravagant since it would only be for 3 days and 2 nights.  I still ended up bringing along a good size luggage with me anyway.  My personal hired driver—Gary—and I had made plans for him to pick me up at 0700 AM since my flight is at 0920.  He was nowhere to be found at 0700.  I figured since all the locals operate on PNG time, I decided to give him a grace period of at least 15 minutes.  When he did not show up at 0715, I decided to call him.  His phone was disconnected.  I must’ve called him about 20 times to no avail.  Of course I started getting antsy.  I did not call any taxi service because who knows what can potentially happen to me.  It was already 0730 and still no Gary; not picking up the phone either.  Finally, I just decided to call the NGO’s driver Aloise and told him my predicament.  It took him a few minutes before he (Aloise) showed up since he also dropped the Senior Technical Officer in the office first.  We arrived at the International Airport at 0815.  I was beside myself because I do not know if I am going to make this flight or not.  I like to be where I need to be early so that I can plan on an alternative in case something unforeseen comes up.  Thankfully, everything went smoothly during the check-in procedure. 

The Qantas Link flight was smooth and uneventful.  I arrived just before noon and after exchanging travelers’ cheques, I called a taxi and went to the hotel.  Cairns Colonial Club Resort was only 10 minutes away.  The resort itself was situated 15 minutes away from the Esplanade—the touristy area of Cairns.  After I checked in, I decided to check out what the hotel’s amenities were.  I immediately made notations as far as where the fire exits and fire extinguishers were just in case, you never know.  I surveyed what the local tourist attractions were.  There was a lot to choose from—hot air balloon rides, wildlife tours, rainforest tours, snorkeling, diving, beach, parasailing, bungee jumping, glass bottom reef marine show, etc…  For Saturday, I decided to book for the Green Island tour aboard the Big Cat, a tour of the Island, then Glass Bottom Boat ride with marine life show and fish feeding.  In the afternoon, I booked for a wildlife tour at the Reef Dome.  Then at night, I decided on a Dinner Show, a modestly uppity up dinner at Monde’s followed by a show by the famous Australian magician Sam Powers at The Reef Casino.  At 2pm, after booking my selections, I took the shuttle bus and went downtown to the Esplanade.  It felt good to be this closely immersed to Western civilization once again.  I felt absolutely liberated!  Understand that for two months, I was not able to walk outside of the apartment complex I am staying in and venture out into the community I lived in.  So to celebrate this short freedom, I decided to take the afternoon opportunity to scale up the town I have never been to before and see the interesting places, ON FOOT!  I walked north, east, south, and west, up, and down, left, and right, you name it!  I was so giddy with excitement as I strolled and walked into the markets, seeing people of various ethnic groups from around the globe, this place being a tourist attraction after all.  Most importantly, I felt so free to just roam around by myself not thinking about pick-pockets, robbers, muggers, and the likes.  The streets are clean and free from litter.  The air, ambience, and environment are just very different, very positive, and just plain welcoming!

