Two weeks in

*disclaimer* This was written a few days ago and now being posted!

 

Mambo from Arusha!

It has been two weeks into our four month long stay with Tanzania. The blog will be updated intermittently by visiting students, residents, and myself and Emily.

I think there are several varying thoughts I have had since arriving. We have rounded for two weeks now on the internal medicine service and now Emily and I will be alternating medicine and pediatrics to disperse the team. 

Two years have passed since any residents or chiefs were able to come to Tanzania, due to COVID-19. Due to the connection that previous chiefs have made with Damas the internal medicine registrar, we were already acquainted with him virtually prior to our arrival which has been very helpful. Other registrars and consultants mentioning the names of previous residents and chiefs that have made lasting friendships is also nice to hear and comforting. It reminds us that we aren’t complete strangers but have a connection through others that have come before us. 

I think for the past two weeks and time moving forward, having the role of an observer / learner of the culture and hospital is primary. Secondarily, developing relationships with the registrars that seem interested in working with us (namely asking us to help with educational support with interns) seems to be also a worthwhile endeavor.

A rotation that is 4-6 weeks for residents and students VS us for 4 months VS individuals like Dr Swanson (American pediatrician who has been living in TZ for the past 8 years with his family and practices NICU at affiliate hospital ALMC) who are here long term, I think grapple with similar thoughts but varying degrees of questioning of the following, I believe: 

(I don’t have answers for the below, but I think hard questions with no clear answers)

1) What is the best way to foster sustainable relationships? 

2) What value do we provide to the host country institutions that have welcomed us here

3) What is most meaningful for the learners from the US

4) How are relationships built between institutions and how do we re examine them periodically?

Until next time!

Hannah 

 

 

Winter count.

 "A winter count is a pictographic record of historical/memorable events for a tiospaye (community)... used by many Plains Indians, is a method of preserving history. Important events are recorded for future generations."

It's our last full day here on the reservation, at least for now, and we just finished rehearsing for the morning report we're to give tomorrow. I think part of the jitters are: how do we do justice to this?

Anyway, if you happen to have time at 1PM tomorrow, consider tuning in. We'll be featuring panelists (medicine and pediatrics!) who have volunteered their time to give us some insight into how to approach these complex (medically, socially, mentally, culturally, interpersonally) situations. 

“100 million doses in 100 days”

Sharon and I are at our final week here at Rosebud. Lots of things have happened in the past 4 weeks – regarding absorption of knowledge/culture/new experiences. However, I wanted to touch upon one specific thing that I was happy to be a part of while here: administering COVID vaccinations to the community of Rosebud! It was public health in action.

So, the last time I administered vaccinations to anyone was at a family medicine clinic during medical school. Sharon and I were ready in no time though, and we participated in 2 full day -8 hr- vaccination events. One was held on MLK day and the other, approximately a week after. The process of vaccinating community members was quite smooth here – two floors were sectioned off and people showed up to get their COVID shots. According to the hospital administrators, approximately 500+ individuals got vaccinated the first day and then 300+ the 2^nd day. This local article highlights the successful organization and deployment of the vaccines at Rosebud: the goal is to vaccinate approximately 15,000 tribal members, and the Rosebud hospital and tribe seem to be well on their way to achieve this, due to their successful and collaborative efforts towards vaccination.

I was especially impressed that people showed up, especially when distances aren’t necessarily close to get to the hospital. It was evident that the community members wanted to do their due diligence for the public and their loved ones. Many people showed up with their family members. We were aware that there was concern about vaccine hesitancy among tribal and community members (informed by our AmeriCorps team members Caroline and Margaret), but I think Margaret and Caroline’s messaging and programming worked (one of their projects was to address vaccine hesitancy in the community), as the turn out demonstrated otherwise.

When I told my family members in S. Korea that I was physically vaccinating people, they were surprised that resident doctors & doctors were the ones vaccinating individuals, but it clearly is an all hands on deck situation, especially as even the University of Minnesota was asking for any volunteers willing to administer doses back at home! This article that outlined how Los Angeles was vaccinating their population through a drive-thru in a massive stadium was pretty fun and interesting to read as well (the Mayor of L.A. was helping out too – I was told this was perhaps a political ploy, but still, heartwarming to see that we are all in it together.)

