Monthly Archives: December 2012

January columns: DSM-5 & Michelle’s 2nd Term

WOMEN BEWARE!
DSM-5 COULD BE HAZARDOUS TO YOUR MENTAL HEALTH

Ava C., adopted from Asia and raised in small-town America, knew she looked different than her classmates, but no one ever talked about her origins. Over time, she began to withdraw. Following a psychiatric diagnosis of depression, she thought of herself as “mentally ill.” One day, while in a major city’s bustling Chinatown, she realized, “All around me were people who looked like me, doing ordinary things. They apparently didn’t feel ‘sick.’ That’s when my depression lifted.”

People like Ava — from different cultures, classes, races, or genders — often experience life’s stresses in unique ways. Too frequently they are labeled ill or abnormal by the psychiatric establishment.

Dr. George Albee, Emeritus Professor at the University of Vermont, once noted that “the highest rate of ‘idiocy and lunacy’ in America was first among the millions of immigrant poverty-stricken Irish after the potato crop failure of 1845, then on successive waves of poor Swedes, then Slavs and Russian Jews, then Southern Italians, now Blacks and Hispanics…as each group achieved economic success their incidence of ‘idiocy and lunacy’ fell to the population average.”

As the new Diagnostic and Statistical Manual of Mental Disorders, or DSM-5, is released this year, experts are sounding cautionary notes. Among the “psychiatrist’s bible” critics is Dr. Paula J. Caplan, a feminist psychologist who served as advisor to two DSM-4 committees before resigning due to concerns about “how fast and lose they play with the scientific research related to diagnosis.” Caplan has become the leading voice in alerting therapists and the public to the manual’s “unscientific nature and the dangers that believing in its objectivity poses.”

“It is widely believed …that if only a person gets the right psychiatric diagnosis, the therapist will know what kind of measures will be most helpful. Unfortunately, that is not usually the case,” Caplan says. “Getting a psychiatric diagnosis can often create more problems than it solves, including difficulties with obtaining health insurance, loss of employment, loss of child custody, the overlooking of physical illnesses…and the loss of the right to make decisions about one’s medical and legal affairs.”

Caplan worries that the authors of the DSM make “expansive claims about their knowledge and authority, wielding enormous power to decide who will and will not be called mentally ill and what the varieties of alleged mental illness will be.” She doesn’t deny that psychotherapy and medication can be helpful, but she sees worrisome connections between “drug companies’ concealment of the harm their products can cause and some professionals’ pushing of particular drugs while on the payroll of pharmaceutical companies.”

The American Psychiatric Association (APA), which writes the DSM, says its purpose is to establish criteria for diagnosis and “not to create medical conditions out of the full range of human behavior and emotions.” It also claims to be dedicated to “ensuring that the development of DMS-5 is the most open and inclusive in the history of the manual.”

Still, Caplan remains concerned about the “shroud of secrecy” that she sees enveloping the process. As director of the Coalition for Informed Patients and Doctors, she has called for Congressional hearings about psychiatric diagnosis “in an attempt to explore the nature and extent of harm that many Americans have suffered solely because of being given a psychiatric label.”

Feminist therapists are concerned for women in particular. Diagnoses such as Borderline Personality Disorder (BPD) and Sexual Dysfunction have disparaged women and compromised them in troubling ways. For example, one expert says that BPD is almost exclusively applied to women because its symptoms relate to emotion and anger. Some women with the diagnosis have histories of abuse and may have difficulty expressing anger “appropriately.” Such vulnerable women need to have their coping styles better understood before assumptions are made about their behavior.

Similarly, “sexual dysfunction” among women is often based on assumptions about what constitutes normal sexual behavior. “If only performance failures or lack of desire count, the entire context of sexual activity becomes invisible and of secondary importance,” says one member of the Association of Women in Psychology (AWP).

Another AWP member focuses on classism in psychiatric diagnosis. “Poor women and women of color are particularly likely to be misdiagnosed or encounter bias in treatment,” she says. “Therapists may interpret chronic lateness or missed appointments as hostility or resistance to treatment rather than the outcomes of unreliable transportation, irregular shift work, and unpredictable child care arrangements.”

