The Girl Effect

I had to post this magnificent video here. It's heartbreaking and uplifting and beautiful. I can't stop watching it.

I've written about what life is like for women having giving birth in rural Uganda. If we are going to help women, we need to start with girls. They need freedom, education, empowerment and opportunity. The revolution will be led by a 12-year-old girl. I love this.

Tororo District Hospital Website

A very generous tech friend has donated his time to help create a website for Tororo District Hospital.
It's still in progress, but I am excited to see it up and running, and looking forward to developing ways to make the website useful for the TDH staff and the Tororo community.

You can see the website here.
There is also a section with information about how to do a clinical rotation at TDH for medical residents interested in global health.

We will be making changes to the site over the next few weeks, so be sure to check back in and see its progress!

Retained Twin

On my most recent trip to Tororo, I am asked by the midwives to see a patient for “retained second twin.” This means that the patient delivered the first twin (usually at home, on her own) but the second twin did not come out for a long time, prompting her to present to the hospital. In this case, the patient presents with a note from the traditional birth attendant, who sent her in.

The patient delivered about 18 hours ago. She looks calm, and not in pain. There is a single umbilical cord coming down between her legs. The midwives can’t determine the position of the fetus. I palpate the abdomen, and I don’t feel a head in her pelvis, but I can’t tell much of anything. I do a vaginal exam, and find that while the membranes are bulging out into the vagina, tense with amniotic fluid, the presenting fetal part is high up in the uterus, and I cannot palpate it, no matter how high I reach, although the cervix is fully dilated. It is very hard to reach around the bulging membranes. The midwife tells me that there was no fetal heartbeat, but miraculously (normally I am quite unskilled at using the fetoscope), I seem to find one. The midwife agrees.

I bring the ultrasound, and find that the midwives and I were correct – the head is not coming first. It is a difficult scan because the infant’s body is bunched down in the lower abdomen, but as I follow the axis of the spine, it seems that the fetus’ pelvis is lowest in the woman’s uterus. The fetal head appears to be at the uterine fundus, so it is most likely breech.

If the fetus is breech (meaning either feet or pelvis coming first), I can try to deliver vaginally. But if the fetus is transverse (meaning torso, arm or shoulder coming first), there is no way to deliver without performing a version.

If I had been present at the delivery of the first twin, this would be easier. Usually, the second twin is still high up in the uterus, and I can actually reach an entire hand in and turn the fetus to either cephalic (head down) or breech, and then deliver. (It helps if the patient has an epidural, of course). But since the woman has now labored for 18 hours since delivering the first twin, the second twin is stuck in position, and I cannot rotate it successfully, despite my efforts.

I would really like to avoid a cesarean in this woman. This is her fifth delivery – she has four living children other than Twin A. She clearly has a proven pelvis, and it is not clear whether Twin B will even survive at this point. Cesareans are much more morbid here than in the US, and I don’t want to put her through one for a non-viable fetus.

However, I can also see on the ultrasound that this fetus’ heart is beating strongly. This kid is alive. So I have to decide – do I try for a vaginal delivery now, or go straight for cesarean?

The midwives and I both feel that she has a good chance at delivering vaginally. She has pushed 5 babies out, so her pelvis is good, and her only problem seems to be the lack of powerful contractions. We decide that we will hang a slow infusion of oxytocin to get her contractions back, and then I will slowly break the bag of water and see if I can deliver the child breech. I am not 100% sure that he is breech, but I am taking a gamble in the hope of sparing the mother a surgery.

Before I do so, though, I want to make sure that theatre is prepared in case I need an urgent cesarean. If I get a cord prolapse, we won’t be able to wait the usual hour (or more) to get the patient to theatre before the fetus is compromised.

They start the infusion, and I take care of some other patients. When I return, she is grunting heavily and telling the midwives she wants to push. I examine her, and the bag is bulging even more tensely in her vagina. The presenting part is still not palpable. I take a needle and puncture a tiny hole in the bag. As water leaks slowly out and the bag becomes less tense, I am able to palpate what is inside. And what I feel is…..cord.

Crap.

I just lost my gamble. Now what? Will we ever get her to theatre on time? If the baby is breech, should I just try to do a quick extraction instead of taking the risk of theatre?

I palpate the cord. It has pulsation, meaning the baby is still alive. Since the fluid is leaking out only very slowly, it is still buoyed by the fluid in the membranes. I palpate further and feel something as narrow as cord, but much more firm. I follow it up..….fingers.

CRAP.

Transverse presentation. Now I have really lost the gamble. I have already called out to the midwives to prepare for theatre. One is bringing over the stretcher – I am impressed as this is unusually fast. I tell them not to bother having her sign consent, just bring her. (That never happens.)

I dash over to notify the theatre staff, and they start preparing. First, they are out of suture. I look in the suture closet and find only silk and a little nylon. AARGH. Both of those are non-absorbable (permanent) and I loathe using them. What happened to the vicryl and chromic that used to be here?

The theatre nurse informs me that they have been out of stock of most sutures for 2 weeks, and the district has not yet approved the purchase of more. Facepalm. Luckily, the anesthetist has just a little vicryl and catugut stored away in a locked cabinet for just this reason.

A tray is already being prepared with a c-section kit ready to be unwrapped. When I was living here, I had bought sterilizing cloths so that instruments could be packed in sets, and sterilized in advance of surgery (so that we wouldn’t have to wait an hour to sterilize instruments right before the surgery). I am pleased to see that the system has continued.

When I left the labor ward, the midwife was moving the patient onto the stretcher. But where are they now? I feel the minutes ticking by. It always takes forever to move the patient, and is one of the most frustrating things that, no matter what I do, never seems to change. I pace and keep poking my head outside the theatre door, staring anxiously. Just when I am about to run back to the labor ward, the patient appears in the prep area. They had stopped to consent her, hence the delay. Fine, whatever. They tell me that the patient asked very clearly for a tubal ligation. I reconfirm with her and document it.

Kevin, a female anesthetist who has training in spinal anesthesia, appears and asks me if she can do a spinal. In the US, we would do general anesthesia in this situation because we have no time to spare in a cord prolapse – the child could be dead in minutes. But I know that spinal anesthesia is much safer for the mother, and given all the other delays we still have to get through in preparing theatre, I don’t think that putting in the spinal is going to make a difference, so I agree.

Kevin is a rusher – I like that. Things tend to go at a slow pace here, even emergencies. But when Kevin realizes she needs a different needle for the spinal, she runs to the supply room, and runs back. The spinal is in very quickly.

I have invited Katie and Hannah two young American possible pre-meds to observe the c-section. They are quietly observing in a corner. I hope they don’t pass out, but I’ve given them instructions on what to do if they feel woozy. I’ve also warned them that there’s a good chance this baby will die.

