Dr. Mukwege: call to action

On 3 hours of sleep and with a lecture deficit of almost 20 hours, I dragged myself out of bed this morning to catch the tail end of Grand Rounds with Dr. Mukwege, Congolese (DRC) fistula surgeon who treats thousands of women every year suffering atrocities from gang rape and violence - mechanisms of "mass weapons of war" in the "deadliest war in the world today."

In the small group breakfast that followed, a group of Ghanaian medical students, American medical students and Ob/Gyn faculty alike were captivated by Dr. Mukwege's powerful words and call to action. He has risked his own life in his work on traumatic fistula, speaking to the need to stay and "fight for change in Africa."

Having worked on obstetric fistula repair and prevention in Uganda with EngenderHealth and the Uganda Village Project, I'm happy to see that the issue of traumatic fistula - with double physical and psychological trauma - is finally gaining international attention.

Much of the story is disheartening - that soldiers also commit rapes and thus cannot help guard the hospital | that people are adverse to hearing about "gross" injuries to body parts not commonly discussed, such that the translator at the Wallenberg Award talk "sanitized" Dr. Mukwege's language | that the government's lack of response may be linked to its financial ties to cobalt mining, and those who speak out are routinely killed. As Dr. Tim Johnson pointed out, this is truly a new kind of terrorism against women.

However, Dr. Mukwege reminds those of us in the medical profession that "Because we see things that others don't see and hear things that others don't hear, we have a greater responsibility to testify." Indeed, the power of the white coat in credibility and ability to use provocative language ("Bill Clinton can't say the word 'vagina'" - TRBJ) means we need to tell those stories, no matter how much apprehension we are met with.

In the face of such global injustices, we are reminded to "keep history near" (Rwandan genocide was not that long ago, and we promised "never again") and to commit to global citizenship (echoing President Clinton's UMich 2007 commencement speech). The international community is failing to halt the tragedy in Kivu -the least we can do is to increase global attention.

To learn more:

The Greatest Silence, documentary recently released on the atrocities committed against women and Dr. Mukwege's work

And a shout-out to Eve Ensler, author of the Vagina Monologues and activist working end violence against women, who is leveraging the V-Day movement to help build a rehabilitation center for traumatic fistula survivors in the DRC.

"what makes life worth living"

a memorial service was held for sujal today, a little over a month after his life was tragically taken away. the strength his parents showed in offering support to others was absolutely mind-blowing. also, as one speaker noted, "there will forever be a sujal-sized hole in our hearts"..."a crater that forces you to appreciate the impact that's been made, and one which has permanently changed the landscape of our lives."

my personal reflections over the past month have vacillated between denial (since he would have been away until next june anyway) and conviction to live with greater meaning. whether or not the semester theme (UMich liberal arts college) of "what makes life worth living" stems from the utter fragility of life, that notion has permeated my day-to-day decision making as well as broader worldview. given all of life's unexpected (and sometimes unfair) turns, i feel compelled to re-focus my energies on those things that are most important to me and make me happy - not just in the distant future, but today, right now.

in making even the smallest decisions, i ask myself - does this contribute to my life, no matter how meaningful or trivial? am i investing enough into the people, relationships, and activities that truly matter and bring me joy, and not just doing things out of obligation? are my decisions congruent with my core values? am i living my life with conviction?

today, we celebrated sujal's life and the incredible memories, love and accomplishments that encompassed it. looking forward, i seek to continuously celebrate all flavors of life, from the little joys to hard-earned triumphs. after all, what makes life worth living anyway?

carrying on suj's spirit

suj and i shared a number of passions and organizational affiliations, and i saw much of myself reflected in him, making tragic loss particularly personal for me.

through the Uganda Village Project, we both threw ourselves into rural development in eastern Uganda, albeit working in the field at different times.

through Universities Allied through Essential Medicines, we both fought for global medicines access. in fact, i first met him at a recruiting table for UAEM Michigan and now, following in his footsteps and through his encouragement, have joined national and chapter leadership teams.

at the Center for the Global Health at UMich, we worked on student-oriented projects and co-authored a poster for the 2009 symposium. this year, i am on my own at the symposium.

finally, as a fellow student at the University of Michigan Medical School, he never hesitated to give me "insider's" advice or connect me with relevant faculty, or offer to edit proposals, application essays, anything really, no matter how insanely busy he was.