Caplan and her colleagues warn that “the absence of science creates a vacuum, and biases and distortions rush in.” Serious problems like depression are overlooked as people are diagnosed with unproven ‘mental illnesses’. “Many people who are suffering because of social problems like poverty or because they are victims of hate speech or violence are wrongly treated as though the problems come from within them.”

That’s enough to make anyone call for hearings instead of professional help.

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WHAT WILL MICHELLE’S SECOND TERM LOOK LIKE?

I have enormous respect for Michelle Obama. She has brought dignity to the White House and set a high bar in terms of intelligence and style for first ladies to follow. Jodi Kantor, author of The Obamas, argues that this First Lady is a force to be reckoned with in the White House. Still, I wonder if she will now be a bit more 21st century in her role.

Ms. Obama’s nutrition initiative is good and so is her commitment to military families, although some say there’s more front than back there. Also, I understand that a lot occurs behind the scenes and that as a mom of adolescent girls, it’s important to put family first.

Still, as an experienced professional and a first lady with deep convictions, Ms. Obama has an extraordinary opportunity to address selected critical issues in this contentious time, and to exert her influence around current issues such as pay equity, violence against women, and reproductive rights. Instead, in her first term, she chose to be cautious, positioning herself as a traditional first lady addressing safe issues. She tread lightly, more akin to Nancy Reagan than to Hillary Clinton.

As first lady, Ms. Clinton set an extraordinary precedent. One can criticize her handling of the health care debacle, but not the fact that she took it on. Nor can you fail to admire her public commitment to women, even though she took a lot of heat for speaking out forcefully on their behalf. For those of us who watched her in Beijing at the 1995 Fourth World Conference on Women there was no more thrilling moment in the history of first ladies than when she read the riot act to the Chinese for their oppression of women.

Cataloging a litany of human rights abuses the world was stunned as Clinton declared, “It is time for us to say here in Beijing, and for the world to hear, that it is no longer acceptable to discuss women’s rights as separate from human rights.”

It’s not as though Clinton is the only former first lady who had fire in her belly. Eleanor Roosevelt was the most influential wife of a president this country has ever seen. She used her role to advance New Deal proposals, education reform, and equal rights for all in a time of violent racism. As her biographer Blanche Wiesen Cook noted, “Her gift for organizing and her astonishing energy and determination to do good combined with her famous name made her an influential figure in both social reform and partisan politics.” Involved with the League of Women Voters, the Women’s Trade Union League, and the Women’s Division of the New York State Democratic Committee, she wrote, “Against the men bosses, there must be women bosses who can talk as equals, with the backing of a coherent organization of women voters behind them.”

There were other first ladies who made their mark. Helen Taft advocated for women’s right to vote. Edith Wilson undertook many “details of government” when her husband Woodrow suffered a stroke. More recently Betty Ford transformed the role of first lady when she publicly confronted breast cancer as well as her battle with substance abuse. In 1991 she won the Presidential Medal of Freedom for “selfless, strong, and refreshing leadership on a number of issues,” including women’s rights.

The wife of the U.S. president can exert enormous influence on issues of her time. She has the ear of the president and her own bully pulpit. So Michelle, show us the real fire in your belly. What is it you truly want to speak out about or see changed? What do you want your legacy to be as a 21st century first lady?

You might as well go for it. As Eleanor Roosevelt said, “Do what you feel in your heart to be right, for you’ll be criticized anyway. You’ll be damned if you do, and damned if you don’t.”

Surely when you’ve got the right stuff – and you do, Michelle – it’s better to be damned if you do. So while you have this unique opportunity, why not go out there and make a big difference? As your husband would say, “Yes, you can.”

Are you “fired up and ready to go?”

Suffer the Little Children

I tried to imagine what it must have been like at Sandy Hook Elementary School on that Friday morning that will forever be part of our collective psyche. Then I tried not to. I thought about a precious three year-old child to whom I am deeply attached and felt the pain of what it would be like to lose her in so vicious and horrific a way. Again, I tried not to. I wept for the loss of the six brave women, still so young themselves, who did everything in their power to keep their young students safe.