I mentioned before that my first mission was to find a good pub with nice ale and homebrew as well as a good cheeseburger, just like Frodo and his Hobbits (well, not really the cheeseburger part), but as I strode down Spence Street, I chanced upon this little market section where a foodcourt is located.  To my surprise, Chinese food also made it here, and I mean the same kind of American Chinese food that we have at Imperial Wok and Golden China in Howe Street New Haven!  There were chicken on skewers, orange chicken, mandarin chicken, General T-Sos chicken, Egg-foo-young, dumplings, sautéed shrimps, eggrolls, and crab legs!!!  It’s been almost three months since I had Chinese food so even though my gastric mucosa was churning and really yearning for a good Grade A USDA beef burger patty, I decided to have Chinese Food instead, the Australian kind that is.  I am now beginning to think that there is a set of universal recipes shared only amongst the Chinese population on how to make these food items because they taste exactly like it is at Pacific Buffet and Grille in Wallingford and Panda Buffet in New London!!!  After dinner, I walked to the other side of the town and found a nice, uppity up coffee place.  Unfortunately, there is no Dunkin Donuts in Oz as a good French Vanilla or Hazelnut light and sweet would have sufficed.  But since I saw a perfectly round, decadent, and delectable tiramisu on display, I decided to really treat myself and indulge.  The cappuccino was ok, so-so to say the least, but this heavenly creation of lady fingers soaked in vanilla, mocha, and coffee syrup and covered with a smooth, velvety, rich, and creamy whipped up creation was really out of this world!  Remember the movie “When Harry Met Sally (or is it When Sally Met Harry???, not sure now)”, well, maybe I was almost just about to become Sally as soon as the first bite hit the taste nerve endings, but I controlled myself and just let the taste buds go wild!!!  After that succulent indulgence, I continued my walk until evening time.  I watched a street side show of a guy who claims he’s the master of flames.  Real good and artistic bloke…  Even though I was tired, I had a good first night.  I stopped by at the liquor store and grabbed two beers for the night.  I did not get back to the hotel until past 11 pm. 

Saturday, July 2^nd:  Big day today so I got up early.  I had a nice “big boy” breakfast at the hotel’s Homestead Restaurant.  After showering and getting dressed, I headed downtown again and checked in at the boat tour.  It was a grey and dreary day; I thought the trip was going to be hampered by showers.  The boat trip was ok for the most part, but there were some moderate waves going to the island.  I was still OK at this time, but a lot of the Japanese tourists ended up needing to take anti-emetics.  Ginger candies to the rescue…  Green Island was really small; I toured the entire area reserved for tourist in about 20 minutes despite the occasional drizzles.  I decided against having cocktails because I knew the motion sickness will probably get the best of me on the way back.  Besides, we still had another boat ride in the Glass Bottom boat tour.  The Glass Bottom boat tour was ok, the glass bottom was not as clear as we would have liked it to be but we were able to see the corals and marine animals of the Great Barrier Reef.  Supposedly, the Great Barrier Reef is one of the largest in the world, it accounts for about 1/5 of the entire reef around the globe.  The one elusive animal we did not chance upon is the Green Sea Turtle, supposedly there is an abundance of these creatures but we didn’t see one.  How interesting is that?  Sure enough, the motion seasickness got me on the trip back home.  When we reached Cairns, I decided to go back to the hotel and rest for a few hours.  I felt like most women feel during their first trimester.  In the afternoon when my stomach had settled, I had a light lunch at McDonald’s.  I was feeling good again because it tasted just like home, even the golden arches were the same.  After lunch, I went to the Wildlife Dome.  Different birds, furry animals, and reptiles were in this small sanctuary.  There was an animal that resembled a small kangaroo.  There were three koala bears.  Huge pythons were in the cages.  I did not see Tarzan or Jane…  J  The dinner at Monde’s was awesome.  I had another spicy creation, a Malaysian curried beef over white Jasmine rice, pickled eggplant, and another rich and decadent chocolate lover’s cake.  It would have been nice to have a company, or a date, to spend the splendor of the night.  The forming and glistening beads of sweat in my forehead due to the spicy curried dish was offset and tempered by the nice sea breeze off of the Cairns Beach shores.  After dinner, I went to The Reef Casino for the magical show.  The Illusions Show by Sam Powers was simply, magical in all sense of the word.  Aside from all the magical artistries and abilities he possesses, he is not bad to look at.  As a matter of fact, he is a very nice, young, handsome Australian bloke that he is!  And I was exhilarated when he picked me as one of his participants in a panel when he did his card trick.  It was a very nice end of the night show indeed.  Afterwards, I ventured into the casino floor to see what kinds of games they have.  Blackjack, Reef Poker (their version of Caribbean Stud Poker), Baccarat, Sic-Bo, and Roulette for table games.  Surprisingly, there was no craps table or players yelling “seven” or “yo eleven”.  The slot machines were in abundance, though, the place is still relatively small compared to Mohegan Sun or Foxwoods Resort Casino.  I was ready to sit down at the Reef Poker, but I decided against it, because if the game would have gone well and on my side, I really would have hated to vacate my seat to go home since my flight is the next day.  My mantra when gambling to go on and continue as long as the tide is on your side, however, when the tide turns, then it’s time to get the “colors in”.  I figured it will be best to not just play this time.  Maybe next time, maybe…