We are finally ready after what seemed like much too long. The spinal anesthesia works beautifully. I get in quickly, but once I open the uterus, the first trouble starts. The position is terrible, and I realize I should have made a vertical incision on the uterus. The fetus is folded over itself and squeezed into the lower uterus, and the back is facing me, with the shoulder at the incision. Mentally, I kick myself, because I should have put together my ultrasound findings (spine up) with palpating the hand in the vagina (transverse presentation) to know I needed a vertical incision.

It is impossible to grab anything. I try to bring the feet out, but can’t. I try to bring the head out, but can’t I try to turn the fetus, but can’t. I try to push the arm up from the vagina to flip the baby, but it doesn’t help. Finally, I extend the uterine incision on one side. It’s still difficult, and I repeat my maneuvers. Finally, as I am trying to move the head, I see testicles pop out of the incision, and realize that the pelvis is out. I have to scold the scrub nurse not to yank on the infant’s body as I am delivering – this is the worst thing you can do, because it causes a reflex in the baby that can cause the head to get stuck. I can now gently sweep the legs out, and carefully ease out the body and the head.

The baby is blue, limp…..dead. I try to palpate rapidly for a pulse in the neck or the cord, but feel nothing. I quickly clamp the cord and pass the baby to the midwife. Sometimes, babies who look like this are assumed to be dead, so I give clear commands to resuscitate immediately. I turn back to the mother, but continue to keep one ear on the resuscitation.

The midwives generally do a good job resuscitating, but the one thing they are often complacent about is oxygen. The oxygen concentrator is often not working, or doesn’t have the right connecting tubes, so people tend to give up and not waste time trying to use it.
But I know this kid needs oxygen if he’s going to live, so I keep calling out to use the oxygen.

Katie and Hannah are watching anxiously, itching to help. I tell them to try to hook up the oxygen while the midwife works on the baby, so they jump in. The oxygen can’t connect to the bag/mask, but there is a small nasal catheter that can be placed down the baby’s nose to give oxygen. I tell them to leave the oxygen catheter in and keep bagging if there are no spontaneous breaths. The heart rate improves to almost normal, but still no spontaneous breathing.

Meanwhile, I am suturing a bloody field. My extension of the incision and my aggressive attempts to deliver the fetus have damaged the left uterine artery, which is shooting blood. The uterine artery is not far from the ureter, which connects the kidney to the bladder. It is very easy to damage the ureter, and potentially catastrophic if it happens. I clamp the artery carefully, and then am able to dissect it away from the surrounding tissue and tie it off so it stops bleeding. All the while, I am calling out orders for the resuscitation without actually being able to see how the infant is doing. It’s hard to focus – one of the knots I tie is is useless because I am distracted while tying, and I have to retie. Finally, I control the bleeding. I start to wonder if I operated on this woman and bled her out only to deliver a dead baby, and I kick myself again.

Katie and Hannah are communicating to me how the baby looks so I don’t have to take my eyes off the field. The color is improving, but it is not clear if the infant is breathing. Kevin and the midwife insist that the breathing is fine, while Katie and Hannah say that there are only infrequent gasps. It’s hard for me to tell, but at least the heart rate is staying up. I tell them to keep the oxygen on and count the respirations per minute. There is no clock in the room, so one of them has to count seconds while the other counts respirations. Now that the bleeding is controlled, I can try to get through the rest of the surgery quickly, and then check out the infant. But my first priority always has to be the woman.

It is time to tie the tubes. I generally try to confirm once more before I cut them, and especially in cases where the baby is not doing well. I have the midwife ask the patient in Japadhola, and there is some confusion. First she says yes, then no. They ask her again, and she says not to cut them, because “her husband will quarrel with her.” I have them ask again. She repeats that she has not discussed it with her husband, so I should not cut them. Everyone is disappointed – this woman has been through so much, and is having her sixth child. If only the men came to the births, the women would all get contraception. I leave the tubes alone, and close the abdomen.

I have to argue with the theatre staff again about the skin closure. All of the doctors at TDH use silk (permanent) suture, in which they drive a huge needle straight through the skin on both sides, and pinch the skin together tightly. The silk suture has to be removed (painfully) after 7 days. Often the incision gets infected, and leaves a giant scar with a keloid. The staff (who are not the ones I have operated with in the past) has never seen a subcuticular suture, which is what I do. I take a tiny suture, and I sew just beneath the skin edge, bringing the skin together gently. When I am finished, you can’t see the suture, only a very thin line. The suture absorbs over a few weeks and does not need to be removed. They don’t get infected the way that the other closure does.

The staff is concerned that the suture I am using is too small, but when they see my closure, they stop questioning it. The midwives have seen how nicely my incisions heal, and they love it.

The patient has lost a lot of blood, but seems OK. I check out the infant. He is no longer blue, just pale. His heart rate is normal, and he is finally breathing spontaneously. His muscle tone is weak, and he does not cry. His arm (the one that was in the vagina) is very swollen, but not broken. I try to stimulate him by rubbing his back or flicking the bottom of his foot. At first, he doesn’t respond, but finally he gives a weak objection, and I am pleased. It’s at least some reaction.

I write my operative note while the patient is being moved off the table. When I come back to the infant, he looks even better. His skin is turning light brown, and his whine when stimulated is getting louder, almost a cry. His hand squeezes Katie’s finger, and we are pleased. Now, his biggest problem is warmth. I write for him to be placed in the warmer, and when the mother is ready, kangaroo care.

Hannah and Katie are pretty stunned. We go out for lunch (it’s 3pm, we are all starved) and reflect. I sincerely believe that if they had not been there to assist with the resuscitation, the baby would have died, and I tell them as much. “You saved the baby,” I say, and it’s true. I joke that this might be the first day of their medical careers. Katie announces that she just might go to medical school to go into Ob/Gyn. I try not to beam too much, but I am proud.

The next morning, we all go to see our patients. I am worried that the infant might have died overnight; he was still weak. Will Katie and Hannah be too upset if he died? At least I have dealt with this before and am emotionally prepared, but the first time is really hard. But no, the nurse tells us both twins are alive.

We find the mother lying in bed, but she beams when we arrive. I greet her and her mother, who is holding the infants. They both look great. The first twin, Opio*, is happily sleeping. The second twin, Odongo, is slightly bigger, and looks great. His tone is a little weaker than Opio’s, but much improved. His arm is still swollen but less red, and when I move it and try to unflex his hand, he cries out with angry objection. I am happy to see that forceful cry.

The woman looks great. Despite her blood loss, she looks happy and bright. I remove her bandage, and the incision is beautiful (if I do say so myself). We ask if she wants a photo with her babies, and she does.



