Friday, March 25, 2011


Over the years we've learned much about our paradigm.

When it comes to the women we're working with in the various prongs of the Women's Program ...

Often times we hear statements and questions similar to:
~ Why do they keep having babies?
~ Why don't they just stop having sex?
~ Why doesn't she protect herself/use birth control?
~ She made the choice.
~ It's her fault/problem/consequence.

Those statements and questions are made from a presupposition of justice and equal power. Every culture has different rules and structure. It is much more complicated than we make it.

I often think back to the day a boyfriend showed up on our doorstep and told Troy to fire his girlfriend.  Troy said, "Why? She is a great employee. I have no reason to fire her."  The man said, "You've given her power and she won't let me beat her anymore."

After five years here, I know I still don't really get how it all works. I only know I personally wish to withhold any and all judgment of the women we work with and respond with mercy and love.

This blog post by Barbie (A Physician's Assistant working in Haiti) speaks to the imbalance in Haiti.  To read the full post go here.

The crumpled piece of yellow paper at my foot caught my eye. I bent over to pick it up. Then halted.

A flimsy piece of trash. Worthless. Discarded. Smudged. Walked upon. Crumpled. With the vague ink stamp of our clinic visible in the bottom left corner.

And above the stamp...a life altering scratch of an ink pen. A plus sign. Positive.

HIV positive.

With two scratches of a pen, a life altered for its duration.

I picked up the paper, quietly folded it, and stuck it in the back pocket of my scrubs.

Of course, I know this patient. I know this paper. Discarded trash from yesterday. That was my writing. A lab order for the cachectic, febrile twenty year old girl from a tent city. I'd ordered that test. I'd passed the paper to Sister Gloria, our nurse, and requested her to run it. She returned to me thirty minutes later, and with a stoic, kind-yet-grim look in her eyes, handed me back the slip. I'd met her eyes in silent, knowing, communication.

Two scratches of a pen. A life altering diagnosis.


The twenty year old girl, skin and bones, laid curled on her side in the next room of the clinic, staring blankly at the wall. A resident of one of Haiti's semi-permanent post-Earthquake tent cities. Mother of a 6 year old child. A quick calculation revealed she therefore became pregnant at 13 years old, and gave birth at 14. She breathed rapidly. She was fragile. Like a small bird, fallen from her nest.

I walked into her room, and through a translator, revealed her test results. "Your HIV test is positive," I explained. "This means you likely have HIV, the virus that causes AIDS. We need to confirm this with another test. But I am very concerned."

She stared blankly at the wall.

"Do you have a sexual partner?" I asked.

"No," she replied. "Not since I got pregnant."

Another simple calculation. Last sexually active at age 13. Therefore, HIV positive at age 13.
Now, likely, AIDS. At 20 years old.

"Did you get tested for HIV when you were pregnant?" I asked.

"No," she replied. She got no prenatal care at that time. At 13 years old.

"Did you breastfeed your baby?" I asked.

"Yes," she replied.

Another mental calculation. Untreated HIV positive mother, never diagnosed or treated, subsequently breastfeeding her infant. Means child at risk for "vertical transmission". Transmission of HIV from mother to child, either at birth, or subsequently through breast milk exposure.

"We need to get your daughter tested for HIV, too," I said quietly. Mother stared blankly at the ceiling. The implication, and subsequent palpable self-accusation, was strong. The risk to her daughter's health. A mother's guilt. Finally, as the information was slowly absorbed, a quiet nod. Empty staring eyes.

I flashed mentally to the World Health Organization recommendations for HIV prevention. The "ABCs" of HIV prevention in sexual relationships:

A = Abstinence

B = Be Faithful to your Partner

C = Condoms

I suddenly remember the semi-angry rant of one of my Tropical Medicine professors -- an HIV and TB expert from India, who spent many years as a physician in the urban public health trenches before becoming a professor at Tulane. To paraphrase her highly-educated and evidence-based rant, in response to the ABCs:

Don't think that women of the developing world aren't aware of how they get HIV and AIDS. They know. They are not ignorant. They know about AIDS and know that it is sexually transmitted. The bigger issue is the ability of a woman to say "no". In many parts of the world, due to imbalances of power in the role of men and women, women have no power in a sexual relationship. Whether it is through physical dominance, or financial dependency. They do not have the social power to refuse sex. They do not have the social power to say no, to demand condom use, nor to demand monogamy of their husband/partner.

I look back at my patient, pregnant at 13 years old.

Infected with HIV. At 13 years old.

Was that sexual relationship an educated choice? Or any sort of choice?

Read the rest of Barbie's post here: