The Heart of the Matter

This post is way over due. I have struggled with how to present the situation of HIV/AIDS here in Zambia in a way to do it justice and for you to understand it on a deeper level.

Statistics tell part of the story, individual stories tell another part, but you can't leave out the cultural, social, economic and political factors both locally and internationally that play a part in this crisis here in Southern Africa. I highly recomend a book called 28 Stories of AIDS in Africa written by Stephanie Nolen, a journalist from the UK. She does a beautiful job of weaving all these complex pieces into the stories of 28 individuals from heads of state to rural children. She includes stories of doctors, scientists, pastors, grandmas, truck drivers, prostitutes, activists and nurses. For those who won't have a chance to read the book, here is my atempt at a snapshot of what I have come to understand during the six months I have been in Zambia. Most of my statistics come from the United Nations.

In 2011 there were 34.2 million people around the world infected with HIV. 23.5 million of those (69%) are in sub-saharan Africa. There were 7000 new cases a day in 2011, 97% of those occurring in the developing world. Zambia's overall prevalence rate is 14.2%. In pregnant women it is higher, 25% in urban areas and 12% in rural areas such as Macha for an average of 16%. In 2008 when the prevalence rate was a bit higher (16.4%) Ministry of Health data showed that 80,000 infants per year were born exposed to the HIV virus.

The most recent stats show 150,000 children in Zambia under the age of 15 are infected with HIV. 90% of these cases were caused by maternal to child transmission either during pregnancy, delivery or breastfeeding. The goal is to get maternal to child transmission of HIV below 5% in exposed babies by 2015. Then we will start speaking of elimination rather than prevention of maternal to child transmission. This is done by focusing on early enrolment for antenatal care (by 14 weeks), testing of both parents for hiv at the first antenatal visit, and early access to arv meds for those mothers who test positive. Mothers who test negative on the first visit continue to be tested every three months through out the pregnancy and breastfeeding period. Exposed babies also receive preventative arv treatment after delivery, some until they are weaned from breast milk. When mothers and infants are treated by these guidelines, the transmission rate is quite low. (Less than 1% in babies whose mothers are on the full lifetime regimen of arvs and around 12% for babies whose mothers are in the earlier stages of the disease and receive only a short course regimen during pregnancy and delivery).

I hear during the 90s there were funerals every day. As it is, I have personally heard of about 6 people who have died of AIDS here in Macha since I arrived in April. I'm not sure how people made it through those times, but the effects are still reverberating through the country. Almost every family has "dependents" orphaned relatives they have taken in to raise. Sometimes these dependents are treated equally, other times not. They may have to work more around the house, they may receive less support for their education (go to public school vs. private or have to miss more school to help at home), their clothes may be of lower quality than the other children in the household. There is an NGO term for these children, OVCs (Orphans and Vulnerable Children) and there are programs to try and benefit the most at risk, paying their school fees, helping the extended family to help them, but they really are quite at risk for abuse and neglect.

ARVs (antiretroviral medications) have changed the face of HIV/AIDS around the world and a bit belatedly here in Africa also. People who have access to and adhere to treatment are now living with HIV instead of dying with AIDS. The ART clinic here opened in 2005. One of our first pediatric patients is now expecting her first child. We have several women who have had 3 children while on ARVs all of whom have remained HIV free. Not all cases turn out as well, but it gives hope that the crisis can be transformed and a future generation may be HIV free.

There are so many stories to tell, but I will leave you with two scenes I saw in the ART lab one day. I don't have a set work space, so I will sometimes grab a corner of the counter in the lab to sort through some charts. I looked up at one point to notice a young girl come in alone with her lab sheet and take her spot on the bench next to the adults waiting to have their blood drawn.  This young girl looked to be 9 or 10, her hair was neatly braided, her bright colored chitenge suit (fitted top and skirt made from the same chitenge material), was clean and pressed, she looked as if she were dressed for church. When it was her turn, there was still no adult by her side. She just moved to the chair and held out her arm. She was what we in the medical world call "a hard stick". The lab tech had to stick her at least three different times and still didn't get the blood he needed. Each stick she held perfectly still, stuck out her arm and just squeezed her eyes tightly shut. She never made a sound, except maybe an intake of breath. Afterwards I went and spoke to her and between my limited Tonga and her limited English learned her name and age. "Grace" was 10 and in the 4th grade in a town several kilometers from Macha. I saw her later in the hall outside pharmacy with a woman who looked to have been her grandmother. At that point Grace had 500 kwacha (10cents) in her hand. Later I saw her heading out the door with a lollipop. We greeted each other both times. The poise and joy that Grace possessed were quite inspiring to me.