The Odongo is on the left, Opio is on the right. The patient, so smiley, immediately puts on a serious face for the photo, as is the custom here. She laughs when we show her the photo. She tells me that I can share her photo, because she is so happy we saved her.

I remind the patient that we did not cut her tubes. “But I signed to cut them,” she says. Sighhhhh. I remind her that she told us not to cut them during the surgery. “Yes,” she says “because I had not informed my husband.”

The nurse lectures her about family planning, and she does not want more children, but is vague about her plans for contraception. She agrees to come back in 2 months for family planning, and I warn her that she could get pregnant after 1 month. The husband is at the window, so we bring him into the discussion. He speaks English.

I tell him what happened at the delivery. He doesn’t realize that the infant nearly died, so I tell him that the situation was very dangerous for both the woman and the second twin, and that the next pregnancy could be complicated as well.

“I was thinking about this yesterday,” he says. “I think that we have enough and we should stop, because my wife was in danger and I don’t want that again.”

We explain that we could not cut her tubes, and we encourage him to make sure she comes back for family planning. Bringing the husband in is essential in getting women to accept contraception here, and it’s unfortunate that most do not come. If he had been around yesterday, we could have cut her tubes. Luckily, we are all in agreement now. We shake hands all around.

Over the next week, I continue to visit the woman every day. Katie comes with me to see the patient every day. I am very impressed with Katie’s passion – I wish more medical students would show this level of commitment. I strongly believe that we should follow up on our patients and take responsibility for them, especially as a surgeon. Seeing patients after you operate on them means that you see the consequences of your actions, and that you don’t put the patient aside once the skin is closed. It also means that you see the pain, the healing, the struggle and the reality.

Many patients are anxious to go home, and often start to ask for discharge when they are healthy enough to get out of bed, but she doesn’t. Her milk is slow to come in, but finally comes in on the third day. But she is emaciated to begin with, her infants are small and the delivery was stressful. I am in no rush to send her home. It turns out that the patient speaks more English than she had initially indicated, and we can communicate a little. I tell her that I want her to eat lots of food, including meat and beans (protein malnutrition is a huge problem here), and that I want her to become “fat” so she can produce plenty of milk. She laughs gleefully when I say that.

I tell her she can stay as long as she wants to rest. I don’t want her chasing after 4 more children and digging in the fields and carrying water anytime soon. I ask her when she wants to go, and she says “Saturday?” That will be around 10 days after delivery. Hey, why not?

Odongo’s arm improves slowly. The swelling decreases, and he cries less and less when it is moved. I palpate carefully, and I don’t feel a bone injury. I have him examined by one of our study’s medical officers who is very knowledgable about Pediatrics, and he agrees that the injury is only soft tissue, and is improving well.

Every day, the patient shakes my hand warmly and proudly displays her babies. Through the nurse, the patient tells me how happy she is. The nurse says “When she goes to bathe, she runs quickly quickly and comes back because she doesn’t want anyone else to touch them. She loves them so much!” She is gazing lovingly at them as this is translated. It is hard to fathom that Odongo was so close to death. With a slightly different twist of fate, all of this love would have been profound grief.



*In Tororo, surnames of children do not match those of the parents. They often relate to the circumstances at birth (eg. born in the morning, or born in the time of the rain, etc.) A first twin is always given the surname Opio (boy) or Apio (girl), and a second twin is Adongo (girl) or Odongo (boy). The first name is not assigned until a chicken is cooked to celebrate the birth.

No Remorse

On Monday, I am setting up a brand new lab. A visitor from the US with lab expertise has come to help us set it up, and I am running around getting the right materials and equipment together.

In addition, word has gotten out that I am back in Tororo, and various nurses and midwives come asking me to see patients. There is someone in labor ward with no fetal movement and no audible heartbeat – might be a fetal demise. Could I do a scan? There is someone in the Gyn ward who might have an ectopic pregnancy. Could I scan? I want to help, but I also need to make the lab my priority. I promise to come later, once the lab has settled down.

Finally, the lab is going, and I am able to take a few minutes. My phone rings, and it is one of our study counselors.

“There is the woman here who wanted to abort, and she is here for an ultrasound.”

I cringe at the fact that he knows this – did she arrive and tell him that she wanted an abortion? Oy vey.

“Ok, yes, I will scan her. Thank you, I am coming.”

When I walk up to the research clinic, it is bursting at the seams. Three months ago, the waiting room was usually full on Mondays. Now, on this Monday, every seat is taken, women and children are all over the floor, seated anywhere they can find, spilling out of the waiting area. Our studies are at their peak enrollment, and it’s crazy on Mondays.

I go looking for the ultrasound, and I find one of the doctors scanning a woman with decreased fetal movement. I take a few minutes to teach the doctor how to check for adequate amniotic fluid. When she’s finished, I take the ultrasound machine with me. There is not a single space I can find in that clinic to do this scan; there are way too many patients to be seen. I decide to bring my patient to the Labor Ward, where there are available beds. Then I can also scan the woman with no fetal heartbeat at the same time. Two birds, one stone.

When I walk to Labor Ward, I look for the patient with no fetal heartbeat, but I can’t find her. I have my patient wait, and I look for other midwives to tell me where the patient went. On the way, I run into three senior midwives, including the Principal Nursing Officer (PNO), who are overjoyed to see me. I get enormous hugs and it relieves some of the stress I feel from having so much to do. Apparently, the other patient has already been seen and was ok.

I go back to my patient. I feel her abdomen first. The uterus doesn’t feel quite 20 weeks, but more than 14. On scan, there is definitely a live fetus that measures at 16 weeks. The nursing trainees who are in labor ward watch me do the scan, fascinated. I write down my findings on the ultrasound form. No one speaks Japadhola, so I bring the patient back to the clinic for a translator.

The counselor who called me about her earlier can speak Japadhola, but he is with a study patient. I ask him to see my patient afterward and explain that she is, in fact, pregnant at 16 weeks, and there is nothing to be done. She should go for prenatal care. He agrees to tell her, and we have her sit in the waiting room until he is ready to see her.

I dash back over, with the ultrasound, to the Gyn ward. The sun is brutal, and schlepping the heavy ultrasound is my least favorite thing about this job. Whaddayagonnado. I take a shortcut through theatre, where I greet some theatre staff.

In Gyn ward, a woman is limping painfully toward the door – that is the patient with the possible ectopic. She doesn’t look good. The nurse has her lie down again so I can see her. In the bed next to her, a young woman looks very sick, crying and moaning with abdominal pain. She looks awful.

“What is wrong with her?” I ask.

“She was admitted for one week with peritonitis in Mbale. Now she came here. Maybe you can see her too.”

“Why didn’t they operate in Mbale? She looks like appendicitis.”

“I don’t know.”