Sunday, July 3^rd:  Time to go home after a two short days of blissful fun and refreshing change of scenery and pace.  After a robust breakfast in the morning at the Homestead Restaurant, I showered, got dressed, and packed my luggage again.  I noticed that the belt felt tight again.  I thought that all the weight I lost within 2 months of time living in PNG I gained back so easily within 3 days.  Oh well, I deserved it!  J  I checked out, settled my bill, and headed for the airport early.  I stopped by at Cairns Duty Free shop to get a few items for the NGO colleagues, especially Aloise, the one who rescued me Friday morning.  I got him a 200 ml Jameson Whiskey to which he was overly ecstatic!  He told me it has been a while since he tasted a good, imported whiskey like Jameson.  I grabbed a few chocolates for the NGO staff as well.  Then I brought home with me a 200 ml Bacardi Rum and 200 ml Tanqueray gin.  These two are exclusively for me, to somehow keep my sanity at night for the next 2 months. 

At 3 pm Sunday, I was back again in Port Moresby and to all things PNG.  The now familiar sound of the native tongue Tok Pisin, the constant traffic, the betel nut stained pavement, the heightened security, the safety alert, the escorts and chaperones to go to places, the PNG time, and most importantly, back to work again.  Cairns Australia was indeed a nice, much needed break.  I hope that I painted you a vivid and visceral picture of what my short travel was like, and that you were able to imagine and feel the freedom that I felt even for 2 short days, and that you enjoyed the mental travel overall as you read my accounts here.  I certainly enjoyed this place and I will never forget the experience.  I don’t know though if this is going to be my first and last here, but if it is, I certainly have no regrets, only memories!  So, in respect of the Australian tongue, I bid all of you “Gid’day mate!”

Most Recent Glimpse of Papua New Guinea

 Boroko Food World Grocery Store - the place where I usually get my food shopping done.  Place is cheap and they sell Pan de Sal and Pan de Coco!!!

 Gary, my personal hired driver, also the one who pushes the grocery cart for me when I go shopping.  He also goes with me to the public marketplace. 

 The Malaoro public market place, a shopping area where some notorious raskols frequent for easy money and easy victims. 

 I only get vegetables in this market, and sometimes fish, when its fresh, other than that, I get everything at the grocery store.  Folks in here also try to sell me Blackberry, Iphones, and other tech gadgets. 

 The four following pictures I posted at my Facebook page already.  But to those who don't have a FB page, these pictures were taken at the latest Caritas Catholic High School Cultural Show.  As you can see, I have a ribbon on my shirt, depicting I was a distinguished guest.  Maybe its the "US Army" in the back of my shirt that gave it away.

Down with the First 2 Months

29-June-2011, 1625

Violence is a real pervasive problem in PNG, a real threat not only to the growth and development of its national identity, but also to the local folks and residents, as well as expatriates.  This countrywide problem is of resounding concern to me that I often find myself mentioning anecdotal occurrences in my previous blog entries.  As per usual, I was again a spectator to similar events that occurred these past two weeks.  Without compromising the identity and privacy of the person involved, only the most important aspects of the following events will be revealed. 

One of the staff that I work with went to work as per usual last week, only this time, I happen to notice him with bloodshot eyes, bruising on the zygomatic arch, and 2 band-aids on the cheek.  The usual morning conciliatory greetings were exchanged and I glanced at him as discreetly as possible to note the extent of the “facial damage”.  I have learned early on that folks in here do not like to talk about things that will cause an embarrassment to them.  So I did not asked what happened.  I figured if he would really like to tell me, he will.  Surprisingly enough, he approached me at noon during lunch time to tell me about the brawl he was into the day before.  Alcohol and betel nuts were involved of course.  Worst, it was a brawl between him and a family member.  A few of the staff also mentioned something like this had happened to him a few times before, mostly because of drinking and fighting. 

