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Cross Cultural Misperceptions

Writing about Linda earlier, reminded me of something else worth mentioning.

On her first night here, I explained some house rules, including to turn off electrical appliances (lights, air conditioning) when she wasn't using them, because it costs money.  Later in the evening, she brought up the electricity issue with me, shyly saying "you gotta pay for electricity here?". Yes. "But you got no power card?". (The pay-as-you-go system used in most town camp / remote communities, whereby a little card that you buy at the shop slots into the meter and credits the house with so many $ worth of power).

I explained that I don't have a power card, but every three months the man comes and looks at the box out there, and then they send me a bill. I got my last few bills out to show her. She was visibly surprised, and said "What about the other people along 'ere , they gotta pay for power too?". Yes, everyone does, noone gets free power. "Even the rich people?". Yes, everyone! Did you think we got free power? "Yeah, coz you don't have power cards, so we all think you got free power...... You pay rent too?". No, I pay a mortgage, so that means this is my house, but the bank gave me a loan for it, and every pay day I have to pay the bank, and I'll be paying them until I'm about 65 years old. If I stop paying them, then they might take my house away and sell it to someone else, so every pay day I have to pay them. Again, a big surprised look on her face, and again "What about along 'ere?". Well, some of them are paying the bank for loans, and some are paying rent. "And the rich people too?". Yes, everyone is paying something, either rent or a bank loan, why, did you think we get free houses? "Yeah, we think these nice houses are for free for whitefellas"!

On her last night here, Grandad turned up from around the corner, having shuffled along with his walking frame.  When I answered the door I was greeted with "You never bring that baby to see me!".  Yes I did, but you weren't there! "Oh, yeah! Is 'e 'ere now?" Yes, come in and see him.

Kinship-wise, this little baby is the old man, and his wife's, "uncle". They call him "that little uncle baby".

Later in the night grandma rang my landline from the community to ask me to call her daughter's mobile, so I had grandma in one ear on the landline and aunty in the other ear on the mobile, conversing via me. Grandma wanted daughter to call her, so once I got it sorted out I said to grandma okay, she's ringing you now. "Okay, I'm closing it off now".

Grandad, Linda and I went out in my car that evening to visit Marcia, who was back in town and had called asking to see the baby before he went home the following day.  We piled into my car, and en route to Marcia's accommodation, we stopped at the shop as Grandad wanted some cigarettes.

I got out to go in and buy them for him, and as I was paying, Linda appeared, to tell me that Grandad wanted me to buy him a lemon.  There was quite a queue and I'd already paid, so I said no, and we left the shop.

On our way out of the shop, a drunk woman approached Linda and was clearly harrassing her for money.  I interrupted and told her to leave Linda alone, which made her aggressive towards me.  I walked to my car and she followed me, apparently threatening me (in language).  I got into my car and reversed, then waved at Linda, who was being held back by this woman, to jump in the car quickly.  She did, and the woman reached through her open window and punched her!!

The security guard at the shop witnessed this, and we drove off before I rang the police.  They asked us to stay nearby, and within about forty minutes they turned up.  The drunk woman had hung around all this time, continuing to harrass the security guard, who took a photograph of her with his mobile phone, and as soon as the police arrived, she wandered off.  They made no effort to chase her, but seemed to think they'd find her - we were able to show them where she was walking.   
 

Second stab of pathos

A couple of weeks ago, 20yo Mary rang from her remote community.  I have known her since she was 11yo and I looked after her now-18yo brother, Maxwell, for a year during a very tumultuous time in their (and consequently my) life.  They and their family consider me a mother.  Which makes me - a nulliparous woman - a grandmother now, to both of their babies!

The other grandmother to these babies is Alice, who I have talked about before.  Alice is the surviving sister to Mary and Maxwell's deceased mother, so she has a strong connection to the children and their babies, but does not have the lifestyle to offer them much help.  When Maxwell's baby was born, I heard a story that someone had said to Alice "Helen is a grandmother now", and Alice replied jealously that "She's not the grandmother - I'm the grandmother!".  A similar story comes from their stepmother, who also allegedly responded in a smilar way when my name was mentioned.  Given that I have no desire to be anyone's "grandmother", I'm happy to relinquish the role to the more rightful owners!