When a minister cried trying to say what it was like to tell a child that his sibling was dead, I cried with him. When a teacher said, “I told them I loved them very much. I wanted that to be the last thing they heard, not a gun shot,” I wept again. And I wept to see the pain our president struggled to contain as he spoke to a stunned nation immediately after the tragedy occurred.

Who among us did not weep at the thought of the all mighty wail that arose when terrified parents were told there would be no more children coming out of the firehouse on that dreadful day?

Sadly, the answer is the monsters who posted social media messages using the N-word to refer to the president when their football game was interrupted for Mr. Obama’s remarks. It is the NRA’s gutless leadership who took four days to issue a tepid and gratuitous comment but who did not have the courage to face the cameras on news programs and Sunday morning talk shows. It’s Republican governors and legislators who also refused to stand up and be counted in the name of ending the slaughter of innocents. It is also the insane among us who argue for the legality of concealed weapons and for armed educators, among others.

The often cited data about guns in this country are stunning. Over the past two years, as newly seated Senator Elizabeth Warren pointed out in a letter to her supporters, more than 6,000 children have been killed by guns. That number went up even after the Sandy Hook massacre: children died from guns on the day after the school shooting and on the day after that. (So did two police officers in Kansas.) Eighty-three Americans die every day from gun violence in America and eight of them are children or teenagers. That’s thousands every year, tens of thousands in the last decade alone.

The rest of the civilized world is stunned in disbelief, and so they should be.

It does no good to divert attention away from the urgent need to pass gun legislation immediately by talking about media violence and mental health issues. Certainly they are part of the picture and must be addressed in a comprehensive approach to stopping America’s madness. But the last thing we need to do is stigmatize people with autism or Asperger’s Syndrome, developmental disorders that bear no relation to violent behavior.

First and foremost, we must get a grip on our gun-loving culture. As Boston Mayor Tom Menino, a co-founder of Mayors Against Illegal Guns, has said, “Now is the time for a national policy on guns that takes the loopholes out of the laws, the automatic weapons out of our neighborhoods, and the tragedies like [Newtown] out of our future.”

It is the time to ban assault weapons and magazines that hold more than ten rounds. It is the time to close loopholes that allow 40 percent of gun sales to be sold without federal background checks because they are purchased privately at gun shows, online, or person-to-person.

The time for talk is over. No more discussing, decrying, deliberating. No more burying our children and binding our emotional wounds. No more prevaricating. No more politics.

What more is there to say? Except this: Enough! Enough senseless slaughter. Enough dead children who might have had lives filled with achievement and joy. Enough grieving parents and siblings and friends. Enough weeping with the multitudes.

Enough! We must stop being a country of killing fields. We must put an end to the false power of lobbying groups that some identify as terrorist organizations. We must say, with one voice, Enough! And we must mean it. Now.

Educating Congress, One Book at a Time

When Rep.Todd Akin, the Republican who sought Claire McCaskill’s Senate seat, declared that “if it’s a legitimate rape, the female body has ways to try to shut that whole thing down,” the women of the Boston Women’s Health Book Collective, now known as Our Bodies, Ourselves after their acclaimed book of that name, let out a collective gasp.

Then they took to the road. Delivering their iconic book to Akin as well as McCaskill on what they dubbed the “Missouri Sex-Ed Road Trip,” they quickly realized that Rep. Akin wasn’t the first or only member of Congress who had his facts wrong, and he probably wouldn’t be the last. So they took up readers’ suggestion that everyone involved in writing federal laws that affect women should have a copy of the widely respected Our Bodies, Ourselves.

Thus began a campaign aimed at educating Congress and informing policymakers on maternal health, preventive care, access to contraception, abortion and a full range of reproductive health services. “It would also serve as a resource on violence against women and a host of other issues that come up before Congress,” organizers said.

At an October National Press Club Newsmaker event in Washington, D.C. to launch the Educate Congress campaign, Judy Norsigian, founder and executive director of the Our Bodies Ourselves organization, said, “We hope to advance evidence-based reproductive health policy-making in this country” by giving copies of the book to all 435 members of the House of Representatives and 100 senators before the end of the year.

