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.

Visit to Nemfwe

It is the dry season now and I am determined to get out on my bike and visit some of the neighboring villages. One Saturday a couple weeks ago I went out to Nemfwe, a village where my co-worker Cliff lives with his family. It took me about 40 minutes each way. Cliff had told me more or less how to get there, and I asked along the way and didn't have too much of a problem finding it. However, when I arrived, no one was home. A neighbor boy named Joseph told me they were probably out working in the field (it is harvest time) and he was able to find two young girls to escort me out there. I was only able to get the girls' names and that they were in 4th and 2nd grade. I offered (in sign language and English) for them to sit on my bike and I would push them, but I don't think either of them could ride and I couldn't get them to understand that I would hold onto them. So we just walked and I pushed my bike. When we eventually arrived at the field Cliff and his family were taking a break from harvesting the maize. I was given a glass of chibwantu (a fermented maize drink with maize chunks in the bottom) and a sweet potato. I was introduced to Cliff's wife Chinyama and we chatted briefly before I joined them for a bit removing the husks from the maize which was drying in an upright pyramid shaped stack.  Soon we headed back home with Chinyama and I biking and the others walking. We arrived back at their home and I met young Mary who is in 2nd grade. Chinyama stoked up the fire in the kitchen, an area with a half wall and a grass roof. She put water to boil (for the upcoming prep of the chicken they would kill on my behalf) and set off to clean the outhouse. As I sat waiting with Mary staring at me, Girl, another daughter of Cliff's also in 2nd grade, came along carrying a bucket with 2 or 3 gallons of water on her head. Her eyes wide at the visitor, she called Mary to come help her lift the water from her head and place it on the ground.  Quite something to see these two spindly girls who couldn't weigh more than 40 pounds each struggling with this bucket of water, but you could tell they were used to it. Girl came and sat briefly with Mary and stared at me while discussing amongst themselves. Soon Girl remembered her task at hand and went back to get another container of water waiting at the nearby pump.  Mary and I sat and fed the baby ducks. We would chew up pieces of maize and then spit them back out for the 1 month old ducks who had been abandoned by their mother. She was still around, but not caring for them. At night they put them to sleep with the baby chickens. During the day the two run around together.



Cliff has a whole collection of animals and enjoys calling them and feeding them. Before he returned, Chinyama had fed the fowl just enough so that Astridah, Cliff's younger sister could grab the chicken we would have for lunch (she succeeded on her first try, I was impressed by her technique). When Cliff arrived, however, the whole brood was fed. Chickens, pigeons, guineafowl (including an albino), ducks, and pigs. They also have dogs and a few cows.

I had brought some papaya (pawpaw) to share and Chinyama pulled out some ground nuts for all of us to shell for me to take home. So I sat with Cliff and the girls and shelled groundnuts while Chinyama and Astridah worked on lunch in between shelling groundnuts. At one point we took a break to eat the pawpaw. Cliff brought out a radio and hooked it up to a small solar battery so we could have some music. A big feast of nshima, chicken with tomatoes, and greens was made. I ate inside the house with Cliff in front of the solar powered TV which was showing a soccer match.



Both Cliff and Chinyama have  12th grade educations. This is rare in rural Zambia. Only around 40% of students continue after grade 7 and of those only another 40% continue on after grade 9. There simply are not enough schools, and so at each of these grade levels, there is a national exam to select those with the highest scores to continue on. Yet, with grade 12 educations, Cliff is working as a general worker/cleaner at the hospital and Chinyama is working as a cleaner at the nursing school. They bike 40 minutes each way to work each day.  The other night Cliff, who works in Maternal Child Health didn't get home till after 8:30pm as they had gone for outreach to another village and returned late. He says he biked home by moonlight.



All and all it was a lovely day in the village. I need to make such trips more often. The hospital compound where I live can become like a college campus, a bit secluded from the outside world.

