Two Years Not Three

Most of you already know that I am soon leaving Macha. My original job description was listed as 1-3 years, I planned on staying three, but am leaving after two. I really enjoy living in Zambia, but my work assignment has not been a good fit. As they say here in Zambia, I have experienced many “challenges”. I have learned much and made friendships which I hope to continue from a distance. In many ways I will miss my life in Macha, but it is time to go.

When I arrived to work in the PMTCT (Prevention of Maternal to Child Transmission of HIV) program, it had been going at Macha hospital since 2008. Much had already been accomplished. I have mainly focused my energy in areas that were being neglected due to too many demands on already understaffed departments. We have been able to improve tracking systems, documentation and data collection and most importantly advocate for more support from the hospital administration. A key nurse is back in the MCH (Maternal Child Health) department the primary locale of PMTCT. Staffing in this department is back up to three nurses (from two) and a support staff person has been hired to deal with the dbs testing (checking for the hiv virus in babies born to already infected mothers) documentation and data collection on exposed babies. If these pieces can remain in place, the program will continue to be a model in the province.

My decision to leave was actually made some 6 months ago, and so an exit plan was made and has been going quite smoothly. In November we hired Michelo a young man who will be handling dbs testing, documentation and data collection on exposed babies. Michelo was already a trained counselor who had been volunteering full time in our VCT department for over a year. We have worked side by side since then and this month he is mainly working independently. This has given me time to finish up a few side projects and focus on saying some good byes and begin the packing process.

A couple weekends ago I went out to the village to say goodbye to Cliff's family. I brought along homemade cupcakes which were quite a hit. I also left behind a few books for the kids to keep practicing their reading. The oldest two, Mary and Girl, were very eager to show off their school notebooks to me. It was a great joy to finally meet the youngest, Mercy, who had been staying with grandma during my previous visits. Being only 3, I thought she might be fearful of me, but this was not the case at all. Somehow she managed to get a hold of two cupcakes (one of each flavor!)

As I leave the country the good news is that the president has agreed to reinstate some 500 nurses who were fired for striking last fall. Not only had they been fired, but their registration was revoked. I have heard a rumor that many of them may be reposted to rural health centers instead of back to the city hospitals where they had been. Also still at stake is whether their accrued seniority and pension benefits will be reinstated.

The not so good news I read this week is that the Zambian kwacha is the poorest performing African currency at the moment. Second worst in the world (after the Ukraine). This seems to have come on rather quickly in the last few months. When I came to Zambia 2 years ago it was about 5 kwacha to 1 US dollar. It slowly went to 5.5 kwacha to the dollar but now all of a sudden it is 6.3 kwacha to the dollar. The price of copper is falling and also a new law was just passed in Zambia where everything must be paid for in kwacha. This law didn't affect normal people, we always use kwacha, but my understanding is big business (mines etc.) are forced to pay everything in kwacha also, even when it is a large bank transfer say for equipment purchase, utility bills, payroll etc. I believe this is demanding an increase in printing of local currency. Also the decreased availability of the dollar is playing a role. I am not an economist, I do not understand all these things, but this is what I have heard.

On top of all this, the rains seem to have been passing over Macha since February and the maize is drying up quickly. Only people who planted early will have much of a crop. Nearby areas have had good rains, but people here in Macha will be hungry this year.

The children have really become quite comfortable hanging out at my house reading, drawing, doing puzzles or playing UNO. Two boys were just here playing UNO and doing a jigsaw puzzle as I was writing this. (I so prefer the groups of twos and threes over the larger ones!). Anyrate, I will miss their company. Most households don't contain such items and after months of asking to take everything home, they have become used to just using it while here and then leaving. I have a whole cabinet dedicated to their supplies and they know where it is and are usually quite good at cleaning up after themselves (unless it starts raining........then they often take off running).

I will spend a few weeks in Europe on my way home, visiting friends (old and new) and hiking the Camino de Santiago. Should be back in the US at the end of June.

Thank you all for your love and support these past couple of years.

Peace,

Lisa

A Warm Christmas Day

My Christmas was bittersweet. I went to mass on Christmas eve with a co-worker at a small Catholic chapel here in Macha. We were a small crowd, 24 by the end including children. My friend Carol with her strong voice led the singing and rejoicing abounded. Afterwards we walked home in the dark silent night.