I read news headlines stating that Joe Biden’s goals of 100 million doses in 100 days was a goal that would, luckily, likely be surpassed.  However, there are clearly concerns that the roll out process isn’t uniform or going smoothly in all areas of the United States, and despite 100 million doses, we still have a long way to go. Regardless, it was clear to me, that maybe we were turning a corner with this whole coronavirus business…hopefully!

I'll end with a funny clip of The Terminator getting his shot...#comewithmeifyouwanttolive

https://twitter.com/schwarzenegger/status/1351973032953188352

 (anything to encourage the public to get vaccinated!)

and some mysterious footprints in the S.Dakota snow...

-Hannah 

Being careful with reusable bags.

 Hannah and I have been working that past week on doing a needs assessment of sorts in the hospital to try to understand perceptions of staff (nurses, MDs, MSAs, schedulers, radiology techs, etc.) surrounding pediatric care. The time has flown by, and we're rapidly approaching our fourth and final week here.

I've been thinking really hard about the values I bring to this community. Ever since our lesson from Damon and starting to review teachings on settler colonialism, I have been working through reconciling my own beliefs, habits, and values with that of the community. 

Weirdly-- or perhaps not-- this culminated yesterday at the small grocery store in town. A few things to know about the reservation:

1) There's no recycling facility here.
2) It's a food desert. In 2014, >38% of residents of Todd County had a BMI > 30. 
3) To get subspecialty services (cardiology, GI, general surgery, ob/gyn), patients have to be transferred to either Rapid City (three hours away) or Sioux Falls (four hours). 

Clearly, the recycling thing is lowest on that list of issues to discuss or tackle. 

Yet, here I exist in all of my urban privilege, and my cognitive dissonance for the past three weeks includes the fact that we've been sticking aluminum cans in the trash and cardboard glove boxes in the dumpster. It's certainly not my biggest source of distress while working with the community, but it would be disingenuous of me to say that it doesn't bother me, me this guest in the sacred, hard-won homeland of my hosts. 

Anyway, we went to the grocery store yesterday, and Hannah and I brought some reusable grocery bags with us-- the ones that live in my car and that I got from Whole Foods (I know, I know) on Selby and Snelling. As I stood there bagging, I had this weird mix of... knowing that I do want to do what I can to mitigate environmental waste and wondering what kind of person I am that I'm thinking about these lofty eco-topics when literally, the morning discussion in the hospital was, "How do we avoid discharging these patients to homelessness?"

I want to be a "good person," and I have a fairly good sense of what that means for me: sticking up for the bullied, recognizing my biases (and working to mitigate them), trying to treat others with respect.

Also: recycling, challenging ideas of fixed gender and sexuality, bringing my own grocery bags, volunteering my time, educating myself on others' perceptions. 

So yes, I'm going to continue to try to recycle and bring my reusable grocery bags... but I'm not trying to do it in a way that makes me seem more "woke" or better or worse or... a million things that would be products of the luck I've had in life, starting with being born with lighter skin. 

Or, when a community member described to me the sacred and culturally rooted sweat lodge ceremonies, where men and women sit in separate areas of the lodge and my question was: well, how do you include and respect the feelings of people who aren't cis-gender? I didn't verbalize this, of course, but what does it say about me that I was very much distracted by that mind space while being educated on a culture that has suffered the ravages of an unrelenting sort of settler colonialism?

I feel like we're falling down a mine shaft reaching terminal velocity, and here I am fussing that I've forgotten to bring my canary. 

Till next time,

Sharon (I beat Hannah to a post....)

Twenty Communities.

Hannah and I had the absolute honor of going on a educational drive around the reservation yesterday, led by Damon Leader Charge, director of Tribal Outreach at University of South Dakota, member of the Lakota Sicangu, and wonderful teacher. 

First of all: Damon now lives in Sioux Falls and drives three hours to do this outreach with learners who rotate here. You can tell by how he talks about his childhood home and the reservation his love for the land, culture, and people-- the pride and also the concern about the challenges the Tribe is facing. More on that later.