Mary's 4mo baby had to travel to town for a medical appointment that Mary couldn't attend, so she was ringing me to say that he needed to stay with me.  He was travelling with her "little mother", the 20yo daughter of her great-aunty.  Oneday I'll try to explain these kinship systems, but suffice to say that there are many mothers, sisters, sons and grandparents that actually are not mothers/sisters/sons/grandparents in the western way of thinking.

Anyway, baby DJ was coming to town with his 20yo grandmother, Linda, and they needed somewhere to stay.  I was happy to have them in my back room.  They had to stay a week because the plane only travels once a week.

I had arranged on the Wednesday night, to have some work colleagues over for drinks, and decided that a young woman and a little baby could share that experience with us, without any hassle.

On Tuesday lunchtime their plane was due to land, and so I tracked Alice down.  She had been in hospital since the day I dropped her there, per my previous story.  But she was discharged this Tuesday, and so I rang Marcia who had Alice with her.  I said to Marcia I want to bring Alice to the airport with me, to meet DJ.  "Yeah, and me too Helen, I want to meet him too".  Yes, but there's not enough room in the car for everyone, so it'll just be Alice and me, but we can come and see you with him".  Okay.  She put Alice on the phone, who agreed to come with me.

We travelled out to the airport together, and arrived before the plane landed.  When the plane did land, and taxied in towards the fence, I "remembered" that the baby car seat wasn't set up in the back seat, so I went to sort that out, and by the time I returned, Alice was holding DJ who was bouncing around happily in her arms.  She can always say now, that she was the first one to meet him, and I felt this would go some way to reducing any threat I might pose.  Not that I believe I should pose a threat in any way, but it had been implied!

He's the most gorgeous little baby I think I ever laid eyes on, but of course the proud "grandmother" will think that!

We drove him into town and straight to Marcia, who wanted to meet him, then on to the hospital, where he was admitted overnight.  On Wednesday he was discharged and I picked them both up after work and we came home together for six nights.

On Wednesday night a knock came at the door at 8pm and it was Nana Alice, slightly intoxicated, wanting a cuddle.  I answered the door holding him, and handed him to her for some cuddles.  Linda came out and was humbugged to give Alice money, but had none and so after a brief conversation and cuddle, Alice left again.

On Thursday night my colleagues came over for drinks.  It was the middle of a heatwave, so we were sitting inside, sipping wine, snacking on nibbles, and chatting happily for a number of hours.  Linda and DJ were there with us, and DJ was quietly happy as he moved from one knee to the next sharing our company.

At 8pm another knock came at the door.  I answered it to Alice, who was very much worse for wear, her hair a tangled mess, her eyes glazed over.  So I said "Please don't come around here when you are drunk".  She replied with "Take me in your car".  No Alice, I can't, my friends are here and I can't drive because I've had a glass of wine.  In a faux-angry voice she loudly stated "Helen!  You getting DRUNK!".  No I'm not.  "You getting DRUNK!  You can't get DRUNK!  You looking after that BABY!".  I'm not getting drunk, go away.  And I shut the door and sat down again.

She didn't stop though, standing at the door - a few metres from where we were all sitting, and shouting out that I was getting drunk!  So I got up and went out the door, shutting it behind me, and asked her to leave.  She stayed there, shouting at me.  So I walked to the gate and she followed behind me, shouting.  I asked her to leave and she continued shouting.
"Please leave now Alice"
"No!  You getting DRUNK!  You can't get DRUNK, you gotta look after that baby!"
"Leave now Alice, or I'll call the police"
"YOU not my SISTER!  I'm calling my LAWYER about you!"
"Okay, you do that, bye!"
My neighbour was over the road swimming, and heard the commotion, so she got out of the pool and came over to ask me was everything okay.  "Yes thanks, but can I borrow your phone?".  She handed me the phone and I pretended to dial the police and have a conversation with them, saying "Could you please come over to , can you hear that lady shouting?  Yes, that's Alice Green, can you come and pick her up?  You'll be here in a couple of minutes?  Okay, thank you, see you soon!".
She walked out then, and I shut the gate behind me after thanking the neighbour and returning her phone to her.

The next day Linda saw Alice near the shop, and told her what had happened.  Alice had little memory of it, and said that she would come to say sorry.  I haven't seen her yet, but I know that all will be okay between us when we do see each other.

Meanwhile, we shut the gate every night after that, and there were no more evening encounters, and DJ went home with Linda last Tuesday, bouncing around in her arms all the way up the tarmac as I farewelled them onto the plane.  I wonder how big he'll be next time I see him?