Christmas morning four of us gathered at the Books' house for breakfast before church. Then I headed off to Lupata BIC church a 30 minute walk away. It was a pleasant sunny day and all was quiet except for the birds. There was a bit of water in the river, but I easily crossed on carefully places bricks and rocks. The service was to start at 10. When I arrived at 10:30 there were less than a dozen people gathered. My friend Priscilla was there so we visited until the service finally started around 12. I was asked to give the opening prayer which was a first. Few people there speak English, so not so sure many understood. The young lay pastor (one of the youth of the church) decided to change the order of service and he preached first before the music. He spoke mostly in Tonga, but that was okay. Later there was music and skits by the young adults and middle schoolers. The young adults perform throughout the year, with a great choir. Church activities are about the only healthy outlet for young people who have finished high school but are not yet settled into family life. The middle schoolers though perform less often since school takes up most of their time. They are mentored by some of the young adults and it was fun to watch some of their enthusiastic but less perfected dance performances and skits. The young adults did the main Christmas story skit which was a series of scenes beginning with the angel speaking to Zachariah. They did a couple subtle things which I think made quite a statement. First the young men wore pink dress shirts while the women wore blue polo shirts for their choral outfits. During the skit, the angel was played by a young man. King Herod's two advisors were women and his two servants (who constantly fanned him and his advisors) were men. Lastly, the three wise men were three wise women. This was not due to a shortage of men, there are actually more young men in the group than women. I just think it was the youth trying to make a few statements. I was most impressed.

After all the performances we all got in line to receive salt. It is a BIC tradition (at least in Zambia) to give salt away at Christmas to remind us all that we are the salt of the earth. Then it was time for the feast. I went out back to sit in the shade with the women who had been cooking all morning and now would serve us all. We had chicken and nshima. The adults were served in the church and the children out back where I was. The chairman tried to get me to go inside with the adults, but I much preferred outside in the shade with the breeze blowing across the plain and the blue sky speckled with white clouds as my backdrop. After eating I helped the pastor's wife serve cake and coke to everyone. She had returned from RN school the day before and spent most of the night baking cakes to surprise everyone.

All and all it was a most pleasant and relaxing day. I walked home with a strong sense of gratitude in my heart for having spent the day in a meaningful way worshiping, feasting and sharing in a community of people. This sense of love and belonging prepared me for the shocking news that came to me that night via e-mail that my friend Rosemary Allen had died unexpectedly a few days before. She had recently been diagnosed with breast cancer and was undergoing treatment, but she was strong physically and mentally/spiritually when due to her suppressed immune system she contracted a rare infection in the colon. She went to the ER on Friday and died in ICU on Saturday night. Her husband, son, daughter and other family were at her bedside singing songs. Rosemary was a strong, vibrant, justice seeking woman who will be missed dearly. We had been in contact recently and were planning to do a hike together when I return to the States later this year. Now I will have to do that hike in her memory.

Meet My Heroes

Zambian nurses are my heroes. The challenges that they face between high demands of performance and documentation with the realities of their work environment (high patient population, lack of human and material resources, supply chain failures and institutional bureaucracy) are way beyond anything I have ever faced. They do their best with what they have at hand, yet are the ones on the front line who get the blunt of criticism that performance goals and accurate documentation are not being met. Some of the nurses get overwhelmed and just do the minimal to keep receiving a paycheck. Others go above and beyond the call of duty spending enormous amounts of their personal time caring for the population around them.

Zambia has a well-designed but poorly managed rural health system. A nurse may get placed several hours from the nearest town in places where transport is quite minimal. They are provided with housing, but this is often in poor condition. Many of these communities do not have electricity or indoor plumbing. The clinic will have a solar panel to keep the freezer running for storing vaccines, and perhaps a gas burner to help with sterilization of equipment. There will be pit latrines out back.