Seriously, he takes it upon himself to drive three hours to Rosebud to give a three-to-four-hour tour of the reservation, then drives three hours back to Sioux Falls. We definitely owe him a thank you card. 

And he was so... well, he called it "blunt," but I felt so honored that he'd let us-- these two random outsiders-- in on little bits of daily life here, on the tooth-and-nail resilience of his tribe.

Anyway, in non-COVID times, Damon drives here, picks up the learners in his truck, and drives around the reservation giving the history of the communities and answering questions. Times being as they are, he met up with us in the hospital parking lot, and we followed his truck in our Subaru with him on speaker phone. 

It's obviously impossible to do a three-hour experience justice in a blog post-- it's one of those you'd have to be there sort of situations (so come to Rosebud!), but here are some reflections I've been turning around in my mind:

1. 60% funded. Per Damon, tribal estimates are that IHS, housing, schools, and tribal resources are about 60% funded-- meaning significantly underfunded. We drove about and saw many a boarded-up house... from what I understand from what Damon told us, the federal government agreed to maintaining housing for natives in return for the tribes ceding land in the late 1800s (the Ft. Laramie Treaty of 1868). The boarded up houses, the housing shortage on the reservation is emblematic of broken promises. 

2. Pride and resilience. Damon described to us the ongoing fight to keep tribal schools open. There's what sounds like a stark achievement gap due to difficulty recruiting and keeping teachers, and yet-- "the intimate classes and the Lakota teachings" are being kept alive in these community schools. They are symbols of hope and self-sufficiency for the communities. He brought us to the structure of a former school in Soldier Creek (one of the communities on the reservation), where students would previously gather despite the state of the building, even when the electricity went out or the water stopped working, to keep the learning going, to keep teaching the next generations. Funding has since been approved for a new school building, "but taking away the school would be like taking away part of the community's pride." And that's one of the many opportunities for advocacy, one of the many fights ongoing. 

3. Love and life. Damon is another of the many people who have met who clearly loves this land and the Tribe. Outside the fact that he committed to a six-hour commute on a random Monday, Damon also showed us where he grew up: "I wouldn't have traded it for anything," which I suppose rings true for so many of us regarding our childhoods. He talked about his cousins and parents, the creek he'd play in with his friends, the strong kinship with his neighbors. Driving through Grass Mountain ("reminds us of the Black Hills, one of our most sacred sites-- where our origin story starts"), through the Parmalee community, along hidden creekbeds, being followed by the families' dogs-- there is clearly so much to love here. Sure, it's stating the obvious, but it bears saying: clearly, there's such deep, unshakable love here and a recognition that there's so much to improve upon, to advocate for. Damon said, regarding the reservation: "Our ancestors fought and died for this." What a gift, then, and also a heavy burden.

Like I said, I feel in no way qualified to tackle educating anyone about the structure of the land or the tribe... I'm super early in my own learning. Here are some resources, though, that I've found helpful:

1. The RosebudREZ communities page (we saw 9 of the 20 communities yesterday)

2. Information about the Sioux Tribal government

3. The Sicangu Community Development Corporation (CDC) YouTube Channel (they even have cooking classes!) and web site  (Hannah sidenote: They even make KIMCHI here is link - a Korean staple wow (modified kimchi but still)) 

4. Information about the Rosebud Sicangu Sioux reservation on the Akta Lakota Museum and Cultural Center (I think it's closed due to COVID?) 

Rosebud...continued.

Sharon and I have completed week 2 at Rosebud thus far. I think the initial impressions and settling in have been completed at this juncture, and some reflection is in order – especially from the vantage point of social medicine; but I’ll describe a bit about the clinical medicine experience we have been having as well. In regards to clinical work, it’s been great to see how medicine knowledge can be somewhat transferred to whatever setting you’re in (a basic example: 8 day old well child check—my brain remembers most of the things we should check for baby and mom, despite having no automated crutches present, wow I must have learned something in residency for the past 3 years!) – and we’ve been having the gamut of experiences from inpatient to outpatient, and the dual training that both Sharon and I have through Med-Peds has been pretty awesome and flexible in this remote/rural setting.

