My First Week in Macha

Hello everyone. Sorry for the delay in a new post. Our internet here in rural Zambia was down for three days. I imagine it may be a not too rare occurrence during my time here. Really, when you think about it, it is quite amazing that I have internet access at all, let alone wireless!  Life is much more luxurious here than in war torn El Salvador in 1990. Water is usually off most of the day, but so far seems to be coming on at night. We'll see if that lasts during the dry season. I have buckets of water in my kitchen and bathroom which I keep filled as back up. It is not uncommon for electricity to go out, especially at night. One night when I was ironing it must have gone out three or four times.

Anyrate, on to bigger and better things. Despite the initial challenges this week of figuring out who my direct supervisor will be, what my orientation will consist of, and what my final job description will be, things are beginning to come together. The nursing officer (head nurse of the hospital staff) was out when I arrived, but was back for a few days at the end of the week so my schedule for this next week is set.  I have started Tonga lessons. So far I have learned to greet people properly, which is a very important part of Zambian culture. I will have my second lesson later today.

Just yesterday I also started tutoring with Mrs. Sitali (the principal of the nursing school here) in preparation for the General Nursing Council exam which I must take at the end of May. Apparently 50% of foreigners fail the exam the first time they take it. Our first session was very informative in regards to how the exam is scored and what expectations there are in the responses. 75% of the score is based on 3 essay questions related to specific patient scenarios. Terminology, including names of diseases here are different than in the US. For example thyrotoxicosis is hyperthyroidism. Also, immunization schedules and other standard practices and protocols are different here than in the US. It's been 25 years since I've taken an exam, time to clear away the cobwebs in the recesses of my brain and refresh my old knowledge and make room for some new information.

On Wednesday of the past week I did outreach with Maternal Child Health (MCH) to the village of Humbbwatu.  Two nurses besides myself, a PMTCT (Prevention of Maternal To Child Transmission of hiv- the area I am focussing on) lay counselor, the data entry person and the cleaning woman from the department all went. I was impressed at how informed and active everyone in the department is in interacting with the clients. We were to leave at 11, we left at 12:20. When we arrived, all the mothers were gathered under a big shade tree by the rural health post and the local lay health workers were providing a short education session on PMTCT.  Soon we were introduced and Mrs. Mabeta, the charge nurse spoke to the crowd and then Granma, the cleaning woman spoke.  This was all in Tonga, so I couldn't understand, but there were lots of questions asked of the mothers to make sure people were understanding the topic. Granma was very animated and got the woman laughing. When the education portion was done, there was a quick market (such a gathering is a good chance for local people to sell their wares). I bought bananas for myself and lusaulo (sp? pronounced rusaro- an "l" is pronounced as an "r" would be in the US) a local root which I was told my Tonga teacher loved.

After this, we divided up in teams. A local health worker weighed the infants under one tree. One nurse and the PMTCT lay worker vaccinated the under 5 kids under the main tree. Inside the health post Mrs. Mabeta and Granma did the antenatal checks on the pregnant women. I went with Vernon, the data entry person, to a small side room to do the PMTCT counseling and hiv testing with the newly pregnant women and their husbands. There is a big emphasis in Macha to get the fathers involved in this area. The pastor of the main Brethren in Christ church here in Macha is actually sponsoring a workshop on the topic for all the men of the church today.

Vernon, myself and the lay health worker sat on the three chairs. The three couples and one woman whose husband didn't come (there was a note presented from  a headman to explain his absence) all sat on the floor around us. I was not completely comfortable with having pregnant women on the floor and myself in a chair,  but it is part of the culture here. There is a definite status hierarchy and places and times when it is not appropriate to question it. Vernon did all the counseling in Tonga and every once in awhile would tell me the current topic.  He tried to include me as he could. The counseling is quite thorough. We all talked together for probably 90 minutes before signing consents and testing. He spoke of hiv (prevention, transmission and treatment), family planning, nutrition, child rearing, hygiene. He asked lots of questions and seemed good at drawing out answers even from those reluctant to participate. The couples were all young, mostly in their 20's. Thankfully the test results all came back negative. After testing, Vernon brought them back in as couples to give them the results. The relief on some of their faces was evident. The women will continue to be tested every three months during pregnancy.

After we were through, we got to eat nshima and greens brought by a local woman to thank us for coming. Yum! A good way to finish the day. We were back at the hospital by 5 (or 17 hours as Zambians say).

On Thursday I worked with the senior nursing students in the ART (antiretroviral therapy) clinic screening room. We mostly saw patients who had been on ARV's (hiv meds) for several years. We would record their vitals, ask if they had any complaints since their last visit and check to see if they have been taking their meds correctly. Macha uses all the national forms for the ART clinic, but has added their own which measures a patient's adherence (compliance). We review their pill count from their last visit, see how many pills the pharmacy dispensed to them, then calculate the number of pills they should have taken since then. The patients know to bring their pill bottles with them. We then count how many they have left. If their adherence is less than 95%, they are sent for  counseling before seeing a provider.  It is a pretty thorough system that people seem to adapt to well.

In Zambia hiv+ patients do not start on ARVs until their CD4 count is less than 350 (there are some exceptions which I won't go into right now). The CD4 count indicates the level the immune system is working at. However, people who don't yet qualify for ARVs are started on prophylactic septra (an antibiotic) and multivitamins. This gets people used to the idea of taking meds on a daily basis in preparation for taking ARVs in the future. Poor adherence can lead to failure of treatment and resistance. People are not put on ARVs until they can prove their ability to adhere to the regimen.

Okay, this is a lot of info for one post. I think I will stop here for today.