Often for a population of 10-15 thousand people there will be one nurse and perhaps a support staff (cleaner/admin assist) and a volunteer or two. The expectation is that you provide weekly under five, antenatal, post natal, and family planning clinics along with just regular outpatient clinics for sick people. Oh, and there is also usually a one or two bed labor ward which you must cover 24 hours a day (hopefully with the assistance of a traditional birth attendant). On top of this there is the expectation that three days a week you go out to one of your smaller health posts in surrounding villages to offer under-five, antenatal, and family planning services. Each health post is expected to be visited once a month. One of our nearby rural health centers actually has two nurses assigned to it, but one has been away at school for the last two years and no one was sent in her place. She is still considered assigned to the post and is expected to return on breaks and work.

Of course besides all the duties at the clinic, there are tremendous administrative tasks. Meetings and in-services to attend, monthly reports to fill out, vaccine and other supplies to order and sometimes collect from the district offices. With so much of the funding for health care coming from international donors, there is tremendous demands on documentation which are unrealistic for the realities at hand. Too much time gets spent on meeting these needs and it takes away from the practicality of providing the needed services. Decisions are made by people far away in big board rooms without input from these nurses on the ground who know the realities. It really can lead to high frustration levels and burn out.

A few examples of what I mean. The nurses understand the importance of preventing the spread of HIV from mother to baby. When a mother tests positive she needs a blood test done called a CD4 to see the extent of her HIV disease to determine if she can be on a single medicine regimen (which can be managed at the rhc) or full haart (three medicine regimen) which needs to be monitored at an ART clinic. These blood specimens need to be processed within 24 hours at a lab with the appropriate equipment. Many rural women do not have the money to get themselves to such a lab. For several years they have been trying to get a system into place by which a courier on motorbike would visit each clinic monthly on a scheduled day to transport these lab specimens back to the hospital and deliver the results. It is a simple system which the nurses keep advocating for, but the district health office has not managed to put into place. Most of these clinics already have environmental health techs who have motorbikes and go to Choma often and could transport these specimens, but bureaucracy keeps that from happening. One nurse I know took matters into her own hands and took the specimens herself to the lab at the district hospital only to be told they couldn't run them because no official procedure was in place yet with the district. The district had promised to set up a courier system and only then would they accept samples from outlying rural health centers!

There are two large problems currently which reflect highly on the daily challenges these nurses face. At the beginning of the year the Ministry of Health wrote into policy that all pregnant women will be put on life long haart (the three medicine regimen which requires closer monitoring and follow-up). This is a great decision, but the implementation is quite difficult for many of the reasons described above. The problem is the country has run out of AZT, the single medicine regimen given to pregnant women whose disease is not so advanced, and which can be managed at the rhcs. So now all the nurses at the RHCs can do is refer HIV+ pregnant women to an ART clinic for management. If the women can't manage to get there, then they will receive nothing to prevent the disease from transmitting to the baby during pregnancy. Full Haart is the long term solution, but until this can be safely implemented the AZT option still needs to be available or all the hard work to reduce the number of babies with hiv will slide backwards.

The second very frustrating thing in the PMTCT arena is that two months before the year ended the country ran out of reagents to run the lab test for early infant diagnosis in babies born to hiv exposed mothers. It was only last week with the new year that monies were acquired to purchase more. They have begun work on the back log of samples.

On top of all this, several hundred nurses were recently fired by the president after striking for a few days. In September the government had given large raises (up to 200%) to the support staff (cleaners and groundskeepers). This in itself was not a bad thing, but the nurses and other professionals such as pharmacists' salary increment was less than 5%. In hospitals this means that some support staff are making the same as a new graduate nurse. The nurses went on strike at two big hospitals in the country for a few days. The government agreed to remedy the situation in the next monthly paycheck so the nurses went back to work. The government did not hold up its end of the bargain so the nurses went on strike again this time at the main hospital again and two other bigger hospitals. Though they went back to work within a couple weeks, the president fired them for putting patients lives in danger. Now weeks later wards of hospitals are shut down and patient care is truly suffering but the president will not budge. The deputy Minister of Health died a few weeks ago of a heart attack purportedly suffered at the state house when he went to talk to the president about his actions and to plead on the nurses behalf. The president is planning on replacing these nurses with new graduates fresh out of school. Many of these nurses had years of experience, the best of them will get hired in the private sector and once again the public health system will suffer.