 

In regards to our clinical work, we spend the morning rounding on the inpatients, and it is like any typical day on the medicine wards back at home in Minnesota – pre-round, have multidisciplinary rounds, see the patients, orders, and then notes.  The medical record system is a familiar VA style EMR (just imagine it as CPRS with fewer features) and I will begrudgingly admit that having training at the VA for residency has actually been helpful for adjusting to the medical record system here. The census has varied while we have been here and we have not had any inpatient pediatrics thus far (which is a good thing for the patients but not necessarily for clinical learning etc, but you get the point…). Regardless, a lot of the admissions of adults frequently have something to do with alcohol, unfortunately. Other things to note though, importantly, is that the hospital’s ability to care for high acuity patients is minimal; there is no subspecialty care, really (we do have a podiatrist on site, who has been very helpful!), and no surgical services.  An important part of learning that seems to play a part here is triaging appropriately. If patients present with problems that we cannot adequately treat or potentially adequately treat, they have to be transferred out to a hospital in Rapid City or Sioux Falls (closest towns that are about 2-3 hour drives away and sometimes a medical flight evacuation is necessitated).

 

Going back to the day timeline: We take a lunch break to eat at home (5 minute walk, which is quite convenient)—and in reference to the literal food desert that Sharon mentioned we are in, we’ve been making all 3 of our meals for the past 2 weeks, and have been forced to cook things we want to eat; Sharon mostly takes the lead as head chef and I help chop and clean things and occasionally make things as well (lumpy pancakes?).  After the lunch break, one of us goes to outpatient pediatric clinic and the other to medicine clinic.

 

A bulk of the medicine here seems to be primary care, and anyone interested in primary care I think would really enjoy practicing here – and not enjoyment in the sense that you’re in a system that has everything set up for you (it clearly is not), but I think I can imagine the providers finding a lot of meaning in the care that they provide for the clinic patients they see. Sharon’s clinic back at home is at CUHCC (a FQHC), and states that the clinic here actually may have a bit more resources than CUHCC, thus her experiences there have prepared for the dysfunction that can occur in the clinical setting (unlike my experience at a smooth, functional, well-funded clinic in the suburbs of Minnesota). 

 

Either way, when we aren’t engaged with the clinical work, we’ve had opportunities to learn more about the Native American community (albeit limited in direct community interactions due to COVID). There have been good podcasts, lectures, book readings, academic articles, to try and learn more about the community we have been working with. In the back of my mind with any sort of rotation where we are outsiders, I try to believe that we aren’t committing medical voyeurism or tourism and I think we try our best not to be in that light. I always try to be cognizant of the fact that hopefully we aren’t committing those less than helpful acts, but intention doesn’t always matter if the reception of it is different. But anyway.

 

In general, I think the main serious reflection that I can offer hidden deep in this post is perhaps sadness about my own naiveite regarding Native American health. I think generally speaking for myself or my cohort of resident friends (fairly well educated, interested in health equity), we have all been well aware that IHS is underfunded, that the Native Americans were mistreated (broadly speaking) by colonizers/Americans/us when they first arrived in the U.S. many years ago, we’ve all heard about food deserts, underserved care, etc etc. 

 

All of this is not news or new information to a lot of us (I presume). I think I knew this in my mind, perhaps theoretically. Maybe it is sad that it required me to physically be placed on a reservation, interacting with patients and community members to realize the severe inequity of care that these patients receive – almost similar to being in a foreign country, sadly, when they are actually in the United States – and the complete lack of interest (or maybe awareness, or discussion?) that most of the medical community, at least to my experience, possesses about the Native American community. Perhaps it is also the fact that I haven’t had much opportunity to work with the “rural” underserved; having lived in cities for most of my life, underserved communities in the inner cities are not new in my mind, but this rural poverty is definitely slightly different…(I’ll have to think more about how to unpack that …but I think the remoteness of everyone in the rural community doesn’t seem to help the situation.) 