In another event, last weekend, I asked my hired driver to go with me to Malaoro public market place so I can get some fresh vegetables and spices.  From what I was told, this particular marketplace has always been a spot for crimes and violence.  Raskols carjacking and pick-pocketing are ubiquitous.  Being the nervous person that I am, I made sure that Gary (my driver) was always at my side whenever and wherever I go.  He is actually very good at what he does, because his eyes are always on me wherever I go.  The shopping was uneventful thankfully.  When I was just about to get back into the car though, I saw a man and a woman, presumably husband and wife from what Gary told me, having a physical fight right there at the sidewalk of the market.  The husband was pulling wife’s hair and he had a piece of wood in his hand that he used to hit wife on the back.  Wife was screaming at the top of her lungs, in Tok Pisin of course so I could not understand.  At one point, husband dragged her along the sidewalk by her hair.  I was so astonished and dumbfounded with what I was looking at and witnessing.  I was really struck with the fact that no one came to this woman’s rescue at all.  The market was filled with shoppers because it was a Saturday.  With that amount of people, nobody bothered to call the police or even made a physical attempt to separate the two.  I wasn’t going to play “hero” and intervene, being an expatriate and an outsider.  Gary told me she was screaming for him to stop because she was hurting terribly.  Finally, he said that bystanders did not bother to intervene or call law enforcement because it was a domestic issue, a fight between a husband and wife.  Therefore, anyone outside the circle of that family, by the virtue of being an “outsider”, will have no business to interfere or intervene.  It will take massive effort to raise awareness, let alone change ideology or point of view, on something that is heavily ingrained and inculcated like this.  There are advertisements on billboards that indicate beating the crap out of your wife is illegal and unlawful.  But there is nothing a complainant could do if law enforcement itself will act slowly, if not at all, to remediate the problem.  Not only will the ideology need to change, the law enforcement system will also need to be re-structured and re-formulated.  So there it is, the violent episodes of the last two weeks, the physical assault of one of the staff two weeks ago, then these two additional instances of physical violence.  These really gives credence to the personal security and safety mandate that staff tells me all the time—“Be careful and always on the lookout!”. 

I was able to finally visit Port Moresby General Hospital and look inside.  Let me make it perfectly clear, it was NOT ME needing to be hospitalized!  One of the sick clients in the clinic had a worsening change in condition and the family brought him into the clinic.  The nurse on duty started an IV line and took history.  I was observing the interactions and processes taking place and jotting down notes on what areas can be improved upon.  I had several items on my list: history taking, vital signs, physical examination, etc…  Based on this incident alone, I thought that more work needs to be done on strengthening clinical practice and improving quality of care.  Initially, the family was adamant for the patient to just go back home after the IV infusion was finished.  The mother of the patient, who was at home at that time, was reluctant to have him admitted at the hospital.  She said that if he was actively dying, she would be most confident and at peace to care for him at home.  Then all of a sudden, they all turned to me wondering if I had something to say as I was auscultating his heart and lungs.  So I explained that he needed clinical care and services found in a tertiary facility where laboratory and diagnostic testing could be done.  Carefully crafting my words, I expressed regret that we were only able to care for him in a limited fashion since the place is just a clinic.  More can be done at the hospital, i.e. blood counts, x-ray, intravenous fluids and medications, maybe parenteral feeding (the patient was bone thin and emaciated!!!).  The family readily agreed thankfully.  Since they were very poor and could not afford to have an ambulance drive the patient, they rode on the back of the clinic/company vehicle (truck) and we dropped them off to the Urgent/Ambulatory Care side of the hospital.  Immediately, I assessed that the setting was just pure chaos, with patients and family scattered everywhere.  I was not able to readily identify who’s who in the milieu.  There were a lot of papers at the desk and there was not one single computer to be found at all.  No one wore scrubs.  The troubling part was that this patient was put on a wooden bench at the back of the hall while his “referral” form was submitted to one of the physicians.  I don’t know how quickly he will be seen because the physician was nodding her head and whispered PLHIV (Person Living with HIV).  Pervasive stigmatization and marginalization of people with HIV is a real problem and threat to the healthcare infrastructure in PNG!  I’m afraid that the patient will not get seen in time just because of the “red-flag” diagnosis.  I also did not hear the familiar beeps and sounds of hospital techies and gadgets, i.e. cardiac monitors, Dynamaps, and call lights!  The X-Ray hallway was filled with people in three different lines from end to end.  I did not even tried to venture inside the psychiatric ward because judging by the looks of the halls inside, I might not actually come out of there alive.  The pediatric ward was the only place in the hospital where at least order and cleanliness were immediately noticeable.  Even though I had a camera with me and I was really itching to take some photos, I decided not to.  I don’t like the feeling of having to take a snapshot of their ill physical state for my own record-keeping purposes. 