Probably because she couldn’t bribe anyone, that would be my guess. I am not sure I would be comfortable operating on her. I could probably do an appendectomy, but what if it were something else, like incarcerated or perforated bowel? Luckily, I know Dr. W is around. I will mention her to him.

I start scanning the patient with a possible ectopic, but it’s a confusing scan. She has a lot of stuff in her uterus, but no definite pregnancy. She has a lot of fluid in her abdomen, which could be blood – implying a ruptured ectopic pregnancy. She is tender but not overwhelmingly so. The woman next to her looks much worse. This could be a miscarriage or an ectopic, it’s hard to tell. If I had a transvaginal ultrasound probe, I might be able to get more information. But sometimes ectopics are very hard to diagnose. In the US, we have the option of laparoscopy, which looks inside the abdomen with a camera through a tiny incision, so that if there is no problem, you can close up without doing major surgery. Here, if you want to look inside the abdomen, you have to open it up.

I call Dr. W, who I know is around and had requested that the nurse ask me to scan, and I ask him to come and look at the sono. He agrees with my confusion, and we discuss a plan. I suggest doing a D&C (uterine evacuation) first – then if he sees products of conception, he doesn’t have to do a laparotomy. He could also do a minilaparotomy (through a 2-3cm incision) to see if the fluid in the abdomen is fluid or blood – and if it is fluid, he can close the small incision without worrying. If there is nothing in the uterus, then an ectopic pregnancy is almost certain, and a true laparotomy is warranted.

I wish I could operate with him, but I need to go back to the lab. I realize it’s lunchtime and I need to make sure the visiting lab technician gets something to eat. The sun is burning incredibly hot, and neither of us has an appetite for lunch. We go into town to buy a few items for the lab, and we have a lunch of fruit and soda – it’s all we can think of eating in the heat.

When I get back, I need to have a research meeting, so I leave my visitor in the lab. As I walk to the meeting, I get a phone call.

“Hello, Doctor!” It is the Senior Hospital Administrator, with whom I have a great relationship. He always appreciates all the work I do, and never fails to help me get anything I need to help patients – from generator fuel to supplies and equipment.

“Hello! I haven’t seen you yet, but I am around,” I say.

“I am glad you are back. I had wanted to have a meeting with you.”

That was unusual. I have barely arrived and I hadn’t even seen him yet – what could he need to meet about?

“Absolutely. I am going to a meeting now, and I have to work in the lab. How about tomorrow?”

“Tomorrow?” He sounds hesitant.

“Is today better? I think my meeting will be about 1 hour. Can I come by your office after that meeting?”

I have a lot to do, but this man has been so helpful to me – I have to make him a priority. I figure he wants me to give medical advice to a family member or something.

“That is ok. I will wait for you here,” he says.

My meeting turns out to be really fast, and so I head to his office earlier than I expected. When I arrive, there are three Ugandan men in the room – one is sitting directly in front of the SHA’s desk, and the others are further back in the room. The SHA looks serious, which is not typical for him, and he is questioning the man near him.

“So after you saw the patient, how did she come to find the doctor for an ultrasound?” the SHA asks the man.

I realize that the woman that had been looking for an abortion is also in the room, in the back. She is staring down at the floor, looking humiliated. I’m not sure what’s going on. What’s the big deal? Maybe they don’t realize that I saw her on Saturday and told her to come today for the ultrasound.

The SHA asks the man the same question again, and the man doesn’t really answer.

I try to be helpful: “I saw the woman and Saturday, and I told her to come for the ultrasound.”

The SHA, still looking surprisingly serious, holds up one finger and says “Just a moment, doctor.” That is also unusual for him.

The SHA asks the man a third time: “If the patient came to you on Saturday seeking an abortion, and you changed her mind, then how did she come to find doctor in the hospital?”

Huh?

Then I notice the logo on the man’s polo shirt – it reads “Uganda Life International."

Weird - it is the same organization that E had wanted to refer the patient to. But from the discussion, it sounds like she had already been there. This is incredibly confusing.

Finally the SHA, not getting an answer, turns to me.

“Doctor, in order that we don’t keep you waiting, let me explain what is happening. These men are from Human Life International. I will let them explain what the organization is.”

The man in the polo shirt turns to me. “I am Father O____, but I am not here as a priest today. I am the head officer in charge of our organization, which is called Human Life International. Our organization has the objective of reaching out to the community in order to save the lives that would be killed by abortion.”

Uh huh. I figured. I nod politely and say “I have heard of your organization. It is nice to meet you.” I am unfazed. Who cares? I don’t do abortions in Uganda. I’m not going to tattle on this poor woman, if that’s what they’re after.

He keeps talking but there is no additional information, just continuing to explain their objective. Then, finally, he gets to the point.

“We have been informed that you took this woman to perform an abortion on her.”

Uh. What?

“There must be a misunderstanding. I do know this woman, but I did not perform an abortion on her,” I reply.

A man in the back with a computer in his lap speaks up. “We have an informant that has said that you told this woman to come here today, so that you could do an abortion on her.”

“No, that’s incorrect. Let me clarify my interaction with this woman and you will see. On Saturday, I was leaving the clinic, and I was asked by another doctor to see her. We were not sure of her gestational age – she thought she was two months, and she looked about 5 months. In addition, we were not sure she was actually pregnant. She had never had a pregnancy test, or an ultrasound scan. The appropriate next step in this case is to confirm and measure the pregnancy. Because we do not have access to the ultrasound on the weekend, I told her to come back today. Today, she came back and I did the ultrasound. She is pregnant, and the pregnancy is 16 weeks, but because she speaks Japadhola, I could not tell her. So I brought her to someone in our clinic who speaks Japadhola, and he said he would tell her. I left her there with the ultrasound report, waiting for him. That was the last I saw her.”

The SHA spoke up, looking relieved. “Now, you see, Doctor has explained. She did an ultrasound. Now we are settled, and we can finish this discussion.”

Everyone speaks at once, but the man in polo shirt was loudest. “No, we cannot finish because she has not shown remorse!”

I am taken aback by the virulence of his response. He appears to be almost salivating with excitement to accuse me further. But of what? I know the woman is still pregnant, so no abortion was done. Everything I did makes sense – anyone would (or should) have done an ultrasound for her. Naively, I had thought that by explaining the logical medical thought process, everyone would see reason and we could all shake hands and move on.

Now, it is clear that reason is not relevant here. Something else is going on. As I watch these men shout at us, I realize that they have already convicted me in their minds (of what?), and they will not be dissuaded. They seem perversely pleased.

The SHA tries to continue the line of questioning he was on when I came in the room.

“You are saying you saw this woman on Saturday and you turned her mind,” he starts.

“We saw her, and we turned her mind. After she was saved, we sent her home,” says the priest in the polo shirt.

