What would you say is the most important thing in life?

Health and knowing how to live in this world; knowing how to enter a place and how to leave.

There are many ways to leave a footprint and many types of footprints to leave. There are the ones in a dust pile that scatter with the next step; the ones in sand that wash away when the tide comes in; and those accidental ones in freshly poured concrete that continue to harden over time.

About five weeks ago, I landed in Fortaleza. It is a large city on Brazil’s Northeast coast that has sat a the center of the recent Zika epidemic. I came down to study the relationship between Brazil’s restrictive abortion laws and the response to this public health crisis. Specifically, I wanted to identify the challenges healthcare providers face when caring for women with Zika-affected pregnancies, given the high correlation with fetal microcephaly. Questions such as how providers advocate for patients, decide on appropriate follow-up procedures, discuss pregnancy options, and respond to patient concerns within a rigid policial and legal framework. 

As luck wouldn’t have it, a few days before my flight I got a rejection letter from a grant for research funding. But my ticket and visa were already purchased. So with that I made my entrance with a little notebook covered in seahorses, some rusty Portuguese, and hope that I hadn’t just made a huge mistake.

Within days after arriving, the heavy disappointment of rejection turned into a relief. I soon realized that had the project been approved, it would have been a tremendous failure. There simply weren’t any new Zika cases to look at. So instead I roamed around the maternity hospital I had been connected to, getting passed among doctors and residents who didn’t mind an eager tag-along. The first couple weeks I spent helping women with large bellies rolled on and off exam tables. During prenatal checkups I took blood pressures, ran measuring tapes from pelvic bones and uterine ceilings, and listened to fetal heartbeats; during ultrasounds I stood in the dark cold room staring at a screen that measured gestational age and health but looked more to me like Escher drawings than any identifiable body parts.

Although Zika-associated microcephaly was no longer on the table, I began paying attention to issues of other maternal-fetal complications. Perhaps these cases would open up similar discussions. At first, I did not hear the conversations I was looking for. The fact of the matter is that in a country where abortion is illegal, these conversations are not obvious. If they happen at all they seem hinted at, touched upon, broken into bite-sized chunks for you to piece together on your own. They require other senses.

But as the days passed, they slowly began to appear. I found them in the absence of patient questions, in the muffled “thank you”s, and silent head shaking. They were in the tears of women who received devastating diagnoses in the ultrasound room. They were in the rejection of a patient’s request to have her tubes tied with her C-section. They were in the swift change of conversation when I began to ask questions.

By slowly connecting the dots, I eventually found who I was looking for. My third week I arrived at Dra. D’s office door. She was the one who facilitated the few legal abortions allowed by the hospital. She met with patients who came looking to terminate pregnancies resulting from sexual assault. It was incredible to watch her work with patients. Her words soothed their wounds and calmed their cries, yet she was firm in her counsel. She promised they would be cared for without sugarcoating the truth of the challenges that still lay ahead. When they collapsed into their chair she did not take them into her arms; instead she helped them stand stronger, walking with them as they navigated the hospital side by side.

This was actually a small part of the work she did as an Ob/Gyn and sexologist. Each day with her was a whirlwind of patients, cases, conversations I could have never planned for:

  • a walk through one of the few psych hospitals where heavily sedated men with glazed eyes sat scattered through hallways and open courtyards
  • a training on transexual health for hospital staff, many of whom had never heard the word before
  • a support group for patients with multiple sclerosis 
  • couple’s therapy where they shared the intimate details of their sex life and relationship woes
  • trans patients looking to begin their transition process
  • Play-Doh therapy with a 3 year-old with a suspected case of sexual abuse
  • life lessons taught to residents about feminism and empathy for their patients
  • physical therapy for a patient with vaginismus
  • identifying a learning disability in a 14 yr old patient who couldn’t find her country on a world map

One of the best days was when I joined the last day of a 5 class course. It was a support group for women with sexual dysfunctions of various types. They had already covered questions of physiology, biology, social constructs of sexuality, religious influences, relationships, etc. The day I arrived was about pleasure and eroticism. Dra. D split us into pairs and distributed an assortment of items, which we had to incorporate into a story. I got a massage wax candle, a small vibrator, and a dice with different sexual positions on each of the six sides. At first most women were quiet, shy or giggling with embarrassment. But not my 60 something yr old partner who order me as the scribe to the heated saga she began to tell. When it came time to share, the room erupted in applause and laughter as women surprised even themselves with the erotic stories they created.

So while my proposed study failed died before it began, the experiences I had were ones which seemed to answer the questions I had better than anything I could have planned for or imagined. As my five weeks in Brazil come to an end I’m curious to see what comes of these footprints. Both those I have made and those which I have stepped into. Only time will tell. 

For now there seems to be only one way to leave: humbled by the generosity that greeted me, inspired by the stories I bore witness to, and motivated to take on the hard work that lies ahead.

Fortaleza: Part 2

Monday morning she was back in the waiting room. With the nervous look of a girl embarking on her first sleepover, she had her pink backpack on her lap, ready for however many days the hospital would be her new home.

She would have to initiate and terminate her pregnancy under the careful watch of the hospital. First, they would administer a dose of misoprostol vaginally to stimulate uterine contractions. After six hours, an anesthesiologist and Ob/Gyn would perform a D&C (Dilation and Curettage); in reality, a procedure that is longer and more invasive than most protocols recommended for her pregnancy of only 7 weeks.

The reason for this? Like most questions of “why?” here, the answer is unclear. Maybe this is for her safety.  Maybe the hospital doesn’t have access to the Mifepristone or vacuum aspirators typically recommended. Or maybe the additional procedures offer financial incentives that outweigh the health of the patient.

Time certainly wasn’t the issue. They had no problem keeping her in a room waiting for a doctor to see her with the misoprostol to begin the abortive process. The problem was that when he rounded on patients he skipped her room, repeatedly. What she thought was first a mistaken overlook, it became clear the doctor was actively avoiding her. Dr. B doctor warned her to be prepared for these so-called conscientious objecters. So she waited, hoping the next doctor on-duty would be more empathetic. But day 1 passed and still no one came to see her. She closed her eyes and prayed tomorrow would bring better luck.

Dr. B told her to be strong, but as day 2 came and went her patience turned to desparation; she had a daughter to take care of, a job to work, and a life she wanted to get back to normalcy. When she could wait no longer, she called Dr. B, alerting her team to what was happening. Phone calls were made, words were exchanged and on day 3 the patient was finally attended to and discharged from the hospital.

Maybe the invasiveness and time consuming nature of the procedure will serve as a reminder to be more careful next time.

Maybe next time she shouldn’t talk to strangers, shouldn’t drink, shouldn’t go out at night, shouldn’t leave her daughter with her parents.

Maybe she should be a better mother, a better daughter, a better woman.

Yes, maybe this time she would learn her lesson.