while our acquaintanceship grew out of shared "work" (global health) interests, our frank, open connection led us to really "click," and i saw him as a friend, a peer mentor, a pillar supporting all of our shared work. it wasn't until the end of the school year, as he prepared for his move to Uganda, that we began to hang out simply to hang out. and i truly looked forward to his return, where we could catch up on a year's worth of travel and global health activism stories.

i cannot imagine the pain endured by his family and best friends, as i myself struggle in the grief of losing a pillar. in reflecting on the tremendous impact he has had on the lives on others - both in global health efforts and through mentoring peers/encouraging student activism, i realize how my own efforts could and should be expanded.

i cannot live up to all that suj had the potential to accomplish, but i do hope to channel my utter grief into conviction to fight harder against global injustices, to make my networks available to others as much as possible, to dream big about changing the world and commit to doing it. throwing myself into the unfinished work suj has left will perhaps ease the pain.

let us all draw strength from suj's impact on our lives and carry his spirit forward.

"hope for the best but prepare for the worst"

when a tragic situation forces you to "hope for the best but prepare for the worst," is that really possible?

in medicine, we spend a lot of time discussing the need for earlier end-of-life planning in response to the current state of irresponsible end-stage care. exorbitant amounts of money are spent in the final days on aggressive therapies that often fail to prolong life in any meaningful manner and instead increasing suffering. by mapping out decisions earlier, the final march could be far more peaceful and less torturous.

but when that life in question belongs to someone you care about, and it takes nothing less than a miracle for "the best" to be realized, acknowledging "the worst" as a possibility almost feels like conceding or hopelessly accepting it. with emotions on full blast and all rationality aside, it seems near impossible to simultaneously grasp onto fleeting hope for a miracle and also lay a mental foundation in preparation for death.

without condoning overly-aggressive end-of-life care, how do we find the "right" balance in maintaining hope and yet being realistic?

on the incremental levels of grief

on one level, death of anyone, for any reason, anywhere in the world is tragic, especially if unexpected or premature.

on the next level, when that person has the vision and capabilities to truly change the world, as suj did, it is even more tragic.

and when that person is your friend, someone you know personally, had insightful conversations with and shared quality time with, the grief escalates, regardless of his or her potential contribution to society.

and when you see much of yourself reflected in that person through shared passions, career ambitions, global footprint - and had been in the exact same situation in the same location (many times) that he or she was when the fatal incident struck, the grief reaches a new height.

sujal parikh was one of the most inspirational people that i know, and his tragic accident undoubtedly affects many across the globe. thank you, suj, for your impact on my life. my heart is with you.

The Bottom of the Base

Of all of the poverty that I’ve seen over the past few years, nothing is as destitute or heart-breaking as the poverty of the street-dwelling migrant families in India. They’ve left their homes (“because there is nothing to eat,” as my colleague explained matter-of-factly) in search of labor – often in construction– and have essentially become homeless in the process. Living on concrete sidewalks, under bridges, in open fields, on dusty roadsides – any uninhabited space is turned into an open-air “home,” with the occasional blue tarp covering in the rain. Whatever meager income obtained, if any, is not enough to break out of this homeless, migrant trap.

The other day, while stopped in traffic in an auto, I saw one such family at an extreme. The mother, disheveled with messy hair and visibly soiled clothing, was tending to her baby, who sat bare-bottomed on the roadside, one foot away from traffic. Moving slowly and with a dejected air, she wet a rag to wipe the baby’s face then hung it on an adjacent road sign, as if it were a hook in a wall, and the open air was her home, and she and her family were not surrounded by Hyderabadi pollution, dust and traffic.

In much of the world, sparsely populated rural areas often lack adequate transport, health and sanitation infrastructure; increased urbanization has led to overcrowded slums and, at least in China, a “floating” migrant population of second-class citizens. Yet all of these groups have access to a basic human need that the street-dwellers in India lack - shelter: a roof, however rudimentary, above their heads and a space, however small, to call their own. These street-dwellers are truly at the bottom of the Base.

The Base of the Pyramid (BoP) is diverse group and measurable by different metrics – income, living conditions, affordability. Collectively, they comprise a significant portion of the world’s population; “1 billion living on $2/day” is a commonly cited figure.

The appeal of social ventures that serve the BoP in clean water, energy, microfinance, health is the increased sustainability and scalability of market-based mechanisms over traditional aid. Instead of giving away malaria nets, for example, they can be manufactured locally (creating jobs) and sold by micro-entrepreneurs (efficient distribution channel) at low prices. This socially-driven form of capitalism makes the nets more widely available and valued compared to grant-dependent distribution of free nets. However, in order for the system to work, the participants must have some level of affordability, even if it’s as little as $2/day.