“So how is it that she then came to find doctor to have the ultrasound?” asked the SHA.

“I don’t know. But we saved her, we turned her mind, and then this doctor said she would do an abortion.”

This is interesting. E had suggested sending the woman to Human Life International, but we didn’t realize she had already been there. Apparently, they didn’t change her mind, although they don’t seem to want to admit that. It seems that she walked out their door, and straight into the hospital. I wonder if some of this has to do with their wounded pride – they were congratulating themselves for their heroism, when in fact the woman merely said what they wanted to hear so she could get away.

“Our objective at Human Life International is to save the innocent lives from people doing abortion.”

He points to the woman. It is unclear to me whether she is his implied “innocent life” or only her fetus.

“We have come to investigate because we were called by someone who reported that YOU were doing an abortion on this woman!”

I feel blindsided by this. What is going on? I try to keep my cool. Since they are clearly ridiculous, and since I get prickly around the subject of reproductive freedom, I am already poised to be annoyed with these men. This loud, irrational yelling doesn’t help. I tell myself not to shout the way they are shouting – so that I am always the calm one – and to keep the discussion strictly on what I did rather than my feelings on abortion and the misogyny of reproductive oppression. I have plenty of time to remind myself of these things while the men grandstand and speechify. I try to say only what is necessary, and to say it calmly but seriously, without showing weakness or fear.

“This woman came here seeking an abortion. You told this woman that you would do an abortion on her! You did the ultrasound in preparation for an abortion! You took this woman to theatre to perform an abortion, where you did the ultrasound scan!”

Responding to this is easy. “This woman has never been to the operating theatre with me. Where did you hear that?” I reply.

“You were seen taking her to theatre to do the abortion!”

“I took her to labor ward, so that she would have a bed to lie down on while I did the ultrasound. That is not theatre.”

They look confused for a minute, but then the man with the computer repeats the accusation. “You told this woman you would do an abortion! Abortion is illegal in Uganda, you may not know that. We are here to save the lives of those who might be victimized by abortion, and we are here to investigate. We have information that you planned to do an abortion. That is a crime and it must be investigated.”

“I am aware that abortion is illegal in Uganda, which is why I don’t do them here. This woman is still pregnant, so no one did an abortion on her. Therefore, no crime has been committed. You are right; I have no remorse, because I did the right thing. I provided adequate medical care, which no one else did for her. What are you accusing, that I provided adequate care?”

The SHA backs me up.

“There has been no crime. I think we can all stop talking of investigation now,” says the SHA, getting annoyed at these men, but still trying to be diplomatic.

The man with the computer says “Although the act has not been done, there is still criminal intent, and criminal intent needs to be investigated!”

I don’t know the Ugandan legal system, which has its roots in the British legal system, but I suspect he’s bluffing. It would be absurd to charge someone for what you accuse them of intending to do, unless they actually attempted to do it. Then again, you never know. Legal systems can be crazy, and even more so in dysfunctional countries.

A brief image enters my head of being arrested - the way that the midwives were last year - while the case gets “investigated.” Another image appears of being on trial for “intention” to do abortion in a court here. Several thoughts rush through: American consulate getting involved, Hillary Clinton, Rwanda, Iran, international politics and diplomacy, and what if the American government couldn’t help? That is all very scary, but I do not allow myself to think that through immediately. I bring my focus back to the discussion.

The SHA has responded to the criminal intent comment. In addressing the man with the computer, the SHA said something about him being a “legal officer.” I’m not sure what he means by that. A lawyer? A lawyer should know that this is preposterous.

The legal officer with the computer speaks up again. “We have evidence. There is something called CIRCUMSTANTIAL EVIDENCE that can make a criminal case.” (More hint that he’s bluffing) “We have information that you told this woman you would do an abortion on her!”

I have had it with this “we have information” nonsense. I challenge that directly.

“Who is this person accusing me? You should tell me who it is, because that person should come to this room and accuse me directly. I have already explained, and I have been clear. None of you were here when I saw this woman, so you cannot say what happened. In fact, we have no information at all beyond this supposed accusation.”

“Are you saying that the person accusing you is lying?” says the computer man.

“Yes, that person is lying. There were only two other people in the room with me when I met this woman on Saturday. One of them works with me and it is definitely not him, and the other one is her attendant. If it is not one of those people, then this person was not there and cannot testify to such things. If it is her attendant, let her come and say it to me, because she will know she is lying. So you tell me who the person is who is claiming these things and I will tell you whether or not they were there.”

“We cannot tell you the name of the accuser, because this is an investigation and it is confidential.”

Bluffing again. The SHA calls him on it.

“This person should come to this room and discuss,” the SHA insists. “Doctor has told us what has happened, and now we have no other information. We shall need to discuss the matter with this person to clarify this investigation. We should end this now until this person can come and speak.”

It is clear that these men have no intention of stopping now. They have not brought any new information to the table, nor have they been able to contradict my story at all. But they behave as if they have cornered their prey, and they are savoring the attack.

“This person has accused, and has testified to knowledge of this doctor’s intent. We will take this matter to the police. We shall even take this matter to the first lady, who is deeply opposed to abortion! We shall prosecute this doctor for committing abortion. We have evidence.”

The first lady? Come on. I want to roll my eyes, but of course I don’t.

“This woman is still pregnant. There has been no crime, and this is truly ridiculous.” I say.

The SHA agrees. “Who is the one accusing? Is the patient herself accusing the doctor?”

“No, it is not the patient,” says the computer legal officer, “it is another person. We cannot divulge the name.”

Then the man by the window, who looks very young, pipes up.

“Doctor, what did this woman tell you was her purpose for coming to you?”

I have heard him try to shout that previously, but I ignored it because he was out-shouted by the other men – and because it was a dumb question. There is no way that I am going to incriminate the woman herself.

“As I have said, I do not speak Japadhola, and this woman does not speak English, so we cannot speak directly to each other. I cannot tell you what her intentions were, because I was never able to speak to her myself. I was only able to speak to her attendant, who is not here.”

In my mind, I note that the attendant is not here. Could she be the “accuser” who called these men? She didn’t seem like it, but who knows. Her English was basic as well – could she have misunderstood what I said to them? That is possible. What if she couldn’t understand that we only wanted to do an ultrasound, and thought that we had agreed to do the abortion? Although we specifically said it’s illegal and told her we can’t, it’s always hard to know how much people understood, especially because people are too polite to tell you they didn’t understand. If they misunderstood us, that could be a problem. Worse yet, what if it was a setup? The attendant’s absence is conspicuous – what if she was in cahoots with them to try to catch and threaten a mzungu?