Paint Me Black

In recent years I've read a lot about being "painted black", also known as "splitting".  It means thinking in extremes, and has been described by such people as Anna Freud and Sigmund Freud.

Splitting occurs naturally in childhood, as part of the developmental process where children learn about good vs bad, and how to integrate the entities of positive and negative (eg love vs hate).  The final stage of this developmental process, is the ability to recognise that good and bad can co-exist, ie a person can have good as well as bad qualities, or a relationship can experience combined love as well as hate, conflict as well as friendship, etc.

When this developmental process doesn't mature well, the person can have trouble in adulthood with integrating good and bad images, so that they will either idealise, or completely devalue a person, depending on whether the focus is on that person's good qualities, or bad qualities.

This polarised thinking results in people being considered "all good", or "all bad", perhaps at different times, or perhaps permanently as they maintain the rage.  Relationships consequently become very unstable.

It's much more complicated than this brief synopsis, and depending on certain other factors related to the "splitter", can involve imagined offences which become real to the person, and can help to reinforce a negative split.  You can read more about it here http://www.toddlertime.com/dx/borderline/splitting-countertransference.htm
http://borderlinepersonality.ca/BorderlinePersonalityInsideOut/2009/06/splitting-devaluation-projection-and-lack-of-trust-in-borderline-personality-disorder/

I have been split in a number of different situations as an adult, and have struggled to understand it, hence my reading up about it.  It's been a real challenge for me at times, as noone likes to be hated, or to find themselves in situations where they go from being considered oneday as "good", "a friend", etc, to being rejected, ignored, and treated as a pariah the next.  Being falsely accused of things which never happened also exacerbates the experience to levels that can be hard to come to terms with.

It's not only hurtful, but can  be extremely confusing, leading to reactions of confusion that may reinforce the negative conclusions being made about you.

Reading about it though, the practice of painting others black when they are perceived to have done you wrong, is not an uncommon phenomenon, as seen in discussions at this forum
http://www.bpdfamily.com/message_board/ .

So if you find yourself painted black, make use of the resources available to you.  Your pain doesn't need to be experienced alone, and understanding the reasons for someone's behaviour definitely helps you to process your own reactions to what is happening to / around you.

A stab of pathos at the front door

I came home this afternoon after a swim and some grocery shopping, and was about to get in the shower when a loud knock came at the door.

I went to the door and Alice, Marcia's "sister" (cousin), tried to come inside.  She is a big drinker, so I stood my ground in the doorway.  She had one foot inside, and the other outside, and I was holding the door as near to closed as I could push it while we debated who was going to win the battle.  She was almost crying and told me she was sick and I need to take her "to clinic".  I said I can, but I need to get dressed first.  "Let me inside, it's too hot out here!".  I said no because I can smell grog, and I don't let people in here who have been drinking, you'll have to wait outside.

When she realised I wasn't giving in she relented, and I locked the door behind me and went to have a quick shower.

When I was done, I went outside to find her, and she'd laid herself down on the footpath along the side of my house, with her arms under her head acting as a pillow, stretched lengthways up the path.  I walked to my car and said "Okay, let's go".

Alice looked up at me and said "I'm dying Helen!".  What?!  "I'm dying!  I'm gonna die tonight, you gonna lose me tonight!".  No you're not, come on, jump in the car and I'll take you to the hospital, you just need to listen to the doctors and do what they tell you and it'll be okay.  "Nah!  You gonna lose your sister tonight!".  But as she protested, she stood up and got in the car.

We made our way to the Emergency Department, and I helped her through Triage before heading off to sort the rest of my night out.  As I was leaving, I instructed her to follow what the doctors told her, and she said "Yeah, because last time I bin run away, but I don't wanna die, you know, like my little sister".  I know, I'll see you tomorrow.  Okay, bye!

I picked up John, my little foster boy, from his Mum, and we came home in time for dinner.  Marcia rang to ask if she can stay here again tonight because "I wanna stay with you, not at Visitor Park, there's too many people there, I wanna stay with my friend".  Okay.  She's no problem, stays out all day and asks for little, really just wants the bed, so it's no loss to me if she stays.  She was out at one of the hostels visiting family when she rang me.

I then had a call from a friend, who was waiting for his partner at a restaurant and she had not turned up, and he believed she was asleep, two doors from here.  So I said I'd go around the corner and wake her.  Once John had his dinner, he jumped on his skateboard and we wandered around the corner to wake her.