It is quite frustrating to see this as Zambia is a country rich in human and material resources. In my eyes it is simply poor management and corruption that keep the system from running well. Too many good people get frustrated trying to fix the system from inside and leave to work with NGOs or the private sector. In the meantime the health of the country suffers.

Where Are the Books?

I am a lover of books. At least since I have been an adult. My niece and nephews will attest to the fact that I try and encourage this love of books in children. They all know that Aunt Lisa gives books as gifts, no electronic gadgets from me. Luckily, they all have a love of books. Truly, what child doesn't. Books tell stories, and stories are exciting, I believe there is a natural inclination in all of us to learn, and if one can read, one can learn about any topic that grabs your interest.

During my five years in El Salvador, I always felt one of our biggest ministries was just spending time with children on our porch, encouraging their creative skills by providing scrap paper and crayons or supplying a few books for their entertainment. So it was natural that here in Zambia I would also have some books, paper and crayons and a few games on hand for the kids. It quickly became clear that the kids could not read in English (though it is the official language, the first three years of school kids learn in their local language). So thanks to another volunteer that was a teacher mentor, I got my hands on a set of early reader books in Chitonga that are part of the Ministry of Education's new literacy program. Unfortunately many of the children in 4th and 5th grade can still barely read in their own language.

Chitonga is similar to Spanish in that it is phonetical. Each letter, particularly the vowels, have only one sound. So, even though I don't speak tonga, I can help the kids read it, and pick up some vocabulary along the way. Besides reading with the kids here at home, I have taken to bringing the books with me when I visit the village. The other day I visited Mwanambiya village after going to church in Lupata. A friend had invited me over for lunch, and I was sure there would be some kids around. Sure enough, she had a 5th grade granddaughter who was an avid reader. She lives alone with grandma so gets some special attention I think. The other kids recognized the books and glanced at them, but quickly got discouraged. To my amazement, it was the adult women who grabbed onto the books and started to read them. At one point I was between two women in their sixties who were reading away out loud and sharing the stories with the rest of us. The younger women read to themselves, and only one teenager was showing off her reading abilities. It struck me how the literacy rate seemed to be poorer in the younger generations.

Recently at our team planning meeting I was able to speak with Aubrey Moono, a Zambian teacher who is the chair of our advisory committee. I shared with Aubrey my unofficial observations and concerns that literacy rates seem worse in the younger generations. He confirmed that it is not just a hunch, but a fact. He says this is because for many years, the curriculum kept changing. Whichever latest donor or expert came in with a new idea, the government jumped on it. Also he said for some years the government just gave money to the schools and let them buy their own books. Each bookseller had something better to offer than the next. In the end, the teachers got fed up with all the changes, and gave up. He also says when he was in school the focus in primary grades was on the basics reading, writing and math. Now he says they are teaching science and social studies etc to first graders and that reading is left behind.

Of course the other big critical piece is the lack of books! You are lucky if the teacher has a copy of the pupils handbook (teachers manuals are few and far between). The students never have text books and have to copy all the important notes from the board. Libraries are basically non-existent, but the kids are hungry for books. The other day three bored boys came by my house asking for cookies, but instead I gave them the chance to look through my box of books. One was in grade seven and tried to act cool and perhaps not so interested, but his two fifth grade buddies weren't worried about hiding their eagerness and soon they shared their excitement with him. A couple times the older boy suggested they leave, but the younger two weren't ready. Daniel with his 4 sizes too big trousers and terribly skinny arms was quite taken by a junior I Spy book and Brian with his bright yellow shirt and trousers that hit him mid calf was fascinated by the Zambian Atlas. Daniel found the alphabet in one book and was quite eager to recite it and Brian found the world map and was quick to find Zambia and also could recognize a few national flags. Neither one of them, however could read even the first level of books with 2 or 3 simple words per page. James, the oldest, could read these easy readers, but knew he should be able to read more, so would pick up the books with more words and act as though he was reading, making up the story according to the pictures. He had just finished sitting his grade 7 exams in English. I can't imagine how he will pass.