If they do question the woman, what if she says she thought I was going to do an abortion? These men would go even crazier, and wouldn’t care about the fact that the woman can’t testify to what I said, only to what was reported to her. I don’t even know why she’s in the room in the first place. Why would she have gone back to them after the ultrasound, or even gone to the SHA’s office herself? Wouldn’t she want to leave – either to go back to the village quietly, or to find someone who would do the abortion? From the look on her face, I doubt that she is collaborating with them. She seems just as much their victim as I am.

I realize, also, that no one has even spoken to her yet, after about 20 minutes in this room. I feel so sorry for her. She looks terrified and humiliated, and she seems to be subtly curling herself into a ball in the corner, almost willing herself somewhere else. She doesn’t understand a single word. I want to speak up to protect her, and suggest that she be allowed to leave the room, but this has already gotten too intense, and I need to defend myself first.

Eventually the men realize that they can’t get around the fact that I am the only one among us who was actually present.

“We have not spoken to the victim. Let her speak for herself,” one of them says.

The SHA points out that she only speaks Japadhola, and asks if any of the men do. They all look at each other. No one can speak to her. How interesting. They are accusing me so vehemently, and yet they have never actually questioned the woman herself. Not only that, I am the only one who offered her any medical care. She saw them on Saturday and was “saved”, and yet by the time I saw her, she had had no pregnancy testing whatsoever. For all the lamenting over her soul, they don’t seem particularly interested in her personhood.

The SHA jumps in to defend me again. “This doctor has done so much work at our hospital, and she has not asked for any money, ever.”

He is interrupted by computer legal officer. “Well other people take money to do abortions but maybe she is doing abortions for free.”

I take over. “Why would I do abortions? Are you saying that I am stupid?”

I am interrupted by polo shirt priest, “People who do abortions are not stupid.”

I ignore him. “You are saying I am stupid. Because if I were to do abortions, then I would be risking everything I am doing here. As you have heard, I do a lot of work in the wards here as well. If I did abortions, I would put all of that at risk. I also work with the research group, and I would be putting them at risk. I would never, ever do that. The work I do is too important, and I am not stupid enough to risk that.”

“You told the patient that you would do an abortion. You intended to do an abortion.”

“If I intended to do an abortion, then why is she still pregnant? I did her ultrasound this morning, and now it is 5pm. Why didn’t I do the abortion already?”

“We can’t answer that but you had the intention to do an abortion. That is why you did the ultrasound, in preparation for the abortion.”

“So what are you accusing me of? Are you accusing me of providing adequate medical care to this patient? Because it seems I am the only one who did. And, no, I don’t have any remorse about that. I would do it again tomorrow. Because it doesn’t matter to me what the patient came in for, she deserves respect, and adequate medical care. She needed an ultrasound for her own care, and I did it. None of that has to do with performing an abortion. So is that your accusation? That I provided good care?”

We are going in circles. They keep saying the same things, and we keep pointing out the same holes. As I am repeating the fact that two people were in the room with us, I realize what I need to do.

“There were only two people in the room when I spoke to this patient, and I am going to call one of them right now and tell him to come, and you will see what he has to say.”

I call E. “I need you to come to the Senior Hospital Administrators office immediately. It’s an emergency.”

More arguing as we wait. Two additional men who appear to be from Human Life International silently enter the room and sit down as the discussion goes on. E arrives in less than five minutes. As he walks in, people are still talking. E has no idea what they are saying.

“E_______,” I say. “These men are from Human Life International. The woman that we saw on Saturday is here. They are saying that I told the woman that I would do an abortion on h---“

Immediately, the priest in the polo shirt starts yelling objections. “She is informing him of what we are discussing before he has testfied!”

Oh, for crying out loud. Do these guys think they are a court of law?

“We have been discussing for a long time, and he is not aware what we are talking about. Doesn’t he need to know why we have called him here?” I ask.

The SHA quiets them down, and invites E to sit down. Immediately, E takes over the conversation. He holds out his hand to the priest in the polo shirt.

“Hello, my name is E_________ A___________I am the senior study coordinator of the IDRC research collaboration. And you are?”

The priest relents and shakes E’s hand, and states his name.

“Now, you see,” scolds E. “THAT is a proper introduction. That is how we should introduce ourselves.”

The men are stunned into silence. I am impressed.

“Let me tell you first that I am angry. I am angry because you did not call me. Why didn’t you call me? You are wasting this doctor’s time with this, and if you had called me I wouldn’t even have involved her,” says E.

The men don’t know what to say. The priest in the polo shirt tells me to explain the situation to E.

“You stopped me from telling him. You want me to tell him now?” I ask.

“You tell him what we have discussed so he is aware,” they command.

E doesn’t even let me talk. He starts talking.

“Let me tell you what happened. I called Dr. Veronica to come and see the patient. So, in fact, if you were going to call someone, you should have called me. I asked her to help me because the woman looked more pregnant than she was saying. Dr. Veronica and I thought she looked five months pregnant. We NEVER told her we would do an abortion. In fact, Dr. Veronica specifically told her that is illegal in Uganda. She was very clear. Dr. Veronica said that she might not even be pregnant, since she had no pregnancy test or ultrasound. For that reason, she offered to do an ultrasound. The ultrasound is not available on the weekend, so Dr. Veronica offered to do the ultrasound on Monday. We very clearly told this woman that we could not do an abortion because it is illegal. And you never should have spoken to Dr. Veronica without calling me first because I never would have involved her. These accusations are totally false, and I am very angry.”

His story matches mine exactly, because it is true. Suddenly, the mood changes. The men seem cowed and start to cover themselves. They try, less confidently, to make the same assertions – that I had the intention to do an abortion, that I took the patient to theatre, and so on. But E shuts down every accusation immediately, and powerfully. Suddenly, the men are on the defensive.

They start a new line of discussion.

“Well, I think that maybe we can bring this to a close because we have already saved this soul,” (still unclear which soul they are referring to) “and so we can go from here and conduct an investigation.”

Retreat.

E is having none of it. He is not interested in letting them off easy.

“I am so embarrassed. I don’t know how I am ever going to apologize to this doctor for the trouble you have caused for her. She never should have heard about this, because it is ridiculous. This doctor has done so much for this hospital.”

Computer legal officer speaks up. “We don’t’ know her. Of course we know you, but we don’t know her, so we couldn’t know. We had to investigate the accusation.”

“You may not know her, but everyone here in this hospital knows her, because she has done so much work here.” E is right. If they don’t know me, it’s because they never come to the hospital, because everyone there knows me. “You should have called me, because if you had called me first, I would have told you that everyone knows her, and I wouldn’t have wasted her time.”

E continues lecturing them. He is amazing. They try to interject, backing off and talking about how they had “already saved this soul” and so they could move on, but he doesn’t let them.