Once that was done, we continued on down the street with some lamb I'd cooked, to give it to Kevin who is staying at a hostel around the corner from here, because he has to stay permanently in town now, to attend regular renal dialysis.  We stopped in and delivered the lamb and had a chat.  He was hanging out for cigarettes, and I deliberately took no money with me.  But when he heard that Marcia (his step daughter) was in town, he asked if we could call her, so we did.

She was sitting in town with some family, and agreed to give him some money.  So John and I walked home and picked up the car, then we drove around the corner to pick up Kevin (who is too weak to walk far), and drove him into town to Marcia.  She came to the car window with a $20 bill, then another family member came over and another $50 was passed across to him.

We then drove via Coles for cigarettes, back to the hostel, where our now-happy nicotine addict got out of the car and we came home.

Judging Disadvantage

There's an excellent book I recently finished reading, called "Mountains Beyond Mountains" by Tracy Kidder.  It's a biographical account of Dr Paul Farmer, an American doctor who became involved with a poor community in Haiti during his medical training at Harvard.  Since then he has become a Professor at Harvard, a consultant at a Harvard Medical training hospital in Boston, and the creator of Partners in Health, a charitable public health organisation involved in providing quality public health programs to disadvantaged communities.  Particularly, but not exclusively, in Tuberculosis programs.

I don't often recommend books to read, but I would recommend this one to anyone interested in issues of global health and social inequality.

There are many things in this book that hit home for me, but one of the strongest was the following, quoted as Dr Paul Farmer talking to a group of prison doctors in Russia when one of them asked him if America is a democracy.  Farmer replied that the rich can always call themselves democratic, because when you have no shortage of resources and opportunities, democracy comes easy, but that this is not so much democracy, as privilege.

It hit home to me because I so regularly hear people judging the disadvantaged with the same criteria as they apply to themselves, in their state of privilege.

Today I arrived home from a delightful holiday with my lovely mother, on Norfolk Island in the Pacific Ocean, north-east of Auckland in New Zealand.  It's a tiny island lush with rainforests, clifftop views of the Pacific, restaurants, interesting history and an economy almost entirely reliant on the tourist trade.  We had a lovely week there, and I followed up with New Years Eve celebrations overlooking Sydney Harbour Bridge with a small group of family/friends, sipping champagne and enjoying the very civilised festivities.

When I arrived home, I was immediately drawn back into Alice Springs life, with Marcia contacting me asking to help her.  Her 1yo child has been removed from her care after he became progressively ill during last week.  She was in a remote community with him, and took him to the clinic every day from Monday onwards, expressing concerns for him.  When Friday came around, the nurses decided he was sick enough to warrant being transported to hospital, 500km away, and Marcia became extremely irate and aggressive, arguing with her partner (the baby's father) and destroying some property in the clinic (apparently by slamming a door and kicking a hole in it).

I've worked as a Paediatric nurse in city hospitals, and I am well aware of the aggression that parents of sick children can express when they feel they have lost control over their child's situation.  As I am not a parent, I can only imagine the emotions that evoke such reactions, but I can completely appreciate where they come from, without excusing bad behaviour.

Due to her aggravation and refusal to cooperate with medical advice for her son, Marcia had him removed from her (and her partner, who was also terribly upset), and he was transported to hospital without a carer, and has gone into state care until they can work out the family situation.

So today, a few hours after I flew in on Qantas from Sydney, I picked up Marcia from the bus stop.  She was a forlorn figure sitting on the footpath looking more dejected than I've ever seen her, when I pulled up in my car.  She was hungry and alone, and asking to stay at my house.  I resisted at first, and she accepted my resistance, but wanted me to help her find somewhere to "be", where she wouldn't be alone.  The services were full though, and as she was hungry I took her to get some food.  While waiting for her order of fried rice to be cooked, I relented, and so she is sleeping here tonight.

She ate some food, had a shower, gave me her dirty clothes to put through the wash, and has quietly gone to bed, not before telling me how worried she is for the baby, who has never been away from her before.

I mentioned part of this story to someone tonight, and it was greeted with a critical comment, that had I not come home when I did, would she have stayed at my house anyway?  I didn't argue.  But the reply is "no, she would have found a space under the bridge in the riverbed".

No matter how wrong she has been in her reactions, the fact is that her child has been removed from her, which is not an experience any mother is going to take easily.  She was upset with the clinic staff, that they didn't recognise the baby's condition earlier than they did, and I have spoken to her about how difficult it can be to diagnose illness in small children, and the way children can simmer for a while before they become obviously sick.  She understands this now, and has apparently made amends with the clinic staff.

None of this even touches on the social circumstances of living in a community where poverty and alcohol fuelled chaos reign.  I know that if I was in Marcia's position, I would be no different, so I try not to judge her because the closest I get to understanding, is imagining how her life must be.

Timor Tuberculosis Tales

In October 2012 I travelled to East Timor to volunteer at Bairo Pite Clinic (BPC) in Dili, for three weeks.  BPC provides free health care to those in need, and is the most visited health clinic in East Timor, with over 530 people attending the clinic per day (with a single doctor reviewing patients, coordinating clinic and overseeing the various programs).  People travel from all corners of the nation to seek medical attention here, and a number of primary health care programs are coordinated from the clinic, including a very busy TB unit.  This is a very brief synopsis of my experience from a TB program perspective only.

It took me an hour to travel from Darwin to Dili, but I could have travelled to another planet, the differences were so vast.  As I sat outside the clinic on my first morning, amongst the waiting crowds I observed an emaciated man sitting against the wall with his knees tucked under his chin, struggling to breathe, his whole rib cage recessing with every inspiration.  I was tempted to diagnose him on-sight with all-consuming pulmonary tuberculosis.  I then sat in on the morning clinic, and in my first two hours, witnessed seven people (including this man) diagnosed with probable tuberculosis.

The TB section of the clinic consists of two ward rooms with eight and ten hospital beds, and a TB laboratory next to them, where Ziehl-Neelsen staining of sputum specimens is undertaken daily, on specimens ordered for both inpatients and outpatients.

TB Lab (left), TB wards (centre and right)

One of the TB wards

Most sputum specimens are not cultured (specimens have to be sent outside East Timor for culturing, and this is only done after treatment failure with persisting smear positivity).  There is also a GeneXpert machine in use, for PCR and Rifampicin resistance testing.  This is reserved for smear positive specimens, or smear negative specimens where TB confirmation would be useful, eg sputum with haemoptysis; or cases of TB treatment failure.

CXR is only ordered for those in which clinical confirmation would be useful, and patients travel to the radiology department at Guido Valadares Nacional Hospital, approximately 2kms away, if this is required.

The clinic have a coordinated DOTS program, run by competent local health staff with specific training, who provide treatment to an average of 103 new cases per month, including an average of 5.4 children under the age of 5 years old, commencing on DOTS each month.

There is also a TB sanatorium at a fishing village 20 minutes’ drive west of Dili, where I observed approximately 20 people at any one time, living together in a pretty setting behind locked gates, awaiting sputum clearance.

WHO estimates the TB prevalence rate in 2011 for East Timor to be 701 per 100,000 (http://www.who.int/countries/tls/en/).  Other health, economic and education statistics include 54% of infants with chronic malnutrition – the world’s third highest child malnutrition rate.  BPC have a malnutrition program including inpatient area for severely malnourished infants, and a World Food Program distribution centre providing fortified cereal to malnourished outpatients.  More than 40% of Timorese live in absolute poverty (less than US$1.25 per day).  80% are unemployed.  Many of those employed are in the informal labour market, eg fishing, weaving, even selling stones along the foreshore, and therefore not protected by the new National Labour Code which has implemented a minimum wage (US$115/month) as well as other employee rights.  All statistics I could find online or in discussion with local staff reflect a population surviving in extreme poverty, which was certainly my observation during my time in Dili.

In my time at BPC, the TB beds were usually full with constantly rotating admissions and discharges of people with either confirmed or suspected tuberculosis.  TB cases I encountered included: a 56yo man with ten years of weight loss and cough; a young man with overwhelming disseminated TB; a 27yo woman reporting chronic cough who weighed 24kg; a number of cases of TB uveitis; a 60yo woman with total right pleural effusion; an 11yo girl with left hemiparesis, disconjugate gaze and drooping left eyelid following TB meningitis with TB otitis and optical nerve involvement.