It is really heart breaking to see these challenges in a country with no war in its 50 years of independence, and relative wealth with plenty of agricultural land and many mineral resources including copper. Of course, as in the United States, there is a parallel private school sector with much bigger coffers and more resources but the large majority of Zambians at least begin their education in government schools. Only with support in the home environment is a student able to learn enough to proceed to higher education. Fifty students in a class is quite common and in rural settings teachers may have over one hundred students in their classroom. My friend Fannie has 112 students in her second grade class.

Aubrey says the Ministry of Education is coming out with yet another new curriculum. Fortunately the literacy program is staying the same. Hopefully the training of teachers in how to use the literacy curr and the supply of the kits to the necessary schools will quickly be implemented. For now, MCC is working on both of these things at the BIC schools where we sponsor our Global Family projects. I continue to read with the kids and am currently deciding where to leave my small library when I leave so that it will have the most impact on multiple children.

Beautiful Birds

Kori Bustard

Hello everyone! Thanks for being patient with me. I know it has been some time since I have posted. My parents came for a visit in September and we had a lovely time. They brought along a new camera for me with much more zoom power. I would like to share with you a few bird shots from my time with them in Chobe National Park just over the border in Botswana and several from my trip this past week to South Luangwa National Park here in Zambia. I hope I can figure out how to label them. Please enjoy (even those of you who aren't birders!). Pictures of other animals soon.

 

African Darter "Snake Bird"

Lilac-breasted Roller

Saddle-billed Stork

African Fish Eagle

Swallow-tailed Bee-eater

Grey Crowned Crane

Southern Carmine Bee-eater

Lilian's Lovebird

A few comments on the birds. The Kori Bustard, Saddle-billed Stork and Grey Crowned Cranes I have only seen a few of. The first only in Botswana and the other two only in Zambia.  I have been told that the Kori Bustard was a favourite food of the chiefs and was almost extinct before the first president after independence banned the killing of them. Note the yellow saddle on the stork's bill, thus the name. 

The Fish Eagle, Darter and Lilac-breasted Roller are quite common. The darter, a large cormorant, is called a snake bird because of its long neck.  The roller is as common around Macha as the robin is back home, but it's colors are so lovely, especially when in flight with it's royal blue and aquamarine blues shining brightly. You can't help but turn your head. The fish eagle has a distinctive call that often pierces the air especially near rivers.

The Southern Carmine Bee-eaters are probably my favourites. They are migrants who come here to breed. They travel in flocks of thousands and their beautiful red colour is a sight to see in the African sky. They build their nests in riverbanks. This colony was the backdrop for a pride of 21 lions feasting on  a dead baby hippo one morning.

The lovebirds and cranes are new species for me just this past week. The bright green of the lovebirds once again catches your attention in the bright sunlight.

This is all for now. The rains are slowly starting which is cooling off the weather. People are starting to prepare their fields for planting. Hope to post again soon.

Ndaamba Chitonga! (ashyonto)

A couple weeks ago I finally had the chance to formally study Tonga, the language spoken here in Macha and most of Southern Province. There are a few local dialects with variable vocabulary depending on which part of the province you are in, but the grammar is the same and one can be understood if you have that down. Kind of like British English compared to US English. Anyrate, MCC has three new couples coming into the country, two of which will be based in Choma (the town just an hour away from Macha where I go to shop), and the other will be our new country reps based in Lusaka. The Southern Africa regional reps decided they should all get some language study, and I was able to join also. Although my co-workers in the hospital all speak English, the patients, most young children and people in the villages around the area do not. It has been frustrating to not be able to have simple conversation with the moms I work with, the kids who come by my house and people I run into walking in the area.

It actually was good timing after 15 months of hearing Tonga and learning a few words and phrases, I was able to understand better how they all fit together. The main trick that was hard for my brain to wrap around is that verb endings don't change. The root, which comes at or near the end of the “word” has many prefixes which let you know, who, when and to whom or what the action is being done. In short, the heart of the word/phrase/sentence is towards the end, the beginning is the fine tuning. This is a characteristic of bantu languages which was quite foreign to my minimal language experience. Before arriving here, I spoke only English and Spanish. The other difficult issue for me is that there are over 15 classes of nouns in Tonga. Each class has its own prefixes for singular and plural and other words in the sentence must also have a corresponding prefix. That issue I am just going to have to fumble with for awhile. This time I focused on verbs and sentence structure.

