Saturday, January 29, 2011

A Salty, Prickly Gift

I return to Uganda in January, and my reception is sweet. The clinic staff is happy to see me, and I get exuberant hugs from the midwives.
Even some of the grouchier nurses, who were hard to win over originally, receive me warmly. One In-Charge nurse, Sister A, a sometimes intense and surly individual, stops by the clinic to talk to someone, and she doesn’t notice me seated in front of her. I’m not sure how she can miss my glaring white skin. Finally, I joke, “You don’t want to greet me?”
She finally looks at me and jumps in surprise, then lunges toward me and punches me hard in the arm, turning it into a hug. Then she laughs and shakes my hand.

I walk around the hospital grounds looking for the other nurses and midwives I know so they will know I am back. I can’t find anyone on the female surgical ward, though. Later, I run into one of the nurses from female surgical.

“You know, your friend, she lost a daughter.”

“Which friend?” I ask.

“The one you operated on, I don’t know what it was, for something?”

I remember who she is talking about. It was a woman she had introduced to me as her "sister". The woman was around 50 years old, had HIV that was well-controlled, but she also had severe uterine prolapse. I did a vaginal hysterectomy on her.

“Your sister?” I ask.

“Well, I say my sister but she is not my sister, she is my cousin. She is the daughter of my father’s brother. My sister-cousin.”

This is usually how it goes here. Relationships are fluid – people will say “my auntie” or “my sister” even when the person is a distant relative, or even just a friend. It denotes a close relationship, especially when they want you to help the person. I don’t mind.
I remember the woman well. I liked her a lot. She was very educated, spoke excellent English, and had sent all of her children to university, including the girls. She was very proud of her children’s accomplishments, and she was meticulous about her HIV care. It is rare to find someone that educated and that empowered in this rural area.

“Yes, how is she?” I ask.

“Well, she is ok, but she is not very ok. She lost a daughter,” the nurse tells me.

“That’s terrible,” I sympathize. “From what?”

“Well, the girl was a university student, and she got pregnant, and she didn’t tell anyone. And she went and had it removed, and she died. Imagine! In University! She didn’t tell anyone.”

A few days later, I am at the clinic late, finishing up some work. I realize that it is almost 7pm, and I need to rush home before the sun sets at 7. I drive a motorbike that is old and decrepit, and the electrical system doesn’t work, so it has no headlight. It’s good for me because it forces me to go home before dark. I really shouldn’t be riding such a thing at night anyway. On my way out, I poke my head in the window of the office of E, a Ugandan colleague. He has a leadership role within our research clinic, and I respect him a lot. There are two local women in his office, which is unusual. He doesn’t see patients often, and they are not employees.

“Is everything ok?” I ask, noting their presence.

“Not really. Can you come in for just a quick second?”

I walk around to the door and enter, shaking both women’s hands in greeting.

He asks me, “How far along do you think her pregnancy is?

I look at the belly of the woman he is pointing at. It is small enough that I wouldn’t assume she is pregnant, and yet there is a certain bulge there.
“20 weeks?” I guess, still wondering what this is about. Does she want to enroll in our study for pregnant women? Is she supposed to be further along? If so, it could be growth restricted.

He asks the women to guess how many months that translates to. They can’t. He explains that it is about 4 months.

“She thinks she is about 2 months,” he says.

The pregnant woman has her eyes cast downward the whole time. She is wearing a 3-inch crucifix around her neck, the kind that has a miniature Christ carved into it. The other woman, who speaks some English, looks confused.

Finally, he turns to me and says, “They want an abortion.”

Oh. I see.

This is a really hard situation. At home, this would be easy. But here, abortion is illegal. At home, I would do it. At home, even if it were criminalized in my lifetime, I would probably still do it. It’s not really a question for me, and I don’t struggle with it. But I am not willing to do it here – I am not that brave. A Ugandan jail does not sound appealing. But more than that, it is the laws of a country I am a guest in, not my own laws. I feel that, as a foreigner, it is not my place to decide to violate the laws of this country. Even more than that, I wouldn’t want to risk compromising all the other work I’m doing here. It would be deeply unfair to the research collaboration and all its employees to risk associating them with illegal abortions. It would also stop me from seeing all the other patients I have been able to help.
Maybe it is cowardly, maybe a part of me would like to be able to throw caution to the wind and say “I am brave enough.” And maybe others would be brave enough, but I am not.

As a foreigner, would I be more at risk or less at risk than the Ugandans who do illegal abortions? I know that they are being done, everywhere. I have seen so many women bleeding and infected and nearly dying as a result. And for each one of those, there are maybe 100 who had no complications.
I know my position on this – I already had to turn down an even more compelling case, and even that one still haunts me. The women who see abortions in Uganda are desperate. I want to be able to send them somewhere safe, where I know that they will receive adequate counseling and a safe procedure if that is ultimately the woman’s decision. Ugandans are so stoic, so I can only imagine the shame and desperation they must be feeling to approach us and ask for this. I want her to know that I do not judge her for wanting an abortion, so she doesn’t have to feel ashamed with me.

“In my country, in US, abortion is legal, so I don’t mind that you are asking.”

The attendant nods but looks confused. “Tomorrow?”
She is not getting me. E tries.