A bit later a mother came in with an infant tied to her back and a 6 or 7 year old daughter holding her hand. Once again, they all were dressed in their best. First the mom calmly supported the young girl while she had her blood drawn standing in front of and leaning into her seated mother. This little girl shed a few tears but recuperated well. Then mom had her blood drawn, then she pulled the sleeping infant around to her lap to have his blood drawn as well. The scene went like clock work. It struck me how "normal" it looked, just a regular visit to the doctor. In fact, it is all so unjust. This mother most likely became pregnant with her older daughter not knowing she was hiv positive. If she lived near Macha during that time, even if was tested and knew her status, there were no meds available back then for her to prevent transmission to her baby. So the daughter is now also living with HIV. The infant will have a much better chance of being HIV negative as now his mother would have had full access to meds during her pregnancy with him and he will be followed till 6 weeks after he is weaned to verify that he is not infected. On the slight chance he were to be infected, he would immediately have access to hiv treatment.

I leave you with these snapshots.

PMTCT Training

 

Well, after three weeks without internet access, I think the situation is finally fixed thanks to my fellow MCCer Ingo. He was able to get the dongle I purchased work with my ubuntu operating system! Thanks to him I should be in more regular contact.

I had my first official training in PMTCT (prevention of maternal to child transimission of hiv) last week. There were three of us from Macha hospital who went. Two midwives from maternity and myself. The people who led the workshop are with AIDS Relief, a conglomeration of NGOs who work with hiv care in Zambia. The workshop was coordinated by Catholic Relief Services. There were participants from two other Mission Hospitals, one run by the Sisters of Charity and the other I think run by the Sisters of the Holy Spirit. There were also people from a church affiliated organization that runs clinics in Livingstone and Lusaka.

It was good to meet other people from different places and hear how they do things and get new ideas for how to improve care. The workshop used to be two weeks, but due to budget cuts, they condensed it into one. That meant there were certain things we only touched on briefly. There was a big emphasis on counseling and education which I am glad to see. People need to be informed if they are going to make good choices for themselves and their babies. We also went over documentation and the myriad of registers and reports we are required to fill out. It was good to get clarification on many things.

We stayed at Tooter's Golden Pillow Lodge. How's that for a name? It actually was quite nice. We each had our own rooms with small bath, a fridge. There was tv and ac. The ac was only working part of the time because of the low voltage and power outages, but it was nice to have warm running water 24 hours a day to shower whenever I wanted. We were on the outskirts of a town called Monze. I walked into town a couple times, but the evenings were pretty low key. If I had had internet, I would have had plenty of time to catch up with you all. As it was I read, knit, studied a little Tonga and watched a lot of soccer and rugby games. So much so that I now understand rugby more or less. CNN was also showing at times, so I watched the 2^nd presidential debate, heard about the shooting of the school girl activist by the Taliban, and saw coverage of the awful bombing in Lebanon It was ironic, I had just met a Lebanese man the night before at his restaurant. The last evening we had a party and the Zambians all wanted to see the makuwa (white person) dance, so I indulged them to great hoots of laughter! Here it seems 95% of people are born with the ability to sing, dance and keep time. It was a good week, but I missed Macha and was glad to get home. Have been catching up at work.

It was nice that Wednesday was Independence day. A day off mid week was good especially since I had been gone so long. It has made today, Saturday much more productive for me. Zambia is 48 years old as a country. God-willing I will be here for the 50^th anniversary of independence. That should be an exciting time to be around.

Just a quick post to let you know I haven't forgotten you. The rains have begun here in Zambia. I have had a good strawberry harvest and the mangos are ripening. Hope you all are well as your seasons are also changing.

Busy! Busy! Busy!