Most educated adults in Zambia speak at least 4 or 5 languages. Many children speak 2 or 3 before they finish school. There are over 70 languages in Zambia, English is the Official language of the country, but there are 8 Nationally recognized languages of which Tonga has the second largest number of speakers. The Ministry of Education's curriculum is printed in these 8 national languages plus English up to grade 3, from there all educational materials are in English. You can imagine the cost this puts into any publication of news or health information campaigns for example when so many languages are spoken. The reason most adults speak so many languages is the mobility of the educated class. You may grow up in one (or two depending on your parents' jobs) areas of the country and learn the language there. Your parents may be from another area and speak a different language in the home. Or your parents may be from two different regions adding another language to the mix. Then, when you apply to school, high school, technical school or university, you may be selected to attend a school in another region of the country. There are very limited slots for higher education. You usually apply to several places and go where you get selected. The nursing school here in Macha usually has over 400 people apply for the 50 spots each year. Though you will be taught in English wherever you go, your classmates will be from many different regions, and as you shop and go to church in the surrounding community, you will learn that language also. Then, if you train as a teacher or nurse for example, the government will post you wherever they need you, irrespective of your language abilities. Therefore you may need to learn another language in order to communicate with your students or patients. Then there is a trade language in Zambia, Nyanja, that is used in the capital of Lusaka, and many people can speak at least a bit of that. So, for instance, if one of my co-workers is Bemba and the other Lozi and one or the other of them isn't yet fluent in Tonga, they may speak English with each other, or they may speak Nyanja. In the beginning they all sounded the same to me, but now I can at least tell if someone is speaking Tonga or another language.

I had a week long intensive course together with Jan and Kajungu. Kajungu is Tanzanian and Jan lived in Tanzania for 11 years, so they are fluent in Swahili and familiar with other bantu languages. Even though they were brand new to Zambia and Tonga, that put us on a similarly equal footing. Their familiarity with Swahili allowed them to understand the basic structure of Tonga. It would have been the same for me, for instance if I was trying to study Portuguese, already knowing Spanish. We studied 4 hours a day for 5 days with Uncle Jebby. Uncle Jebby has worked with the Peace Corps for the past 15 years helping orient their 100 volunteers a year to Zambian culture and language. He has mostly taught Bemba, Nyanja and Kaunde, but has recently moved to Southern Province and is beginning to teach Tonga. He was a great teacher. It was his first time teaching such an intensive course and he was impressed with how well we did. Usually he deals with people brand new to the country and things move much slower. We focused a lot on conversation. It is so nice to speak with someone trained in the art of speaking to language learners. He would speak slowly and repeat things and use simple words and phrases while also trying to keep the conversation real.

The hymns at church suddenly have more meaning and I can get the general gist of what people are saying to me and I am trying hard to use simple sentences on a daily basis and look over my notes each night. I am so happy to have had this opportunity and window into being able to speak with people in their own language. Now I just have to keep the self-discipline going. I am supposed to get together with Uncle Jebby for a few follow-up appointments, so that should be good also.

This past weekend I rode my bike out to Halwiindi village near Nemfwe to visit my co-worker Cliff's family again. I figured it would be a good place for me to practice my Tonga. I brought along a few of the beginning reader books from the Ministry of Education's Literacy program. I keep them at my house for the local kids to read and also use them myself to help with my Tonga learning. 8 year-old Mary and 4 year-old Chris were there to read along with me. After a quick wash of the hands, they must have spent two hours looking at the 5 small books I brought along. After reading them to them a couple times, Mary put herself to memorizing them. Chris just enjoyed holding them (often upside down) and making up his own stories. Books are so rare in Zambia, even in the schools. Teachers usually write most things on the board and students copy them. Even the young men at the house(late teens, early 20s) were picking up the books and trying to read them.