“Do you know where doctor is from?”

She can’t guess: “Far.”

“You are right, she is from far,” says E.

I try to hint, so I say “Obama.”

“Do you know which country Obama is president of?” asks E.

“Kenya?” she says. She can tell from our reaction that she’s not correct. “America?”

“That’s right, America. Doctor is from America. In America, women can have abortions,” he says.

“Yes,” I say, “so for me, I don’t mind. But in Uganda, it is illegal. We cannot do an abortion here.”
The attendant understands.

E and I discuss what to do. At 20 weeks, it is unlikely that anyone would be able to do an abortion safely, as the equipment wouldn’t be available here. But I feel her abdomen and realize that her uterus is not palpable – she might be early still.
She is 30 years old, and has 5 children. She keeps her eyes downcast, and only looks at me when I address her, although she knows no English.

“When was her last menstrual period?” I ask.

“She doesn’t know. She was on injection family planning, so she didn’t get one for months,” E tells me.

“How does she know she is pregnant?”

“She went somewhere, and they told her she is pregnant,” her attendant tells us.

“Did they take her urine?” I ask.

The attendant translates, and the patient shakes her head no.

“Did they do an ultrasound scan?”

Again, no.

“So how can they know she is pregnant?”

No answer.

E suggests sending her to a woman he knows who is doing some kind of research study on why women want to have abortions, and how much they know about it. I haven’t heard of this person, but it could be an interesting study. I once saw a study presented on pre- and post-abortion counseling from Uruguay that was quite revolutionary. But I doubted this was the same thing.
In addition, why send this woman to a study when what she wants is care? He says that the woman doing the study can do appropriate counseling. Maybe, but who can counsel someone truly objectively unless they are actually capable of performing an abortion? If it’s not legal here, then how can this person provide that counseling?
Finally, he tells me that she is funded by some organization called something like “Human Life International.”
That sounds incredibly suspicious. And like a bad idea.
To me, it is unethical to send these women to someone who might berate them, or lie to them, or worse, get them in trouble for seeking an abortion. I don’t trust anyone.

I realize that if she is 20 weeks, no one will be able to do anything. And at this point, how do we even know she is pregnant? Maybe she thinks she is pregnant because she has not had a period, and maybe she’s wrong. Maybe she is third trimester with growth restriction. Maybe she has an ectopic pregnancy. Who knows? What if she goes to this “Human Life International” group asking for an abortion, and gets arrested when she is not even pregnant? Before we send her anywhere, I should at least do an ultrasound to check for pregnancy and for gestational age.
I don’t have access to the ultrasound on the weekend, so we instruct her to come back on Monday. We also tell her about the dangers she might encounter if she does try to get an illegal abortion, especially if the pregnancy is as far along as we think.

As I ride my motorbike home, I think of the words of an American friend who struggled with the decision of whether to keep an unplanned pregnancy. Aware of how lucky we are to live in a country where we have the choice, she spent weeks crying and talking and deliberating. Later, reflecting on her ordeal, she wrote to me in an email: “Choice is a salty prickly gift if you’ve got a conscience.”

In the United States, people who believe abortion should be illegal call themselves pro-life. People who believe it should be legal call their opposition anti-choice. Neither term is particularly accurate. Abortion is far more common in places where it is illegal than where it is legal, so criminalization doesn’t “save” any lives. But making abortion illegal doesn’t take away a woman’s choice, either. It changes that choice. When abortion is legal, the choice is between bearing (and usually raising) a child, and undergoing a safe, minor procedure. When abortion is illegal, the choice is between bearing (and usually raising) a child, and undergoing a procedure with the risk of death or imprisonment. Apparently, for many women, that is still a risk worth taking. Perhaps the appropriate term would be pro-criminalization. I doubt that terminology makes a difference in something as polarizing as induced abortion, but I also wonder if most people who think abortion should be illegal understand what that really looks like. Then again, that doesn’t seem to be the part of the equation that individuals in favor of criminalization are interested in.

Those who oppose abortion use the term “abortion on demand” to make it sound as easy as watching a pay-per-view movie. Anyone who knows a woman who has considered an abortion knows that this is far from accurate. What stops a woman from getting an abortion is her own conflicted emotion about the pregnancy growing inside her. Some think that showing women an ultrasound of their pregnancy will create guilt that will deter them. That guilt is a drop in the bucket compared to what these women already feel. Women are not children; they think long and hard about their decisions, and often do what they know is best with a heavy heart – whether that is continuing the pregnancy or terminating it. The idea that these decisions are taken lightly is disrespectful.
Trust women.
Wanting to criminalize abortion is a legitimate position, even though I disagree with it. But disregarding the torment that most women go through in making the decision is unacceptable.

I don’t know what will happen to this woman if she is pregnant. I will do her ultrasound, and try to explain why illegal abortion can be so unsafe. I want her to think about the consequences to her five living children if she were to die from an unsafe abortion. But I also know that if she made such a huge effort to come from the village and wander around the hospital asking for what she knows is an illegal procedure, then she is unlikely to be dissuaded from her search. I hope, at least, she will know enough to ask questions about safety. I don’t know what her emotional state is, since I can’t speak to her, but I imagine this was a wrenching, bitter choice for her.