 

Now I know that this can be said of many topics (as in, you might be passionate about something that others are not!) but after having been here for 2 weeks, I truly feel that as a residency program and medical community, we don’t really talk about Native American health as much as we probably should. Again, maybe it requires one to suffer through actually being a food desert for 4 weeks, ie experience a personal inconvenience, to have empathy towards having poor access to nutritional food (food that you or I would want to eat on a daily basis -- and I personally would blame capitalism for this one -- making processed low quality food the cheapest thing and most accessible thing to be available for these patients). But I want to believe that to possess empathy, it doesn’t require you to actually experience something, I mean, that’s the definition of it, after all…(anyway, I’m trying to find reasons for my feelings and thoughts above). 

 

The revisionist history that Americans are taught, about Native Americans, and the lack of detail perhaps about the atrocities/massacres that has happened in the past, and the rippling effects that this has had on native American communities << I personally learned more of this through this documentary which, I would recommend  (resources provided by AmeriCorps Members here in the community, Caroline & Margaret!)>> is pretty bad. History is obviously recorded in a certain way (usually by way of the dominant (?)/colonizers / oppressors) in the world, but one thing that stuck out for me that was mentioned by the documentary was that, if we think of most Americans, we teach and learn a certain type of history about America through our U.S. public education system. If this "truth" is what the majority of Americans understand and have lived with, it sadly is not surprising that the Native American community is forgotten by us-- as the majority of functioning and active members of society mostly know only the public school's rendition of the telling of America's history.  

 

There are a lot of further thoughts that I could expound upon regarding the above, but I think I’ll end it here. One of the doctors that come from the Mass Gen team mentioned this to me at clinic one day and she stated she hopes to “elevate the quality of care” that these patients receive. And they certainly do deserve this, as much as any one of us.

 

Photo of me vaccinating Sharon for COVID19! (2^nd dose, and her immune system in action below, making her very sleepy after her vaccine)

Solar panels that are right next to the hospital that are pretty cool!

If you look carefully, there are about 3 pheasants in the photo. A lot of them run around in the morning on campus. #postcardpheasant

Next update to be provided by Sharon.....!

-Hannah

Rosebud IHS: Global is... here.

We've been in South Dakota for just over a week now. Last Monday (1/11), Hannah got her second dose of the COVID vaccine, we packed up Sharon's Subaru, and headed west 7.5 hours for our block-long adventure. 

Views from our government compound housing at dusk. The skies in South Dakota are incredible.

One of the first things that struck us on arrival was that we weren't able to find much by way of infrastructure and (what we've come to think of as) "essential services" like grocery stores, post offices, gas stations, quaternary care hospitals.

(Just kidding on that last one.)

We had thought about bringing groceries with us but, due to lack of time and perhaps planning, we elected to figure it out when we got here. Turns out, it was less that we weren't able to find fresh produce and postage stamps and more that there aren't any accessible resources, and perhaps that's the lesson lived here: right here, smack dab in the middle of the country, on the open prairie and right next to a federal hospital, we are living in a food desert, a critical access site, and among Americans who are, in so many senses of the word, underserved. 

It's been a steep learning curve and daily-- hourly-- work to stay humble, interested, and grateful to serve this community and to learn from it. 

After four years, the medicine and clinical aspects of the work are very familiar; mornings are spent rounding on the inpatient ward, and we've been doing afternoon clinic (one each in pediatric clinic and internal medicine clinic). This past weekend, we made the three hour drive to Rapid City (the closest "big" town) for groceries and stopped by for a quick hike in Badlands National Park along the way. 

Dr. Lee on the Notch Trail - Badlands National Park, SD. 

With any immersive rotation, the lessons and reflections on culture, equity, justice, lifestyle, access, and history are myriad, and this is no exception. On our drive for groceries, we listened to a podcast and did some reflecting on one in particular we've like to share: the role of language in culture. Certainly, neither of us are experts in linguistics or Native American language, so we won't pretend to be. Instead, we'll direct you to listen to this episode of All My Relations, a podcast by Matika Wilbur and Adrienne Keene aimed at reframing how the world sees Native American culture. They talk about the inextricable connections between language and a culture's history-- and how indigenous communities across the country are preserving, spreading, and, in some cases, reawakening long-sleeping native languages. It's no huge news that native peoples were on the receiving end of massive population oppression and extermination-- this particular episode underscores how native cultures, too, suffered the same.

From under the South Dakota sky,

Sharon and Hannah