Just the other day I got a brief glimpse of Mizinga, another nearby village when I helped an older woman haul some water to her house. She walked with a major limp, scoliosis or a short leg would be my guess, and she was struggling with a five gallon bucket on her head which, although it had a lid, was still spilling down her back due to her limp and one of her hands being otherwise occupied carrying another jug of water. I just happened upon her on my way home, and offered to help. She readily accepted. I merely took the smaller jug, but this freed up her other hand to help with the load on her head. We were walking on a slight incline and the ground along the path was not even. I could hear her breathing hard, so slowed my pace to a near crawl. Slowly we made our way with frustratingly minimal conversation as my tonga is just not coming along. I could not believe how far she walked to haul this water. After a good kilometer or so, we came to her village as night was falling. All the neighbors were shouting at her about her “beenzu” or guest. As it was quickly getting dark, I carried her water into her house and then she escorted me back to the road where I could more easily find my way back rather than on the paths we had taken. The next day I asked some co-workers who live in this village about water supply there. I was told there is one bore hole for 1000 people and you have to wait in line 2 or 3 hours for water. One of my co-workers said she has to pay someone to wait in line for her. This rather large village, with no electricity and only one water source for 1000 people, where people still cook over open fires and use pit latrines is located just just a few minute walk from the hospital compound. Granted, we aren't living as one does in the first world, but we have electricity 90% of the time and water about 50% of the time which allows us to fill up water storage containers for bathing, washing dishes and clothes and flushing the toilet when the water is off. Next door to our compound is the Macha Research Trust compound where they have electricity all the time (they have a generator when there is a power outage) and running water all the time (including hot water!) I guess we are a little microcosm of the world with our differing economic levels living side by side. Many of the people who work at the hospital come from the villages nearby. They bring their phones to work to charge them (as do the patients for that matter!).

Finally an Update

Wow! Two months without writing. What can I say. It has been a busy time. I have worked on a post that I hoped to have up by now, but it requires some approval by other people and we haven't coordinated yet.

My work at the hospital has been overwhelming at times and with my personality I am having troubles drawing boundaries and learning to say no. My physical and emotional state are suffering, however, and I have been forced to make some changes. I recently had my annual review, though with very minimal input from the hospital.  With the MCC reps I have decided to take Monday and Friday afternoons "off". This really means missing a total of 5 hours a week on the slowest patient times. It will actually just serve as comp time for all the work I do from home on weekends and evenings. We also agreed I will try and find someone to provide me with some spiritual direction.

A friend loaned me a book by Brennan Manning entitled The Relentless Tenderness of Jesus and I have found it a Godsend.  I am working my way through a Compassion Fatigue workbook that a visitor from the Meetinghouse BIC church in Canada sent to me. I also just finished The Uncertain Business of Doing Good; Outsiders in Africa, which is a frank discussion of some of the concerns I have about what I am doing here. Africa is a continent that for a long time the West has seen as a place to meddle, be it as colonialists, missionaries, aid workers, entrepreneurs, researchers, scientists or government consultants. Not all consequences of this are good even when intentions may be.

So, this is not to rain down doom and gloom to you all, but only let you in on a little bit of what I have been going through and why posting to the blog has been such a challenge of late. This has been a time of growth for me, just not always so pleasant.

Two recent pleasant things were Easter weekend, a 4 day break from work. After a stressful Holy Thursday when I was told to spend nearly $5,000 before the end of the day (end of the fiscal year in the US where our PMTCT monies come from), I attended Good Friday services. The phone network was down for nearly 48 hours and my internet was down for almost 24 which really only helped me to have a reflective weekend. On Saturday, a whole group of expats hiked to the top of the closest thing we have to a mountain in these parts. Then on Sunday morning we had a sunrise service at the dam followed by brunch. Later in the day after church I got to visit with four young women from Choma (two with MCC and two with BICWM) who had come to Macha for the weekend. Then there was another full day off work.

Just last weekend, MCC held its spring retreat at Lake Kariba. It was almost a full day's drive each way, but our time there (2 days and 3 nights was restful). We even got to swim in the lake which I was told you couldn't do because of crocodiles and bilharzia (a waterborne disease carried by snails). It was nice to see another part of the country.