To that end OBOS is well on its way to raising $25,000 to cover the costs of distributing the paperback book which sells for the bargain price of $26 a copy. Originally published as a newsprint edition in 1971, Our Bodies Ourselves proved to be a pioneering, woman-centered study of women’s health and sexual issues. Today its 40th edition, weighing in at over 900 pages, shares the work of more than 350 experts and readers who worked collaboratively for more than two years to complete it. The book, which has sold over four million copies since its initial publication, has been translated into 30 languages and is recognized internationally as “the go-to authority” on women’s health and wellness. This year the Library of Congress included it in an exhibit of 88 books that “shaped America.”

In response to Akin’s comment about “legitimate rape” and Illinois Rep. Joe Walsh’s claim that because of “modern technology and science, you can’t find one instance” where an abortion was required to save the life of a mother, the American College of Obstetricians and Gynecology (ACOG) issued two statements correcting the legislators’ false information about pregnancy and abortion. According to ACOG “many more women would die each year if they did not have access to abortion to protect their health or to save their lives.” Akin, Walsh and their uninformed, right-wing friends seem not to have heard of conditions such as pre-eclampsia (pregnancy-related high blood pressure), nor are they aware that the U.S. ranks 50th in the world for maternal deaths in childbirth.

They’re not the only ones who need educating, it appears. A medical student in Chicago reportedly told a professor that condoms aggravate the spread of HIV-AIDS. As Judy Norsigian says, “This country has a long way to go” when it comes to reproductive health education.

Norsigian, citing the clear need to provide Congress with accurate, evidence-based information, especially in the face of dangerous and uninformed comments being spewed about women’s bodies, said more politicians and their aides need to have a copy of Our Bodies, Ourselves readily available. This is especially important because the new edition focuses on topics that are sometimes misrepresented or misunderstood, such as pregnancy and childbirth, birth control and abortion, and sexual health.

The bottom line is this according to OBOS and other women’s health advocates: Congress can save women’s lives by advancing evidence-based reproductive health policy that, among other things, preserves access to and coverage of reproductive health care; improves maternity care and reduces maternal mortality; uses accurate language to describe rape; and ends restrictions on women’s access to safe abortion.

Not so long ago none of those markers seemed excessively demanding or difficult to achieve. Now they are under assault in unprecedented and frightening ways. Thankfully OBOS is there to help educate those most in need of solid, factual information, and to continue advocating in Congress and elsewhere on behalf of all women.

For more information, visit http://www.indiegogo.com/educate-congress

Re-posted by request:
In October 2011, I had the opportunity to spend two weeks volunteering as a doula in a hospital in Hargeisa, capital of Somaliland. What follows are excerpts from my journal about that experience.


The airplane which carries me from Dubai to Hargeisa, capital of Somaliland, is so old it looks like pieces of metal will fall off any minute. The tires are virtually bald and the interior is shocking with broken seats, filthy carpet, no working lights or air vents. There is no cabin crew and the aisles quickly fill up with luggage. There is the smell of urine and sweat. Upon arrival, people at immigration are shouting, shoving, snarling themselves up, barking orders that are ignored. I spot a man who must be my greeter. We drive to the hospital.

Edna, the founder and major domo of the hospital is stunning at 74 in her long dress and elegant head dress. She greets me warmly. I am shown to my room – a basic but perfectly adequate single with private bath in a dorm for visitors. I shower, unpack, and join the others for lunch. Along with Edna are a French physician who has come to do ‘hands on’ work after years in research medicine; a Finnish nurse-midwife and former missionary who has worked in Ethiopia and Somalia for most of her long career; a German-American nurse from New York City and another newly graduated nurse from Mass.; an OB-GYN from Germany; an energetic Austrian-born nurse-midwife now living in England; and an English nurse-midwife.

Lunch, like every other meal, is goat meat on the bone cooked with cabbage, a diced vegetable mix, rice, gravy with potato and carrot, salad, watermelon and bananas. There is fruit juice or bottled water to drink. (Breakfast is cereal, bread, a watery porridge and Somali pancakes.)

