War on Risk

On September 20, 2013 by ali heller


My hands still smell of bleach. My silk headscarf hangs off the chair, browned with blood. It was a hard day.

The morning began innocuously enough (given the context). Women with pregnant bellies or infants in their arms slept two or three to a bed, some tethered to IVs, others waiting for their labors to begin. A young girl who I’ve been following for the last week, a 16 year old run-away who’s been living on the streets and turning tricks for the past four years, began labor with a dangerously high malaria count. “She doesn’t know who the father is. She is going through alcohol and cigarette withdrawal,” the nurse said as she conducted a pelvic exam. “And,” her voice muffled into a whisper, “she’s positive”. Here, “positive” means just one thing, HIV. “Does she know?” I asked. The nurse shrugged, whipped off her rubber gloves, and moved along to the next bed without looking back.

In the next bed was a tall woman with high cheekbones and an enormous stomach. She sat on the bed completely naked, her long breasts resting on her stomach and following its curves. With the crescendo of each contraction, her eyes would flutter and she’d fall back on to the bed, stifling a cry. Her arm would shoot up into the air, looking for something, someone to grab hold of. Finding nothing, it would eventually fall back at her side. Her labor was as normal as labors can be, like the dozens that I’d seen before hers.

As I jotted in my pad of paper, taking note of the nurses and doctors moving here and there, doing this or that, caring for one woman or another, my eyes returned to the tall woman just in time to see her baby emerge with the umbilical cord wound tightly around his neck. The midwife deftly untangled the bluish cord, and I breathed a sigh of relief and returned my pen to my notebook.

But then I was wet. My words drowned beneath pools of red. Blood speckled my arms, chest, and hands. I felt the wetness on my face.

While a couple of others were also showered in the laboring woman’s blood, I seemed the only one immediately concerned. I quickly found the nearest sink, and although there was no soap, I splashed bleach in my hands and on my face. I tried to wash the blood from my chest and arms. I was alarmed. I didn’t know what had happened, but I wasn’t interested in following the protocol, taking clues from the doctors and nurses around me (who seemed rather unshaken by the event). I made mental calculations, ran through lists of blood born pathogens.

It is in moments like these that I break character.
It is in moments like these that as an anthropologist, a cultural chameleon who takes the shape of those around me, I am left exposed without camouflage. In moments like these, I am unmasked. And in that moment I was a hyper-conscientious, risk averse, play-it-safe, me-first kind of creature.

I am a tourist into this world, trying to understand (or some might argue, exploit) this reality. But these people, these doctors, and nurses, and patients inhabit this world, and they live with the risks inherent within it. Here, 1 in 23 women will die due to childbirth related causes. 1 out of 8 children will die before the age of 5. 1 out of 10 deaths are due to malaria. The odds aren’t good, but one is obligated to accept them.

As researchers, we enter their homes, we eat their food, we participate in their ceremonies, we say their proverbs, we learn their norms and we follow them. We become characters to some extent, playing a role that closely resembles who we believe ourselves to be, but isn’t quite her. And besides a handful of us who, as we say, “go native”, when we leave, these newly learned ways of being are left behind in international airport terminals. Experiences become seeds for stories, vestiges of our time spent in a far-off country.

But in moments of risk, moments of threatened permanence, the façade begins to crack. The panic becomes insuppressible. And as I frantically scrubbed my face, my mask washed off with the blood.

“Do you know her status?” I asked a nurse. “Has she been tested?” I pushed. As the blood browned my all white outfit, I wondered what codes of confidentiality I was breaking. “We will write a lab order for a hepatitis b test, but she will have to get it done in a private lab. We don’t have laboratory capabilities here” the lead midwife told me as she bent over the sink, carefully washing the blood out from her hair. I knew very well that the woman wouldn’t conduct the expensive blood tests. I knew that even if she did, I would never receive the results.

In a true break of character, I asked if I could take her blood to a lab and conduct the tests for her. She hadn’t dressed yet. She held her gooey baby to her breast. There is no delicate way to ask for someone’s blood, no way to disguise your fear of contamination. With more grace than I, she accepted and a vial of her blood was placed in the finger of a rubber glove which I drove across town to a lab. I ordered a HIV, Hep B and Hep C test. At a cost of over USD $100, there’s no chance this woman would have completed these tests on her own.

All negative.
I called the midwife (who had an even greater exposure to the blood than I) to let her know. “Ok” she said unenthusiastically before hanging up.

I called the American Embassy doctor who told me that HIV might not show up in the blood right away, he said that while unlikely, it is possible that she contracted the virus in the last couple of weeks. The rational part of me dismissed this improbability. A friend of mine who works as an ER doctor in the States assessed my risk as “vanishingly small”. Still, the Embassy doctor told me, “If you want to take the ‘insha’Allah’ route, that’s up to you” (insha’Allah is a common expression used in the Muslim world meaning “God willing”, denoting a submission to destiny). “But if it were me, or my wife, I wouldn’t chance it. I’d take PEP”.

PEP, or post-exposure prophylactic, consists of four antiretroviral drugs (the same used to treat HIV/AIDS), and when started within 72 hours of exposure to the virus, can prevent it. In the West, following needle sticks or high-risk contact with blood from someone suspected to be HIV positive, health care practitioners are recommended to take PEP.

“These drugs are exceptionally hard to take” The Embassy doctor advised me. Expect nausea, headaches, fatigue, vomiting, diarrhea, and other ghastly G.I. issues. Don’t be far from a toilet, he says. According to the CDC, because of the severity of the side effects, about 40% of those who begin PEP do not finish the 28-day course.

I hunted across town for PEP. Because it cannot be sold for a profit, no pharmacies carry it. Only one man at one center has access to it, and he wasn’t working. I wonder how many Nigerien health workers are exposed to blood born pathogens each day, how many do not know the status of the source, how many know of PEP, and how many navigate this opaque labyrinth to access these drugs. Few, I suppose.

I pulled some strings, and got the drugs. And as I lay listless on the floor, having spent the day and night vomiting, I ask myself, what are the levels of risk we are willing to live with? We Americans, we use instant hand sanitizer after touching the subway rail, we get flu shots every fall, we sign pre-nuptial contracts. We have insurance for our health, our lives, our homes, our travel plans, our cars, our electronic devices, even our pets. Indeed, we invest our time and our money insulating ourselves from risk. And it is a luxury to be able to do so.

But, still, feverishly ill from medicine to protect me from a ‘vanishingly small’ risk, I have to wonder, is it worth it? Has our war against risk gone too far?




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