The rainy season is officially over. The rains ended a bit early this year, so the people who planted late will not have a good crop, but those who planted early will be ok. Everyone is eating mealies (fresh maize on the cob before it has been allowed to dry and harden). I have joined my friend Mulenga and her sister Bwalya (here on school break from university) several nights roasting mealies on the brazier in her back yard.

I now have a fence around my garden and Titus has planted green beans, peas, lima beans, carrots and strawberries so far. He has a nursery going of green peppers, tomatoes and cabbage. Watering is a bit of a trick as right now I only have water in the evenings and he works two mornings a week. I help him out a bit.

I had planned a camping vacation to see some waterfalls in northern Zambia, but not enough people signed up to make it work. So now, at the beginning of May I hope to take a few days at a nearby lodge located in an IBA (Important Birding Area) and conservation area/game farm. Some friends were recently there and highly recommend it.

I include three recent photos of God's amazing creatures. A moth (or butterfly) that spent three days in the same spot on my back porch. My first ever chameleon (Zambians have very strong negative cultural beliefs about chameleons so one has to be careful when wishing to handle them) and a camouflage frog able to turn white. The last two were seen on retreat at Lake Kariba a large lake that was formed when a dam was built in the 50s in order to create hydroelectric power. Tens of thousands of Tonga people were displaced. I read that all the power is sold to Zimbabwe.

Changes in My Work

Since the beginning of this year, I have branched out of the Maternal Child Health department where I was devoting most of my time and have embraced two other areas of my job description.

First I am working more in the ART clinic. I am helping implement some changes to hopefully improve our care and tracking of pregnant women who attend ART clinic and their exposed babies. Some of this work involves what we call DBS (dry blood spot) testing. Most hiv testing involves a simple and inexpensive antibody test that involves a finger prick and a test strip. However, young infants may carry their mother's antibodies in their blood stream up until a year of age. Therefore, an hiv antibody test on an infant may give a false positive. Early infant diagnosis is done via a DNA test where they test for the actual presence of the virus and not just for the antibodies.  The testing procedure is similar to the PKU tests done on infants in the US. A heel or toe is pricked and drops of blood are applied to circles on a paper card which is allowed to dry for 3 hours before being packed and shipped to the lab (in our case to Lusaka) where the test is performed. The turn around time for us is usually a couple months by the time we gather the sample, take it to Lusaka, then return a month or so later to pick up the results. The Ministry of Health is implementing a text messaging system whereby they will send the results to us by phone which hopefully will get them to us quicker.  I am the point person to get this new system off the ground in Macha, try and work out the kinks etc. I just dropped our first batch off at the lab a few days ago. We will see how soon the results come.

We started performing DBS tests at Macha in 2008. A spreadsheet was designed to keep track of all infants who a test was performed on over the years and the long term outcome of the patient (died, started on ARVs, transferred out, file closed after being confirmed hiv-, or lost to follow up). Over the years, with the quantity of work at hand, the spreadsheet has not always been top priority. There was also some erroneous shifting of data which has created problems in the accuracy of the information. I have been working on getting this spreadsheet up to date and accurate. It is a bit tedious, but it will allow us to better track the trends of different treatment protocols and tell whether or not our care is improving the lives of patients or not.

Another aspect of my job description which I am finally getting a chance to attend to, involves visiting RHCs (rural health centers) out in the villages. Macha Hospital has a catchment area of 160,000 people. There are 14 RHCs (including our outpatient department (OPD) and maternal child health department (MCH) which make up what is called a HAHC (hospital affiliated health center). Each one of the RHCs in turn has several smaller health posts affiliated with it where they go for monthly outreaches to do health education, hold under 5 clinics (weight and immunizations), antenatal clinics, and family planning clinics all in one day. For example, the HAHC here at Macha has 9 health posts under it. The MCH staff visits each one of these health posts once a month.