The most interesting clinical case for me, due to the diagnostic delay and resulting debilitation, was the presentation of a 32yo woman (alias “Maria”), from a village in Lospalos District, to the east of East Timor, and her 11yo daughter (alias “Julia”).  Maria reported an eleven year history of extensive, itching lesions over her face.  She had a scar on her right clavicle suggestive of previous Scrofuloderma.  She was well nourished at 48kg, but reported some weight loss and night sweats.  She reported no current or previous respiratory symptoms.  Some right sided sub-maxillary lymphadenopathy was palpable.

Julia presented to the clinic with her mother wearing dark sunglasses, with a chronic, purulent discharge oozing from both eyes for three years.  Upon removal of her sunglasses, she had signs of photophobia, and was unable to open her eyes more than narrowly and briefly.  She was well nourished at 30kg, and reported no weight loss, fevers, night sweats or cough.  She also had palpable right sided sub-maxillary lymphadenopathy.

The doctor immediately diagnosed Maria on clinical grounds, with Lupus Vulgaris (TB of the skin caused by haematological spread from a primary source elsewhere, occurring in people with moderate immunity such that healing occurs in one area, whilst the lesions extend in another).  She also had probable previous Scrofuloderma (TB of the skin caused by contiguous spread from an underlying focus – in this case, a probable supra-clavicular lymphadenopathy).  Julia was also diagnosed immediately, with probable TB conjunctivitis, contracted by direct contact with the lesions on her mother’s face over many years.

Sputums were not taken because neither had respiratory symptoms.  Point of Care HIV and Malaria tests were negative.  Both were commenced on standard TB treatment immediately, and admitted for observation.  Within 48 hours Maria reported that her facial itching had ceased.  Within 72 hours Julia, who had not attended school for three years due to the vision impairment caused by her conjunctivitis, removed her sunglasses and began playing in the sun.  Once able to open her eyes, it was noted that she had phlyctenular kerato-conjunctivitis, inflammation of the conjunctiva and cornea caused by microbes, which has specific clinical features and may result in scarring and vision loss after healing.  TB Uveitis was also diagnosed, as the edges of her pupils had visible nodules, as per the photograph (from www.retinagallery.com).  Upon discharge one week later, her visual acuity was 36/3 (left) and 12/3 (right), with probable permanent damage caused by the uveitis.  No specialist follow up was available for this.

I spent some time talking to Maria via a Tetun translator.  She and her husband are subsistence farmers, growing corn and other vegetables, which they use to feed themselves, and also sell locally.  Maria’s husband is a carpenter, but this work is casual and irregular.  Julia is the eldest of four children, two of whom had stayed home with their father, while the youngest (3yo) had travelled to Dili with Maria and was staying with extended family whilst Maria and Julia were hospitalised.  No other family had any signs or symptoms of TB.  The only contact tracing undertaken is to ask this question, and recommend medical review for anyone reporting symptoms.

Traditional style homes in Lospalos are thatched, elevated huts like the photograph on the left.  However, Maria reported living in a small concrete, ground-level home.  My observations in Dili were that those with a better standard of living have concrete style homes, such as the one on the right, while many live in thatched-roof, mud-floor, bamboo huts without running water or sanitation.

Maria and Julia had visited many clinicians and healers over years, including at two sub-district hospitals, looking for a diagnosis/cure.  In 2010 they spent a week as in-patients, where Julia was given unknown tablets and unknown eyedrops, neither of which had helped.  Maria had been given a number of different creams over the years, none of which helped, and some of which had exacerbated the itching.

The journey from their home in Lospalos District to Dili (approximately 250km) cost $8 each on a bus which took approximately 5 hours.  They stayed with family in Dili, and attended a private clinic first, who were unable to help, but advised them to attend BPC.

This case highlighted the issue of diagnosing a relatively rare form of a common illness in high prevalent settings, with limited education and resources.  The rapid improvement once correct treatment had commenced, after so many years of unexplained suffering, with permanent damage related directly to the delayed diagnosis, was at once astounding and devastating.

Issues working at Bairo Pite Clinic included an extreme shortage of even the most basic supplies such as gloves, masks, medications and dressings.  The below photograph of one of the few handwashing basins at the clinic shows how basic the utilities are.  Taps and water outlets are damaged, and liquid soap is watered down so much that it does not lather up.

 

Coming from a low-prevalence, high-resourced Tuberculosis Control program in Australia, the experiences I had at BPC were informative, astonishing and life-changing on many levels.  I would highly recommend the experience, for anyone genuinely interested in global health particularly in our geographical region.