What has struck me the most through my summer internship and musings with others in the BoP space is that the absolute poorest of the poor, the bottom of the base, are often still beyond reach. I highly doubt the homeless migrants in India, for example, of which the population size is probably unknown, could participant in BoP services. So the question remains: how do we even begin to improve the lives of those at the bottom of the Base? What would be the most effective mechanism?

random acts of kindness

on a rainy night after the day-long "india close" strike, where all public transport across the country protested rising oil prices, a few co-interns and i piled into one of the few auto rickshaws available to go home. with our numerous bags (including a suitcase), we barely fit. to save space, i put my laptop in the back. as we pulled up to the gate after a rainy, rickety ride, i hurried off with the suitcase in one hand and mango + purse in the other.

halfway down the slope to our compound, it suddenly hit me - where the f** is my laptop?? still in the auto!! i throw down the mangoes and run up the slope to chase the auto, but it's nowhere in sight. in strappy sandals, with a bag flapping at my side, and drenched by the rain, i turn and run down the pot-hole filled road. desperate thoughts fly through my mind: i backed everything up a few weeks ago...but i'll lose pictures from this summer....and the hours and hours of data cleaning/manipulation...and i wouldn't have a laptop to use for the internship...what a waste of a summer...!#F!#*$@!#$%^ [repeat expletives]...

at the deserted intersection, i whip my head in one direction then the other, straining to see if there are autos anywhere. suddenly, a man on a motorcycle approaches, also drenched, and asks what's wrong. "my laptop is lost in some auto!!" i wail. "come, i will help you," he says, beckoning me to hop on. without even thinking, i do, and we speed further towards the main road.

to put the situation in context, autos are a form of transport entirely in the informal sector. despite the fact that auto drivers' wives are our target customers at LifeSpring, some of my most frustrating experiences in india have been with autos - negotiating prices, getting lost in the defunct landmark-based navigation system, and fearing for my life as we swerve between cars, sometimes against traffic. recovering a lost laptop from one of the 1238904274e3819 untrackable autos in hyderabad would essentially be impossible.

a few hundred meters away, i see an auto parked in front of a small shop. i hop off the motorcycle and frantically question the auto driver, who looks at me confused. still getting rained on, i forego the conversation and look behind the seat. and there it was - my lone laptop in its case, a miracle to have in my hands again. i thank the random motorcycle driver and start to walk back, but he insists on driving me to the compound.

india is chaotic - true. the masses of people, the conglomeration of cars, autos, motorbikes, cows that form impenetrable traffic, the petty traders soliciting you to buy bangles, fruits, garlands (with a "foreigner's tax") as you squeeze by - it's easy to feel overwhelmed. and yet, a simple, random act of kindness by a complete stranger, who surely had better things to do than ride around in the rain with an absent-minded foreigner, reminded me of the order within the chaos.

the next day, i was struck by another random act of kindness. after arriving at a store that took too much effort to get to, i stood staring at it from across the one-way street. pacing back and forth, i tried hard to figure out HOW the hell to get across. the traffic moved by fast enough that i was too timid to step out, but slow enough that it streamed by continuously with no breaks. my usual trick of crossing with other pedestrians would have failed - the slightest lag in timing or step makes all the difference.

after i stood foolishly for at least ten minutes, defeated and gaping at the traffic, a nearby auto driver jumped in front of me and motioned his hand towards me. i followed in his step as his outstretched hand momentarily slowed traffic, overcome with gratitude by his random act of kindness. as i watched him weave back through the traffic to his auto, i couldn't help but wonder where else in the world this would happen. that a man who makes 4000 Rs ($88) a month, instead of soliciting business and attending to his vehicle, would inconvenience himself to help a visibly incompetent (and likely rich) foreigner do something so simple as cross the street, and for no more remuneration than completing the act. he barely stood at the other side of the road long enough for me to thank him.

the entire night i thought about the dynamics of human behavior in overcrowded countries like china and india. when i experience an unruly situation, i often attribute it to the necessity to fend for oneself, citing that circumstances do not allow for much regard for others. these two recent incidents may be anomalies, or they may illustrate the pervasive human concern that contrasts with the chaos and crowdedness of everyday life. either way, they make me deeply appreciative of my experiences and interactions in india.