Some hiv+ pregnant women come to the ART clinic for care, but others are seen at the RHCs. Since these RHCs provide many PMTCT services (antenatal  care, voluntary counseling and testing, labour and delivery, and care of exposed babies) we want to improve our coordination with these centers to help improve the quality of care to hiv+ moms and their babies in our coverage area.

One key part of PMTCT care which the RHCs cannot do is assess pregnant women for the staging of their hiv disease in order to properly treat them. Access to a lab for CD4 counts (to show the extent of the disease and its response to treatment) and tests to assess and monitor kidney and liver function (which can be adversely affected by the arv medicines) is a big limitation for providing full care to HIV+ women at the level of RHCs. The RHCs must resort to referring their patients to us. Then there is a communication break down as far as getting info back to the RHCs regarding the patients they refer. There can be finger pointing on both sides with the ART clinic saying the RHCs aren't doing a good job of following their patients and the RHCs saying the ART clinic is stealing their patients and not sending back info on the referrals they sent our way. By visiting these RHCs and building relationships with the nurses there, I hope to facilitate conversations and plans about how to improve this situation so as to better serve our clients.

Change can be a hard thing to implement especially when there are so many players. I hope we can be successful over the next couple of years to get a system into place which is sustainable with the resources at hand.

So, work can be tedious and not very rewarding on a daily basis, but occasionally there are those bright spots which lighten ones heart. Just the other day I got to hold a bubbly 4 month old baby named Arnold. He was born to an HIV+ mom and they were in for a med refill for Arnold. He was babbling and trying to stand and weighed in at a hefty 6.4kg. It is so nice to see a healthy happy baby anywhere, but to see a healthy happy baby born to an HIV+ woman in rural Zambia is just that much sweeter. To know that the regimens we are implementing are giving Arnold a chance at a life without HIV and his mom the chance to parent a healthy baby are very rewarding indeed. I was able to hold and play and laugh with Arnold before putting him on his mom's back to be wrapped for the trip home.

The New Year

Blessings on your new year!  For some, including a few dear friends of mine back home, this year has already brought challenges in the form of physical illness or injury. Whatever joys and challenges may come your way, may you all have the grace, strength and support to face them head on.

My 2012 was filled with more challenges than I expected, many of which I did not share in my blog. However, things are shifting and 2013 is already feeling more sustainable and satisfying especially in regards to my work. At the beginning of each year, the hospital shuffles staff. Though it is sad to see some co-workers leave, I'm excited that my friend Mrs. Bakasa (who I work closely with on PMTCT monthly and quarterly statistics) will be returning to the in-charge position in MCH. She was previously in charge for 6 years, then was pulled to Maternity this past year. She is organized, hard working and committed to the patients. Her presence in MCH will allow me to focus more in ART clinic and out in the villages.  I have had recent good conversations with my supervisor and other higher ups regarding my plans for the year in regards to some changes in my work.

I also recently moved out of temporary housing and into what should be my home for the rest of my time here. I am still acquiring furniture and figuring out the best place for things, but it feels like home already. I'm working on getting screens built for all my windows. So far only the bedroom ones are finished, so I usually close the rest of my windows when I am not home, and at night when the lights bring in the insects.

It is rainy season which adds a different element to life. It is hard to dry clothes. Heavy rains flood rivers and keep people at home. The dirt roads get rutted and turn into small lakes in places. Carrying an umbrella becomes a must. Learning which paths are low lying or engulfed in tall grass is important. So far, I have not fallen in the mud, but I did buy a pair of rubber boots in town the other day to make walking to work less stressful.

I've been enjoying sweet corn and green beans from the garden and bananas from the yard, but in general it is a rough season for garden vegetable growing. Everyone is busy tending their maize fields. My neighbor has a plot which is towering over my head already. Sweet potatoes are also being planted here and there. The school year started this past week, so the students are getting back into their routines.

I miss the snow more than I thought I would. If you have some where you are, romp about a bit in it for me!

I include some random pictures of life in Zambia; the bus station in Lusaka, hospital laundry drying on the line and some of our nursing students prepared to go out to the village for outreach.