I was able to eat lunch with Chinyama, Cliff's wife, this time, because Cliff was at work. That was really nice to sit and chat with her a bit. She has very good English, but was happy to oblige me with a bit of Tonga and helping me practice a bit. She finished grade 12, but did not do so well on her exams. She says she needs to resit biology and math to be able to apply to nursing school, which is her dream. She is hoping to resit this next year. Currently Chinyama volunteers each morning as a cleaner at the nursing school. She has been doing this for over a year now in hopes of getting a job when one opens up. Her husband, Cliff, worked almost three years as a volunteer before getting his position. Volunteer here does not mean you come in once or twice a week. It means you work on a daily basis. There are many full-time volunteers at the hospital. People are so desperate for work they will do this. It often pays off, but not always. Remember, it is a 40 minute bike ride to Macha from their village. Cliff bikes to work, but Chinyama walks. Chinyama says she likes to read, so I told her I would bring a few books next time and she could pick one to borrow.

Patient Stories

So, for some time now I have been wanting to write some stories of some of my patients. Some are stories of frustrating struggles that paid off in the end, and some are stories of the lengths mothers will go to for their babies.

HIV here in Zambia, as around the world, still has stigma attached to it, but that is slowly changing. When the ART clinic first opened, patients were allowed to register with false names, and doctors saw patients after hours or at their homes. Over the years, however, led by a few with the courage to share their status openly, the stigma is breaking down. People greet each other in the halls of the ART clinic, share their status with visitors and openly come to VCT for testing. Occasionally you still find the nurse in charge seeing people in an office so the patients don't have to be see waiting in the halls with the other patients or you might hear of hospital staff dying of AIDS because they refused treatment, but not so frequently. There is denial, fear of family or friends finding out, the belief that herbal remedies or faith healing will work better than imported ARVs. A whole host of reasons why people refuse treatment. Luckily in Zambia, there has been lots of training of lay counselors who talk with people about hiv, give them information and encourage them to make wise decisions about their diagnosis, treatment and lifestyle. Many of our counselors are hiv+ themselves, they make the best counselors as they can speak from experience. Recently I was reviewing with some of our counselors a couple cases in which our persistence paid off.

L was a 19 year old with her first pregnancy. She came for prenatal care when she was 5 or 6 months pregnant. We drew her CD4 and it was only 57, (below 200 is considered AIDS and below 350 you are put on lifelong HAART.) Despite this, she seemed healthy and strong, and maybe that contributed to her refusing treatment. Several of us met with her and talked to her and pleaded, but she was fearful the people she was staying with would find out (she was not married). When the CD4 is so low, the viral load is very high and the disease is very contagious. Finally one of our nurses convinced her to take AZT which we usually give to pregnant women with CD4 counts over 350. It was better than nothing, but we didn't think it was enough. It was not until after the baby was born, that one of our counselors who is hiv+ herself with 2 children was able to convince L to start on full HAART. L knew this counselor and her children, and the counselor revealed her own status and that her children were hiv – after she took HAART during pregnancy. Finally L was caring for herself and hopefully there was still a chance the baby would not get infected, but I was doubtful. The baby's first DBS done at 6 weeks came back negative, very good news. Then came the 6 month test, still negative, it was beginning to feel like a small miracle. Just the other day L came in with 10 month old S who is weighing in at 9.8 kg! Quite large by Zambian standards, he looks like he is nearly 2. L and I can't speak to each other, but the way she looks at me, I know she realizes what a good thing it was that she came around for her and her baby, and I am sure she is grateful for all our concern and persistent nagging of her to get on board.

Another story is of a woman who did not come for prenatal care till she was nearly 9 months pregnant. Turns out her husband (a friend of one of our counselors) had been hiv+ for three years but had never told his wife. As we ask women to come with their husbands or partners to their first visit, so they can both be tested, it was probably his reluctance that kept them away so long. They both tested positive and we put mom on AZT while we waited for her CD4 results. They never came back for those, and by the time one of our counselors went to their home to find them, she had already delivered. If a woman delivers at home, but gets to the hospital within 72 hours, she and the baby can still get meds that will decrease the likelihood of transmission to the baby. 5 days had already passed, it was too late. The mom's CD4 was low enough to warrant her to be on full HAART, as was the husband's but he was refusing treatment and she didn't want to start without him. We tried to work with her and encourage her to go on treatment despite her husband to protect her and the baby. At first she refused, but eventually after a few weeks she came in on her own to begin treatment. The baby didn't look so healthy to me, and I was concerned perhaps the virus had already transmitted, so we had mom and baby open files at ART. I am happy to report that this baby also has had two tests come back negative, and mom continues on treatment despite lack of support from her husband.

