During the summer of the year 2000, I was working on a women’s health project in Kosovo as part of the war recovery effort. One fine day, I had an appointment to meet Dr. Z., the director of a health house. A health house is a large facility that provides primary care to residents within a municipality. On the way, Sami, my driver, gave me lessons in speaking the Albanian language; I gave him lessons in American slang.
On our arrival, Dr. Z. greeted us with a warm handshake and grandly showed us into his office. Sami, who served as our translator, told me that Dr. Z. was inviting us to have coffee. Nothing happens in Kosovo before coffee—or, putting it more aptly, everything in Kosovo happens over coffee. Whether you are in a home, a school, or a hospital, you are always offered Turkish coffee. To decline is unthinkable.
I soon found myself balancing a miniature cup on a child-sized saucer and stirring the contents with a very small spoon. As I sipped the thick, black sludge, flashbacks of drinking mud tea at childhood tea parties danced through my head.
Dr. Z. was eager to learn more about my team’s work with the women from the villages. When I told him about the prenatal care we were providing, he expressed his deep gratitude with the comment, “This we have needed for so long, for our women to have healthy babies.”
We began to talk about gynecological care. I told him how difficult it was to diagnose and treat infections in the stark ambulantas (health care clinics located in rural areas) without a laboratory or even a microscope to guide us. Dr. Z. nodded his head with understanding. The dreary laboratory in his health house could handle only a few basic tests, and the microscope in the corner was gathering cobwebs, waiting for someone to be trained in its use.
The conversation turned to the subject of family planning. I explained some of the options available to the women, such as condoms, oral contraceptives, and intrauterine devices. But when I mentioned medroxyprogesterone acetate injections, his eyebrows shot up in alarm. Then he and Sami began to engage in animated conversation. I wondered what I had said to cause such a commotion.
Finally, Sami turned to me with a serious expression on his young face and said, “That drug will cause our women to be sterile. It will also cause tumors to grow in their bodies. Dr. Z. asks why are you giving it to our women?”
I tried to assure both Sami and Dr. Z. that medroxyprogesterone injections were safe. I told them that although a woman may encounter a delay in the return to fertility for as long as 18 months after discontinuing use of the drug, she will not experience permanent sterility. I told them that we inform the women of the possible delay and encourage them to use a different method of contraception if they want to conceive in less than a year. I also stressed that this drug absolutely does not cause cancer.
Dr. Z. put his coffee down with a clatter, abruptly left the room, and promptly returned with an open book, which he handed me with a questioning look. It stated that the US Food and Drug Administration (FDA) had not approved the use of medroxyprogesterone in the United States due to its possible carcinogenic effects and association with infertility. I was momentarily dumfounded because I knew with absolute certainty that this was simply not true!
“Your FDA will not even allow it in your country,” he stated firmly, gulping his coffee. “This is a book from my training, my own medical school. It tells me one thing and you are telling me another. How can it be both?”
Finally, the light of understanding dawned on me. I took a deep drink of the strong coffee, even though I knew it would cause a spasm in the back of my throat. I paused to consider how to best handle this delicate situation without embarrassing my host.
After a moment, I turned to the front page of the book, pointed to the 1981 copyright date, and explained that he was absolutely right. When he had attended medical school in the United States, the FDA had not yet approved medroxyprogesterone because not enough was known about it. But after much study, the FDA did approve its use in the United States in 1992. I rifled through my backpack and retrieved an informational pamphlet about prophylactics, including the injectable types, and handed it to him.
“The FDA has approved?” he asked suspiciously as he glanced through the pamphlet. I nodded my head, taking another sip of sludge. “And you, do you recommend it?” he asked with a small sip and a twinkle in his eyes. Steadily meeting his gaze, I replied, “I have recommended it to hundreds of women, even to one of my daughters.”
“Ah, my books are like me; they are old,” he sighed.
I had a book that I wanted to give to him and I promised to bring it with me on my next visit. He thanked me. “I would be so proud to have a new medical book. My English is not so good when I speak, but when I read, especially if it is medical, I very much understand.” Dr. Z. smiled broadly and sat back in his chair.
The only thing left in our cups was the fine ground sediment in the bottom. The meeting was over. I left the health house hoping that Dr. Z. would offer more contraceptive choices to his patients in the future and become a leader in educating his fellow Kosovan doctors. It could happen, perhaps, after he has read his new medical book—and after more conversations with clinicians from other parts of the world over miniature cups of thick, dark coffee.
By Nancy Leigh Harless, BSN, WCHNP
Reprinted with permission from Clinician Reviews. 2001;11(7):99-100.
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(Images provided by Nancy Leigh Harless. Image 1: Nancy with MCH medical team in Ferizai, Kosovo. Image 2: Nancy with Doctor Z in Kosovo.)