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Opening Doors : A Veil Lifted

I know I'll view this trip as a major event when I look back on it later in my life. My interest in international health is not a passing whim—a great foreign adventure during medical school. It is now a part of me, a part of every day, a part of my future.

Two years after I wrote the journal entries and reflections above, and one year into my residency in obstetrics and gynecology, my plans have evolved but not changed dramatically. I still intend to complete a fellowship in gynecological oncology. I still plan to practice at a hospital that has a partnership with a program in the developing world. The lack of routine preventive care in many countries still keeps me awake at night.

What surprises me is how much my everyday behavior is influenced by my time in Dar. On any given day, several of my clinic patients skip appointments without canceling. When I follow up with them at a later visit, they often blame transportation problems: "I don't have a car, there is no bus to my neighborhood, and my friend didn't show up." I understand what it means to lack resources differently than I used to. Our specialty obgyn emergency room is open 24 hours a day, staffed overnight by an on-call team of residents. At 3:30 a.m., when the on-call doctor has missed dinner and is exhausted, it seems a misuse of a high-tech emergency room to handle a routine question like "What is the best birth control for me?" But after a fiveminute interview, it becomes apparent that for a patient who works nights, has no doctor, and takes care of two children at home during the day, preventing another pregnancy is very important—and 3:30 a.m. is her one chance to get an answer.

I also make everyday use of what I learned from caring for people of another culture, with different medical beliefs, while speaking another language. A majority of the patients I now treat were born outside the U.S. I often feel as if I'm in an international clinic, here in Providence, R.I. In fact, practicing international health in the 21st century does not necessarily involve traveling to faroff lands to treat impoverished patients in remote jungles. It also means taking care of the Dominican patient who asks "Will I be ready to fly home next week?" or the Liberian woman who comes to the hospital in labor but has had no prior obstetric care. Many of my patients travel frequently to visit family and friends in their home countries, and I can visualize the advice I give about starting prenatal vitamins prior to conception spreading like a wave to women in Cape Verde, Nigeria, Ecuador, and Cambodia.

Blood samples are transported in a picnic cooler from the clinic, left, to the lab at Muhimbili University, where they undergo testing. Above, Lab technologist Betty Mchaki has run a set of blood samples through a number of tests before incubating them.

Above right, another sample awaits its turn. The green rack says "MUCHS/DMS," referring to Muhimbili University College of Health Sciences and Dartmouth Medical School. A whiteboard in the clinic, above left, lists any patients who miss a routine visit. If patients miss two consecutive appointments, then a member of the medical staff goes looking for them.

Above, Safina Sheshe and a colleague are about to look for six such patients. "This is much more difficult than might be imagined for two reasons," explains photographer Patrick Saine. "This population can be very itinerant—if they do not like the landlord . . . then they just move on. There are no . . . long-term leases and no forwarding addresses . . . which leads to the second problem," he adds. "There may be neighbors who know where they have moved, but because there are no street addresses, the directions are on the order of 'Turn right at the large drainpipe and left at the big mango tree.'" But maintaining the study population is essential for a reliable outcome, so the staff works hard at finding lost patients. Mangoes are common in Tanzania—at right, Amelda Urasa takes a break to go out and buy one from a street vendor in front of the clinic.

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