Two babies that I have been following were diagnosed about the same time. A's mom tested negative during pregnancy, but later when the baby was a few months old, he fell sick and entered the hospital. There mom was tested and came back positive. For over a year we have been testing all patients in maternity and peds (the mother/caregiver if infants are younger than a year). So a dbs was performed on baby and it came back positive. Unfortunately, before we got A on meds, he got quite sick again and was admitted for TB and malnutrition. People must be on TB meds for 2 weeks before they can start HAART. I visited A and his mom a few times a week and prayed for little A. This was mom's only child and one of the doctor's told me he had a 50/50 chance of pulling through. He was running a fever and very lethargic. We don't do IVs on kids here, because we don't have machines to control the amount of fluids going in and fluid overload can cause too many problems in small children, so mom's have to work hard at keeping the kids hydrated. A was put on antibiotics, antiparisitics, analgesics and later the TB meds and then HAART. So many meds for this little body. He spent days just laying still, I remember going in one day and seeing him holding a balloon animal someone had given him. He wasn't playing with it, just holding it as he lay in bed and looked at mom. I was unable to speak to mom, but I would bring food and stay for a few minutes, somedays he seemed better than others. Eventually he got better and went home. Mom lives quite some distance away, but thankfully she lives with her parents, so she has some financial and emotional support. She didn't lose all her crops while spending weeks in the hospital with her son. She has had frequent clinic visits over the last few months as A needs to come to both the chest clinic and the ART clinic for meds. He started his TB treatment on 4 meds, now he is down to 2. For HAART he is on 3 plus a prophylactic antibiotic. I can't imagine mom keeping track of all these meds and working on feeding this wee one with all the other tasks in life. One of the meds he is on for hiv is very bitter tasting and lots of babies spit it back out. Mom has been expressing her gratitude to several of us in the clinic by bringing gifts of food. I have received two live chickens, a bunch of groundnuts, some sweet potatoes and a large papaya. Recently she made an extra trip to the clinic for a med refill as there would not have been enough to get A through the long holiday weekend. He had just had his one year birthday, and I bought him some clothes and a little toy car. He is still a bit timid around me (understandable with all the poking and prodding he has been through) but he was quite eager to hold the car and push its wheels round and round. He is still quite skinny, but seems quite long, so I think his growth is picking up.

A's mom tested negative during her pregnancy, but was never retested. We have started retesting pregnant and breastfeeding women every 6-8 weeks, because hiv is most contagious when you are first infected and then years later when your CD4 count starts dropping. We hope to catch women as soon as possible after they are infected to better prevent transmission to their babies.

There is another mother in a similar situation, though her baby M is a few months older, and never got quite as sick as A. However, he was in the hospital and is also on TB meds as well as HAART. Mom and M came into the clinic one Friday for meds. She was two days late for her appointment because she rides 60 kilometers on her bike (with M tied onto her back) to get to the clinic and she had had a breakdown on the way. This would mean finding a place to stay in the nearest village until parts could be found and the repair made. Fridays we don't see patients in the clinic because we do mobile clinics on those days. So if patients show up, it takes us a bit to find a file and then a clinician to see them. As they were waiting, I could here mom talking to M and his playful, happy laughter like that of a healthy toddler. It was quite heart warming.

M's mother tested positive but had a high CD4 count. She received what we call short course, AZT during pregnancy and then 2 other meds during labor followed by the baby receiving Neveripine while breastfeeding. While this course of meds, if administered correctly reduces the transmission rate from 35-40% down to 12-15%, some babies, like M are still infected. As of this year, we have started putting all hiv+ pregnant women on life-long HAART. This reduces the transmission from mother to child to less than 1%.

A and M are doing well, having gotten on treatment early in life, but our goal is to prevent more such cases. With these new methods, we hope to do just that.