For a change, I did something out of the house last weekend.  One of the security guards at home mentioned a mini cultural show held at one of the Caritas Catholic School just around the block.  I was welcomed to go for a nominal fee – 10 Kina, which is not bad, but since Paul (the security guard) was going with me as my own personal security person, I had to pay for him as well, which I didn’t mind.  Since I was readily identified as an expatriate, the guards at the door automatically gave me a “Guest of Honor” ribbon and pinned it on my shirt.  I did not ask what it was for, I just said “Yes I am and I am glad to be here”.  Later on, I found out that Guests of Honor were major funders and contributors to the school cause.  I just wore it for the day, that’s all.  I liked the benefits of it too—sitting up front, lunch, and beverages.  But I gave my lunch and beverage to Paul, since he did not have the ribbon.  I have many pictures and a few videos.  I will post them separately and hope that you enjoy a glimpse of the Papua New Guinea culture, tradition, and attire. 

So, this is going to be the last blog entry under heading “The Beginning”.  It finally came to it; the first 2 months of this Fellowship is over.  1/3 of the proverbial pie has been consumed already and the leftover 2/3 are well under way as well.  Tomorrow, July 1^st, I will be heading to Cairns Australia for 3 days for a much needed personal R & R, a mental break that is so richly deserved, I think.  It also means to say that I will be starting on the third month by the time that I get back.  I am missing home already.  Hopefully, the days will go and fly by a bit faster from this point forward.  The next blog installments will be under the heading of “The Middle”.  Ta – ta for now!!! 

Full Pledged Immersion at Work

12-June-2011, 0917 AM

It has been a little more than two weeks since my last blog entry.  Throughout this time, there had been quite a few noteworthy events, some of which even caused a stir and mild anxiety.  Really, the nervous person that I am worries just a tad bit too much I admit, but considering the most recent events and the status quo in PNG concerning personal security and safety, I do strongly believe that my perceived need for a mild anxiolytic, albeit low-dose, is really warranted.  Somehow, I feel that Dr. Dabdoub will readily agree to prescribe a short-acting benzodiazepine should I present my case to him right now. 

Raw and descriptive statistics from previous Global Health Fellows indicate that isolation, loneliness, and homesickness rise and peak through the entire first month of the assignment.  Anecdotal accounts also dictate that it should gradually dissipate from partial to complete situational adjustment and internalization of the normalcy of these emotions and feelings during the second and subsequent months.   Colleagues, and most especially family members, will agree that this was the case for me during the entire first month (May).  At the onset of the second month (June), my full pledged immersion at work, now that the final version of the Scope of Work (SOW) has been created, revised, and submitted multiple times for quite some time, caused a bit of distraction in my mind and helped to temporarily forget about home and family.  I’m not completely out of the woods yet, but it seems that I am slowly adjusting somehow.  My daily work routine generally goes like this: 

