Betana

We set off in the late morning, later than hoped for but before I had expected we would actually depart. I climbed into the front seat of the white Land Cruiser, the kind that are famed for their ability to drive up, over, and through any river or swath of mud. Today we were heading for Betana, a community only 40 minutes drive south of Puerto Cabezas along the dirt highway to Managua. Over the past several months I started volunteering for an organization called CAIMCA. They provide health services to women with a special focus on women suffering from domestic violence. Under the same roof there are lawyers, psychologists, nurses, and a physician to support women by providing medical care and guidance through the legal system when filing a complaint against an abuser. My role at CAIMCA has been to perform Pap smears in the mornings, free of charge to any woman that wants to be tested. Our goal for this day was to head out to the community to provide the same service. One of the female leaders of the community had petitioned to have us come out to the women to perform Pap smears, rather than take the women to Puerto Cabezas; the 50 who had listed their names in a worn, yellowed notebook stating their desire for cervical cancer screening.

We arrived in Betana dusted by a thin layer of clay colored dirt. We pulled to the side of the road to ask a woman emerging from the tall grasses where the health center was. She turned her back towards us and pointed to a one story, pink, cement building just across the field. The health center sat squat upon a low rise in the plain, flanked by stilted wooden homes painted emerald green and Caribbean Sea blue. The Land Cruiser bowled up and over the ditch, through the grasses to park in front of the health center. It appear locked and dark. A passerby informed us that the nurse, along with the key to the health center, was in Waspan, a town 6 hours north of us.

We gathered our supplies and lugged them across a one plank bridge that guided us across a muddy ditch, passing through the chain link fence to the health center. The condoms, speculums, anti-parasite syrup, gloves, etc. were seated upon a wooden bench flush against the health center’s rose colored wall. As the four of us sat and chatted about what a speculum is, a thick legged woman in a hand stitched black tank and skirt with red flowers blooming across her chest ambled through the gate. This was the community leader who had organized the Pap smear event. She explained that she had expected us on Tuesday. All the women had arrived early and patiently waited for us; but we hadn’t arrived. Today was Thursday. She stated that we could make it work, but many of the women were out in the fields planting and would not return in time to receive the service. And she confirmed that the nurse was in Waspan so we would not be able to use the health center.

Ingenuity is a common quality amongst the people of the Miskito coast that have learned to reuse, recycle, and reinvent objects. When I think of the lifespan of an electronic device in the RAAN versus in the United States it has been rewired and reworked various times, buying it at least 10 more years. So when we knew that we couldn’t use the health center it was a simple transition to transform the school house into a clinic room with some simple equipment: one table, three sheets, two clothes pins, a flashlight, and a chair. I draped a yellow sheet edged with eyelet over the table and voila we had an area for examination. The clothes pins were used to hang a white sheet printed with climbing green vines dotted by delicate pink flowers to the side of the table creating a privacy curtain. I pulled an old-fashioned wooden school chair with built in writing plank to the side of the table and lined up the necessary supplies: lubricant, Pap smear kit, gloves. I dressed the flashlight in a latex glove to help me visualize the mysterious insides of the women that I would be examining. The bag of 40 sterilized speculums individually wrapped in torn white sheets held closed by masking tape sat to the side of my makeshift equipment table. Ready to begin.

Slowly but surely the women began to arrive, lining up outside the school house with curiosity. Elida would ask them their names, age, date of last menstrual period, and whether they had previously received a Pap smear in Miskito, and then pass them back to First Grade Classroom A for their exam. One woman after another came to receive her care, many for the first time in her life. I used my basic Miskito to ask them to climb onto the table, lie back and relax. The first few exams were quick and uneventful.

A woman, 68 years old, mother of twelve children came into the examination room. She wore a simple black polyester skirt, hemmed to hang at the knee, black cotton t-shirt, and hot pink bandana covering her long salt and pepper hair. She removed her undergarments and climbed nimbly onto the table. She didn’t complain of any pain or discomfort, she actually didn’t say anything to me, just got onto the table and lay back, knees bent and folded into each other in a shy, protective manner. I donned my gloves and prepared my field for the Pap smear, opening up the plastic case to reveal the glass slide, and inching out the wooden and plastic brushes that I would use to take the sample. I placed my hands gently across the woman’s knees and encouraged her to let her legs fall open. With a sigh of embarrassment she began to open her legs, and then shot her hand down between them to hide something. From between her fingers I could see the pale-peach color of something. It looked thick and muscular. I said some soothing words that I can’t quite remember because I was just as shocked as this woman was at what was hanging between her legs. As she lifted her hand it became clear that three-quarters of her uterus had fallen out from her vagina and sat between her legs. I slumped back into my wooden chair and let the image fully settle in. Now, I have seen uterine prolapses before. A bit of tissue protruding through the vagina, more so with a push referred to as the Valsalva maneuver. But, never in my life had I seen a prolapse like this. I could see cervix, discolored and dry, the upward curving of the upside-down pear shape of the uterus, and the thick muscular layers of the organ. I stood, removed my gloves, lowered the woman’s black skirt, and helped to lift her to a seated position.

“How long have you had this problem?”

“I noticed that it came down, and stayed down about two years ago when I was lifting a bucket of water. Before it would stay inside, but not now.”

Two years. Possibly longer.

“Does it hurt?”

“A little bit.”

I guided the woman outside to the community leader and had her explain in Miskito that she had a severe uterine prolapse and that she would need to be seen in the hospital in Puerto Cabezas. I imagine that the ObGyn will recommend a total hysterectomy. I can’t imagine that there is another remedy for a prolapse so severe.

I was shocked by the presence of this grave uterine prolapse, but by the time I lifted the skirt of the fifth woman whose uterus hung down between her legs it was less shocking and more disturbing. There was a pattern that I was noticing: older age, many, many babies, and a history of hard living with planting, hauling buckets of water, and hand washing. I imagine that in the history of these women there were also some prolonged labors with extended periods of pushing to get their babies out into the world. What began to stun me the most was how close these women were to the city, and yet completely isolated from general gynecological care. Two years? How does a woman cope with having her uterus bulging out from her vagina for two years? Why didn’t she seek care sooner? Is it the cost of bus fare to get to the city, the need to be at home to mind the house and children, or shame? Hopefully these five women will make the journey to Puerto Cabezas this Tuesday with the community leader to be seen at the hospital. Hopefully they will be treated with kindness and concern and not discrimination and ridicule for delaying treatment. Hopefully these women will receive the care that they need and live the rest of their days with more comfort and dignity.