The hospital is smaller and less developed than I had thought but still the best hospital in Hargeisa. It is clean and equipped with one (rarely used) incubator, two (probably overused) ultrasound machines, and a decent delivery room and surgery. There is a lab, a library, Edna’s Computer Room, Edna’s Pharmacy, Edna’s Supermarket, and an ambulance on the well-guarded compound situated on a busy road unofficially called Edna Street. The hospital has a maternity wing and a medical-surgical wing which includes a room for pediatrics. It accommodates about 60 patients.

Many people mill about in the compound, most family members and visitors, some guards or other workers. The women, all in hijab and many fully covered with only eyes showing, stare curiously when I walk around the grounds. They do not allow me to take their picture. Several mosques surround the compound in this deeply Muslim country and there are frequent mullahs’ calls to prayer beginning at 4:30 a.m.
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The history and politics of Somaliland are complex. Suffice to say that it is one of several colonized regions of Somalia that tried to unite for independence from France, Italy, and Britain in the 1960s but failed to coalesce effectively. Somaliland declared itself free and independent several decades ago and has been fighting for recognition as an independent nation since.

Somaliland is dry and dusty in the long absence of rain, and mostly flat with a pleasant climate at just over 4,000 ft. above sea level. It is one of the poorest countries I’ve ever seen. The canvas or wood business stalls, the goats in the road, the deeply pocked dirt roads, and the simple, inadequate houses (often no more than shacks made of corregated metal and rags) all provide a visual for the deep poverty here. Life expectancy for men is about 47; in the absence of data the high maternal and infant mortality rates are not known. Women are usually married between ages 15 to 25 and can expect to have between 5 and 12 pregnancies. FGM is universally practiced. It is a deeply religious culture and a mysterious place. I have no idea what is actually going on around me: I can’t understand a word that’s being said, and people outside the compound resist communicating (unless it’s to beg). They generally find us so aberrant as to be laughable. Many men are addicted to the local narcotic weed, khat, which they would sell their souls to chew.

The first night there I have my initial doula experience. The mom is about18; it is her first child. She labors so well I think she must be in early labor but she is on the delivery table (women always deliver in lithotomy position in a delivery room) and Asha, the midwife, is doing things that tell me the baby is coming. Mom moans and clings to my hand; I stroke her arm and whisper that she is strong and can do this; soon her baby will be born. A student nurse translates what I am saying. The mother nods to me. I support her head while she pushes; she grasps my arm. And then her son is born, his wet little head emerging first, then his body sliding quickly out. “Good job! Look at your little baby!” I tell Mom. “Thank you!” she says in English. “Thank you,” squeezing my hand. I go to bed happy that I’ve been able to help in this remote place.

On the morning of my second day I have my second birth. This is Mom’s third child and she too labors well, choosing to stand through most of her labor. Hibo is the midwife and a more gentle, calming, competent soul I’ve never met. I encourage Mom, massage her hips and back, stroke her arm, talk to her in whispers. Even when she doesn’t know what I’m saying I sense that she is comforted by my voice and my touch. As she leans on my shoulders she lays her against me as if she were a child. I stroke her head, reassuring her. At 9 cm. she climbs onto the delivery table. Hibo gently examines her, tells her when to push and when to stop. She is holding onto me for dear life. Three student nurses observe; I hope they are seeing the importance of emotional support during birth. Mom’s mom appears — I cannot tell from her expression if she thinks I am usurping her position, but then she says to Hibo, “This woman is beautiful the way she is helping my daughter.” A bigger reward I cannot imagine. Finally, a big, healthy boy is born. Mom thanks me profusely. I tell her I honor what she has done. She kisses my hand and thanks me again. I kiss her hand back and thank her. Hibo is not surprised by this exchange but the young nurses seem stunned at what they have just witnessed.