1. Wake up at 0630, snooze alarm clock twice.
2. Coffee, eat breakfast, and prepare work lunch, which is usually egg and cheese sandwich on a buttered hoagie roll.  Hopefully, there will be no need for me to re-start a cholesterol and lipid lowering agent and the Fish Oil I am taking currently will be good enough. 
3. Shower and everything else that goes on with morning hygiene, get dressed, and take AM meds. 
4. Wait for my hired driver who picks me up usually between 0745 – 0815 (notice the long variability on wait time). 
1. On Mondays and Tuesdays, he drops me off at Lawes Road Clinic. 
2. On Wednesdays and Thursday, he drops me off at Nine Mile Urban Clinic. 
5. FHI driver picks me up at the clinic around 1300 then lunch at the office from 1315 to 1415, though last Friday, I did not get picked up until 2pm.  I had lunch at 230 pm due to road traffic.  Back at the office, I also use the extra minutes of lunch time to check my personal e-mail, Pfizer e-mail, update blog, check and update FB status, and respond to queries and tweets at Twitter. 
6. I summarize the day’s events and make plans for the next day from 1430 until 1700.  My hired driver then picks me up at FHI country office late in the afternoon and brings me back home around 1715. 
7. Fridays are my personal administrative time.  This is my planned time to develop in-service trainings and powerpoint presentations for clinic staff.  At the moment, I am planning on doing the following in-service and training:
1. Pharmacology of Anti-retroviral Therapy and Newer Classes of drugs
2. Occupational Health and Safety
3. Standard Precautions and Transmission Based Precautions
4. Bloodborne Pathogens
5. Personal Protective Equipments
6. History of Present Illness, Medical History, Art of Interviewing, and the 7 Dimensions of a Chief Complaint

The first full week of being at the clinic was initially nerve racking because I did not know what to expect.  Talks and reminders were given for me to be fully alert at all times, knowing where my belongings are, especially my wallet and laptop computer.  I just remember the mantra to “kill them with kindness”.  So I waved, smiled, and greeted everyone I met and thanked them for their time in their language – “Tenkyu Tru!” (Thank You Very Much!) like I am some kind of a politician running for government office.  At the same time, the clinic staff inadvertently introduced me to clients by saying that I am an “English doctor from America”.  Time and again, I find myself gently correcting these folks and saying that I am actually a nurse.  It made no difference either way, as I later find out that both nurses and doctors are authoritative figures who are equally regarded and treated with high degree of respect.  This is all the more magnified when the clients find out that I am from America as they wanted me to be in during the consultation and sometimes cast a quick glance to see if I have some input regarding their conditions.  Outward appearance definitely plays a role, even though my daily work attire are a little less than business casual, but they can see that I am well cleaned and properly groomed, from head to toe, with shirt, shoes, and socks.  Needless to say, as soon as my patient interactions began, I felt a little bit better knowing that they genuinely want me to be at the clinics all the time.  Therefore, applying myself to work and keeping busy is what I have been doing in order to get distracted and not feel homesick.  It goes without saying that at work, I feel good because I am in the company of my new colleagues, knowing that the small inputs and recommendations I make can provide small changes, if not potential profound improvements.  The loneliness and homesickness still haunts me though as soon as I get home, most especially during the weekends, like today.  Sometimes, I walk around inside the house compound and see if I can find any critters, insects, animals, flowers, or fruits that I have never seen yet, but even that I have not done because it’s been raining like the dickens today. 