As I listen to him talk, I know I don’t have to talk anymore. It gives me time to process all of this. I think about all the work I have done in the hospital. I think about the woman who nearly bled to death on the OR table, the eclamptic 15-year-old, and all of the other people that I have literally saved with my own hands. Thinking about all the death and near-death that goes on in that hospital, I get increasingly emotional at the injustice of these bloodthirsty men. They don’t care about all those people, only about the fetuses of women who want abortions, and only until they are born. I would like to believe that people who do this sort of thing really do want to help the women, and are just misguided. But it is painfully clear in this room that the woman herself is irrelevant to their objectives.

As I look around the room, I realize that the Principal Nursing Officer (PNO) has recently entered the room. She was one of the nurses who had exuberantly hugged me earlier in the day. I am confident that she will be supportive of me, because she likes me so much. But she is also and older, quiet woman, so maybe she will be afraid to support me publicly.

As I think about all of this, a text message comes through on my phone. It is from Dr. W: “1.5 liters hemoperitoneum! Ruptured left fallopian tube.”

The patient I had scanned that Dr. W took to the OR did, in fact, have a ruptured ectopic pregnancy. She is lucky to have survived – there was a lot of blood in her abdomen. Seeing that message, I am briefly stunned. The irony is immediately apparent. I want to show the text message to these men and say “Do you see this? I literally saved this woman. I did the ultrasound, and diagnosed her, and recommended that she go to the OR. If I had not done that ultrasound, she might have waited hours or days before going for surgery. THIS is saving a life. And what are you doing?”

But I can’t say any of that. I realize that I can’t talk again, because I am feeling an increasing urge to burst into tears. I don’t want to show this to them, because I don’t want them to see any weakness, and I don’t want them to know how much they have affected me. I have thus far managed to seem irritated and offended, but not emotional and frightened. The more I think, the harder I need to work to hide the tears below the surface. I twist my lips and look at the ceiling to hide my trembling lip and watery eyes.

I want to tell them to come to the children’s malnutrition ward and raise some money to feed those children. I want to tell them that women need ambulances to get to the hospital when they are dying at home in labor. I want to tell them to build roads for those ambulances. I want to ask how many children could have been fed by the cost of one custom, Human Life International logo-emblazoned polo shirt.

More images from my year in this hospital flash through my mind. The feeling of operating on a woman, and not knowing if she was going to survive, the feeling of trying in vain to rescusitate a dying infant – that visceral feeling returns to me. Waking up in the middle of the night and rushing to the hospital for a malpresenting fetus or obstructed labor. I did all of this good work all year – can it all be washed away by the wild accusations of a this predatory peanut gallery? The hospital staff had always been supportive of me, but would these accusations now cast enough uncertainty over my reputation? I don’t know how much longer I can take without bursting into tears.

E is still going, alternately scolding the men and extolling my virtues. He will not let them off the hook. Then the SHA takes over, emboldened by E’s moxie.

“I know this doctor very well. She has done so much work in this hospital. You have no idea how many patients she has worked on, how many lives she has saved. We owe her a debt. It is NOT only me who owes her a debt, NOT only the Tororo Hospital that owes her a debt, but the ENTIRE TORORO COMMUNITY! The entire community owes her a debt that can never be repaid. She has never asked for any money, and she has saved so many lives…”

At that, I know I am about to lose it. I get up and walk quickly out of the room as he continues talking. I get out of earshot before I burst into tears. I race to the clinic and grab a friend and research study coordinator with whom I have worked closely. Through tears, I tell her what happened. She is furious.

“Those men. Who are they? How can they do that to you? What do they know about you? To accuse you like that! If it had been a Ugandan, they wouldn’t even be here. You know why they are here, because they saw a mzungu, and they thought they could get some money. They thought you would get scared, and offer them a bribe. Ha! They went after the wrong mzungu.”

It is entirely plausible. She is dismissive of the men, and that helps me feel better than nothing will happen. She reassures me that E will send them packing.

It takes me about half an hour to compose myself enough that I can prevent myself from crying again. E is still in there. While I am waiting for him, I place a call to Dr. W, who had operated on the patient with the ectopic pregnancy. I am embarrassed to suddenly start crying as soon as he answers, but I can’t help it. I need his advice. He is seeing patients in his private clinic and offers to stop immediately and meet me. I tell him not to leave his patients, that I will talk to him later.

Finally, E comes to find me and although I am feeling calmer, I am still pretty freaked out, and I need his reflections of what has happened.

He is bluntly dismissive and critical of the men. He tells me that they are just looking to make trouble, but that he won’t allow it. It surprises me to hear a Ugandan, and especially one as mild and diplomatic as E, use such harsh language. Clearly, he is upset by what has just happened. He tells me that he doesn’t know the priest himself, but he does know that one of the men in the room was a police officer. I get nervous when he says this, but he assures me that the man claimed that he was not there acting as a police officer. He also tells me about some negative experiences he has had with that particular police officer in the past.

“Veronica, I feel so bad. I don’t know how I am going to ever apologize to you. I don’t know why they didn’t call me first. OK, I know why. But they should have called me, not you. I would never have even called you. You did the right thing in calling me there. In fact, I told them so much about you that now I have told them that they need to come here and apologize to you.”

“They’re coming here?” I ask. I’m not sure I want to see them. I know I will get angry again, and I am in no mood to accept an apology.

“Well, I don’t think they are going to come, because they are afraid.”

“Afraid of me?”

“I don’t know. I told them so many things. I think they just are afraid now for having falsely accused you. I don’t know if they will come, but I told them they must."

I would prefer never to see those men again. But in the back of my mind, I have visions of what I would do if they did attempt to apologize. Maybe I would lecture them on their own hypocrisy. Maybe I would ask them where they were when I was operating on a patient who nearly bled to death on the OR table. Maybe I would refuse to allow them to say anything, but insist that we all walk over to the children’s malnutrition ward and stand in the middle of it while they apologized to me. I would say ‘What are you doing for these children who are already born? Are you saving their lives too?”

Of course I would never have the guts to do any of those things. But would I accept their apology? It is hard to imagine. I am so angry, so offended, so infuriated at their behavior. An apology is not enough. Maybe I would spit the polo shirt priest’s words back to him “But you are not showing any remorse!”

E and I continue to rehash the situation. He notes that he was naïve about this organization, and that I had pointed out on Saturday that they sounded suspicious. Of course, being American, I already know what any organization with “Life” in the title is and does. But as a Ugandan, it doesn’t have that particular significance.

E tells me that he feels guilty for having brought the patient to me in the first place now because it caused so much trouble, but I disagree. I tell him I am glad he did, because she still needed my medical care, and whatever happened afterward, she still needed an ultrasound and deserved access to care.