The next day a C-section is just beginning when I enter the OR in my scrubs and mask. Mom is getting an epidural. After she is draped the German doctor takes a scalpel and makes the first cut. Working quickly he opens the uterus and pulls out a baby who is hydrocephalic. “Very little brain,” he says. The baby also has a terrible hair lip and cleft palate. She does not breathe readily and is whisked off to be resuscitated. Hibo tells the family what has occurred. By the next morning the baby is dead.

I spend the next morning first on rounds in Maternity where four babies have been born during the night and a woman with eclampsia is in trouble, then in the Outpatient Department where the doctor is doing pre-natal checkups. I’m invited to palpate mothers’ tummies and to listen to the fetal heartbeat through a primitive wooden instrument.

With the other women I visit the local market. Crowded with stalls and not always easy for western women, we are in search of cloth from which traditional long dresses can be sewn. We quickly choose colorful cloth for $4 each and then find two women sitting at sewing machines who in no time stitch the material into full-length “moo-moo” like dresses. (Cost: $1). The women are friendly and try speaking to us as they sew on their antique machines. “Inshallah, I see you again!” one of them says when she is finished. “Inshallah,” I reply.

The next morning I wonder into the maternity ward. Four babies have been born during the night but no one is in labor. I visit baby Hodu, everyone’s favorite – a pretty six-month old little girl who keeps getting a dreadful infection on her head and face that has caused loss of pigmentation and scabbing. No one knows why she has this condition or why it recurs after treatment. Hodu is gorgeous but developmentally delayed. She faces an uncertain future. She lies in a bed all day with her young aunt watching over her

I help the mom with eclampsia who has had a C-section in the night because of her severe hypertension. Her baby boy is a fighter at 28 weeks and less than 3 lb. He seems to have a sucking reflex and has a good chance of survival if he can start nursing. For now, Mom pumps and feeds him through a syringe. I position the baby between his mother’s breasts, a technique known as Kangaroo Care which has shown good results for survival with premature babies. I wrap him in blankets and encourage the exhausted mom. Her mother is there along with a young aunt who speaks good English so we visit as I sit with them. Mom is expert at breastfeeding having had seven other children; she is able to squeeze out a few drops of colostrum and get them into the baby’s tiny mouth.

On Monday morning I hurry to the labor room where an induction is due to begin. Hibo tells me the husband has not yet given permission; he will come at 9 a.m. There are two other women in labor, and another woman awaits her husband’s signature for an induction. The chances are the men will not consent; they have likely consulted numerous family members. More likely, they will take their wives on a round of doctor visits until they find one who tells them what they want to hear.

I am beginning to see the dark side of this country and culture, where voiceless, disempowered women must have their husbands’ permission to have a C-section or an induction for medical reasons. (If they need a hysterectomy their father must agree – her body belongs to him.) I watch as husbands come to sign (or not), ignoring their laboring wives who walk the halls. Imperious and authoritarian, they swagger in and out self-importantly. The doctor says he has seen them deny their wife her life, even when she is crying to be rescued, because “Inshallah” it is God’s will (and maybe he doesn’t like this wife so much anymore.) He has seen babies die unnecessarily – “Inshallah”. A woman here often holds less value than a camel; she has absolutely no personhood. Her function in life is to marry, bear many children and obey her husband. Her body is not her own. She has no genitals remaining; by the age of nine or 10 they have been cut off. A husband expects to have sexual intercourse with his wife every morning and every evening, unless she is bleeding. No wonder women have upwards of nine to 12 pregnancies; they are not even given time to rest from the last pregnancy before their husband demands his right to enter her again. God only knows what kind of domestic abuse occurs in shacks and shanties throughout this country of ritual, tradition and male supremacy.

Watching women give birth here is something to behold; it is a testament to their strength and courage in the face of such a life. “She’s doing all the work and I’m doing all the sweating!” I tell Hibo as she delivers a woman’s ninth child. She makes no sound, not even a mild moan (Hibo says Somali women don’t do that) and suddenly her baby pops out. It is whisked away to be cleaned up and Mom seems little interested for the moment; she lies patiently waiting for the placenta to be delivered. Then, cleaned up, she gets off the delivery table as if nothing out of the ordinary has happened, and is taken to her room. I follow carrying the baby boy she has just delivered.