Last week, I was caught in a bit of surprise and excitement when the Country Director asked if I applied for an Australian Visa and made arrangements for flight and accommodation yet.  I realize that the full 1/3 of the assignment is going to be completed soon, July 4^th to be exact.  The two month finish is heralded by a short weekend trip to Cairns since a one-time stay at PNG for a short-term multiple entry business visa is 60 days, which I have to get out of the country on or before the day, and then come back again.  It brought sheer excitement and inspiration because the short trip is scheduled to leave early morning on July 1^st and returning in the afternoon of July 3^rd.  A complete change in scenery will do me well I suppose, and I put myself on a mission to find a good burger house and pub.  What’s profoundly even better is the easy process to apply for an Australian Visa.  I did it online and got approved within a matter of 1 minute!  Remembering in retrospect the bureaucratic red tape I had to go through to apply for a PNG visa, I was ecstatic afterwards because it took me a total of only 10 minutes to get the whole process done for Australian ETA (Electronic Travel Authority, no passport stamp though).  Then I booked a hotel accommodation in the heart of the Esplanade in Cairns, where the touristy attractions are located. 

It’s not all gravy these past few weeks though.  One of FHI staff, (For privacy and confidentiality purposes, I am not going to say who or what this person does), was punched in the face, shirt ripped, and assaulted while inside the truck last week.  The FHI staff supposedly hit another parked vehicle inside our lot at the compound.  The FHI staff stopped the vehicle, was going to get out to assess damage and arrange for plans to repair, and apologize to an incoming Papua New Guinean who saw the incident, who was eventually surmised to be the owner of the vehicle.  Without any forewarning, the Papuan provocatively assaulted and punched the FHI staff in the right cheek.  I did not saw any of these but later found out something bad was happening because I saw and heard escalating voices from the FHI staff outside the truck, my driver, and the Papuan trying to talk as to what happened.  My driver was the one who later told me the whole incident because he was there waiting for me when the incident took place.  I was a bit edgy and nervous at the time knowing that the perpetrator is inside our very own lot!  But my driver assured my safety and advised me to call him at anytime I feel I am in grave or perceived danger. 

Want more?  On Friday, my driver picked me up in the morning as usual and I saw his car without the right side view mirror and the right side of his face was obviously hurt.  He had scattered bruises and his right eye was red.  He then tells me that the night before (Thursday) he was involved in a not-at-fault car accident.  The driver from the opposite oncoming traffic was going to hit him head on.  He swerved to the left; the other driver hit the right side view mirror, which then hit my driver in the eye and in the face.  I immediately asked him if he had an x-ray done, eye exam, fluorescin stain maybe, and a quick doctor’s visit, and also to press charges.  But because it involves money, he deferred going.  There is no system in place like collision coverage or insurance.  Every expense is out of pocket.  The worse thing is that my driver cannot go after the other party either because he did not stop.  So as far as the incident goes, it was a done deal already and nothing that my driver can do.  He then tells me that this is how it is usually done in PNG.  All that I kept thinking at the time was how sorry I was for him AND how thankful I was that I was not with him during the time of the accident.

Thomas, my housemate who works for AUSAID, is gone and out of the country for two weeks.  He went to Ottawa Canada for some business meetings and trainings.  There is no one in the house but me so I am just trying to keep my mind occupied and busy to help pass the time.  I did laundry and ironing yesterday.  I read two chapters in the current novel I am reading by Bryce Courtenay.  I am now making and entering this blog currently.  The TV is also one of my saving grace as far as distraction goes.  I mean thank goodness and thank heavens for this and the cable; otherwise, I probably would have gone crazy bananas without anything to do.  I discovered the timeslot for the Filipino News program called BANDILA hosted by Julius Babao, Karen Davila, and Ces OrenaDrilon.  I also now remember that today is the actual Philippine Independence Day when the flag was first hoisted and put on the pole in Kawit Cavite by the first President Emilio Aguinaldo.  I usually flip the channels between HBO and Star Cinema for some movies.  Tonight, Titanic and Avatar is going to be on.  It’s good to hear “I’ll never let go” and “I see you” (the two prominent one-liner of these movies) again after sometime. 

October is still a long far ways to go and up until right now, I still do not feel nor observe the saying that “time will go by fast and it will be soon over before you know it”.  At this point, I am only looking forward to the end of the month when Thomas comes back home and I will be going to Cairns Australia.