He makes a good point that I hadn’t thought of – he is frustrated that the accusations of these men caused us to reveal private health information of this patient. He is right. I hadn’t even thought of that. They had no right to ask me to justify my actions, because they are between me and the patient. It is even more of an injustice that they think they have the right to intervene, and violate her privacy. I feel like a jerk for telling them anything. But I can imagine how much more fierce their attack would have been if I had refused to tell them anything.

I ask E for one more favor before we leave. I ask him to call Dr. K, the Ugandan head of our research collaboration. He is a wise and influential man, and he has always appreciated the fact that I do clinical work. In case this problem goes any further, I want to be sure he is aware of the situation. I know he will be supportive. E assures me that he will call.

I am still pretty stunned about what happened. I usually work later, but I can’t focus on work anymore. I am still processing everything, running through it in my head over and over in shock. How did I go from doing an ultrasound on someone to this? In fact, I am lucky that this particular patient was introduced to me by E. But this easily could have been any random patient in the wards. People here know that I will even stop people who are wandering around the hospital grounds if they look particularly sick, to make sure that they are getting care, and if they aren’t, then I see them myself. What if this had happened with a patient I had randomly met? These men would have said I was wandering around talking women into having abortions, and then doing them, and I would have no one to backup my story.

I apologize to the visiting lab technician, who has now been waiting for me for a couple of hours, without knowing why I disappeared from the lab. She is very accommodating, and I drive her back to our house, then come back to the hospital to meet some people for dinner. When I drive up, I see Dr. W, the PNO, and Rose standing outside talking. They all turn to me as I drive up, and from their faces, I know what they are talking about.

Dr. W walks up to me immediately and takes my hand.

“Veronica, I am so sorry. That is terrible what you went through --“

He can’t finish his thought, because the PNO bursts forward, edging him aside. There are tears streaming down her face and she wraps her arms around me. She starts sobbing and then I am crying, too.

“I am so sorry, I am so sorry,” she says. “That was so terrible. What those men said to you. I can’t believe it."

All three of them express their support and sympathy. They are outraged. I very much appreciate their support. I had been slightly worried that people might partially believe the accusation, but I can tell that there is no doubt in anyone’s mind that it was not only false but preposterous. In fact, it IS preposterous. Every single person on that hospital grounds knows what I do. I blend in about as well as Joe Pesci in rural Alabama. There is no way I could ever do an abortion without people knowing.

Later, I call the SHA to thank him for his kind words. Before I can say anything to him he starts apologizing extensively for getting me involved.

“These men were bothering me all day before I called you. In fact, I spent two hours ignoring them in the morning, because I knew what they wanted was nonsense. Then I went for lunch, and they were waiting for me. I told them ‘I am a very busy man, I have to do many things for this hospital I can’t only be with you.’ But finally in the afternoon, I had to see them, and I could not avoid it any longer. I didn’t want to call you but they would not leave my office. I wanted to throw them out, but I am a public official, I can’t. “

“Of course you had to call me,” I reassure him. “Those men were after blood and you had no choice. But I want to thank you for the things that you said. You said such nice things about me, and you couldn’t have been better. I know how hard you were trying to defend me from them, and I really appreciated. When I heard you talking, I knew I had support.”

“You always have my support, doctor. I meant everything I said. Those men don’t understand how much you have done for Tororo. But also the things which you said were very good, very good.”

“Thank you. I was trying to stay calm, but I was very angry with them.”

“You were very calm. You said the right things.”

I can tell he is as shaken by the encounter as I am.

That night, I sleep poorly. I wake up thinking about the situation. I still haven’t quite processed my feelings. I’m not as angry as I thought I would be, and I am unnerved and saddened.

The men don’t return to the hospital after that incident. It seems E really did his job in making them feel ashamed of their accusation. When I first arrive at work the next day, I am a little on edge. Then I run into Sister P a senior midwife I know well. She walks right up to me.

“I am so sorry for what happened, doctor. I heard from Sister. It is terrible!”

“Thank you. It was terrible. Those men were vicious.”

“They are terrible! Doctor, I hope you will not stop your work here.”

“Of course not. I would never stop. And if the same case happens tomorrow, I will do the same thing.”

“I am relieved. We were discussing and we were worried, maybe you would be afraid and you would stop your work from what happened.”

“Never. I wouldn’t stop, because we can’t let them win.”

“That’s right! They can’t win."

That is how it goes all day. I run into midwives or nurses or anesthetists I know, and each one shakes my hand and apologizes deeply for what happened. Every single person expresses their support and gratitude toward me. It is pretty overwhelming. The first thing everyone does, is apologize profusely for the trouble. The second thing they say is that they hope I will not stop seeing patients. Not one person has any doubt about my innocence.

E tells me that he spoke with Dr. K, who seemed to understand immediately what had happened, as if he has seen it before. After expressing his sympathy and support, E tells me, his first comment was “I hope she will not stop seeing patients.”

For several days, people ask how I am doing, whether I am still upset. After about 2 days, the shock passes. I realize that this episode showed me that I was completely incorrect in my concerns that the accusations would taint my reputation at TDH. On the contrary, rather than being in danger of false accusations, I have an incredible network of support from people who know and respect my work. I have a community here, one that was unafraid to come to my defense. The thought kind of blows me away.

People who know that I work here often give me kudos. I am polite, but I don’t think I deserve them. I don’t think that what I do here is particularly brave or heroic because it’s not something that requires moxie. It’s not running into a fire, or fighting a war or standing up to an unjust institution or staring down police dogs and fire hoses or protesting an oppressive regime. It’s incredibly fun and satisfying and amazing. It’s working with really pleasant people and feeling like I did something good with my time. But I do think that what the people in this community did to support me was very brave.

I have had difficult situations in the past, and have found that the people you most expect to defend you often fail to do so. I used to be devastated when these things happened, but as I got older I realized that true loyalty is rare. So to find that the people in this small town - most of whom of are a different culture, religion, background, socioeconomic status than I am, and who are just as vulnerable to being attacked by these men – didn’t blink before defending me to these potentially powerful and vindictive people is astounding. I am no longer angered by the attack. I am profoundly grateful for the community I am a part of here.

Oddly, what made me a target for these men also protected me from them. Being a mzungu, I stood out, and I was a tempting takedown for men who either had something to prove, or wanted money. But also being a mzungu, I stand out in a good way. My presence is noted, my work is appreciated, and I have the ability and resources to come here and do this work without charging money. Of course I am angry at these men for their viciousness and their bullying. But I can’t be indignant about being accused when I know that these men and people like them have probably gone around hunting others, and those others were probably Ugandan. I doubt that a Ugandan would have as much protection as I did, and I am afraid for those people. I think of the people around the world who are doing abortions illegally – many of them are unsafe, but some also know what they are doing and do them well but risk persecution. As a woman, as an American, as a doctor, I am a very lucky person.