In Prenatal Clinic a variety of situations present: a woman is worried about her frequent miscarriages and infertility; another has back pain with her periods; several others are doing routine check-ups; a shy woman appears with her husband complaining of urinary retention post-C-Section. The doctor can hardly contain his rage at the father who took so long to give permission for the C-section that she has had complications.

There are two C-sections in rapid succession. I observe and take photos. I’m astounded at how fast they are; it is a relatively simple (but quite bloody) operative procedure requiring great skill nonetheless. The mothers are again stoic as they are catheterized, receive epidurals and lie exposed on the OR table. (There is an irony about the prevailing female modesty in this culture while at the same time women seem to disregard the lack of privacy surrounding their bodies in the hospital. Do they feel their bodies, which have been infantilized by the removal of sexual organs and pubic hair, are not their own?)

Wednesday I head for the wards at 9:00 a.m. Last night I missed a twin birth, a breech birth, a D&C and a prolapsed cord. Today in Prenatal Clinic there are lots of giggles among the patients and the friends they have brought with them, while the doctor, a pixy of a nurse and I joke back and forth between patients. The longer I’m here the more I like the Somali women I meet; they have a good sense of humor, are generally warm and appear to welcome our help. At lunch we are joined by an American missionary surgeon and his wife; the doctor can hardly control himself as he whispers to me, “Can you imagine going to Wyoming and telling people to change their ways?”

Thursday I teach 26 first-year nursing students about emotional support during labor and delivery. Before class I check to see what is happening in the maternity wing and find three women in labor. I visit briefly with each of them and promise a young new mom that I will return after my class to help her. She squeezes my hand. When I come back after class the midwife asks me where I have been. “The woman, she is asking for you. She says she want that lady!” The mom I promised to help has delivered her baby, asking for me the entire time! I go see her, apologize, and tell her how beautiful her new daughter is. “Next time, Inshallah!” I tell her. “Mashalla!” her mother says.

At the start of class I make small-talk with the students. Then we get down to business. I write “Doula” on the board and tell them it is Greek for “woman helper.” I explain what we do and why and then talk about the importance of emotional support for all patients. I tell them that in America we don’t always live close to our families like they do so we need others to help us when we are in pain or afraid. I talk about how caring is at the heart of good nursing. I tell them about birthing practices in the 1950s and 60s in America and how women got together to reclaim their childbirth experience (careful to use language they can understand). I demonstrate what doulas can say and do to make moms less afraid and more comfortable during labor. They seem rapt when I am speaking, mesmerized perhaps by this elderly white lady who talks of strange things, but when I ask them questions or want to know what their questions or thoughts are, they are silent. I say, “Allah gave you a voice! Women’s voices are beautiful! You must not be afraid to use your voice!” but this falls on deaf ears – they have been long socialized into silence.

I break the class into groups so that can practice techniques to support laboring mothers; they think the role play is hilarious and do not take it seriously so I reconvene the class and try a single demonstration; this too is seen as – quite literally – too funny for words. So I decide I’ve done what I can for one class and ask, in closing, that each of them tell me one thing they’ve learned today. A few whisper rote answers: “Massage.” “Breathing.” “Talk.” A few actually seem interested. To my amazement, one student says, “I learned that ‘doula’ means woman helper!” I am so excited I pretend to ululate; the others laugh and do the real thing. When a few other students say something audible and original I wave my hands in a Hallelujah gesture. I’ve gotten through to a few of them! I conclude with a pep talk about the difference good nurses make, the need to honor as well as support the hard and amazing work women do in having babies, the healing touch and so on. I invite questions but silence prevails.

And so it comes to an end, this African adventure of extremes, of wild animals and willful males, of voiceless women and vibrant girls, of outrageous poverty and obscene affluence, of deep blue seas and desert sands, of market stalls and mega-malls, of break-away nations and tradition-bound kingdoms, of visionary women and violent men. So much to absorb and try to understand; so much more to be done; so many new friends; such amazing experiences! May there be other such times in which to contribute and learn. Mashallah!