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.