These are the words my Zambian co-workers use when they pass through a room with me pouring over registers and trying to get PMTCT documentation up to date.  I'm not sure if it is their way of affirming my work or their way of telling me to lighten up a bit.  Either way, I hear it a lot these days. 

The last few weeks have been busy.  There was the National Measles Campaign which I was not directly involved in, but which consumed the Maternal Child Health department  where I do most of my work.  All week long the nurses would gather there and prepare their supplies for the day before heading out to rural communities and vaccinating everyone between the ages of 6 months and 15 years.  They were also tacking on Vitamin A (to prevent blindness) Mebendazole (for deworming) and polio vaccine (though I think we ran short of that).  There were some communities they had to return to the next day because the response was overwhelming.  They ended up extending the campaign into the first part of the next week.  Besides the mobile clinics, hundreds were vaccinated right in our clinic.  We had lots of crying babies and kids all week.

The following week, there was a Trachoma campaign.  Trachoma is an eye infection which can cause blindness with repeated infections over one's lifetime.  Apparently the health district we are a part of has a high incidence, though I've heard the hospital sees so few cases they have a hard time teaching the interns what it looks like.  Regardless, we were part of a pilot project which is trying to eradicate the disease by treating everyone with a one time dose of zithromycin.  They had tall handmade wooden sticks which were colored coded to tell by a child's height how much medicine they should get.  The adults all got 1gm.  I heard that some who took it on an empty stomach suffered from vomiting or diarrhea.


We had a couple dozen nursing students here for three weeks from Livingstone.  Their time at Macha was their "rural experience".  There was usually 4 or 5 of them in MCH on any given day. There was also a group of Dutch medical students around the hospital, though I haven't seen them much.  This past week a group of nursing students from Indiana Wesleyan have arrived for three weeks.  It really is amazing how the hospital absorbs all these students for learning experiences when we already have our own nursing school and students.

We've had lots of "visitors".  Visitors is the term Zambians use for high officials of the Ministry of Health or NGOs who come to check up on our work.  You can always tell when they are coming because instead of the calm slow pace of the start of an ordinary work day, you come in to find almost everyone there on time and everyone running around straightening things up etc.  Similar to work places in the US when JAAHCO, OSHA or the Health Department are expected.

The entire hospital had a performance review by the Ministry of Health this past week.  The same day they arrived, the Aids Relief people came to check in on our PMTCT work.  I was unaware they were coming, but was grateful for their visit as I was able to learn things and get answers to some questions.  I was also able to participate in a meeting they had with the Community Health Workers.  These are the volunteers at the village health posts associated with our MCH department.  I had been wanting to meet face to face with these workers and start to understand the realities of their work and see how we could work hand in hand.  These workers have been trained in PMTCT, and besides counseling and educating people in the community, they also help track and notify hiv+ moms and exposed babies who have defaulted in their care.  I was able to get their phone numbers and hand them a list of the moms and babes from each of their regions who needed to be contacted to come in for care.  Hopefully, I then can get feedback from them to fill in some of the gaps in information I have.  They usually know these women by face and name and where they live.  They often know details of their personal circumstances which can help us provide better care. They are a crucial link in the PMTCT program.

Tomorrow I leave for a one week training in PMTCT.  It will be my first formal training and I am looking forward to it.  Betty and Grace, the two women who were here this past week with Aids Relief will be teaching the class to health care providers.  It is being held at a hotel in a town a few hours from here.  I hope it goes well.

Chobe!

Well, I finally did my first tourist thing here in Zambia.  I was invited short notice to accompany a pediatrician, who had been volunteering here at Macha for a month, on a weekend trip to Livingstone to see Victoria Falls and go to Chobe National Park in Botswana for a two day one night safari.

The falls were beautiful, though a bit dry this time of year on the Zambian side.  The safari was incredible, and well worth the money. I saw around 60 species of birds, most of these during our first morning riverboat cruise where one of our guides was quite informed about birds. Of the 60 some species, all but half a dozen or so were new for me. (I hope to update my bird list soon, I have been having quite a bit of internet problems of late.) We saw lions, buffalo, crocodile, giraffe, zebra, baboons, elephants, wart hogs, monkeys, mongoose, many types of antelope, hippos, water monitor lizards, and a jackal. (I hope to put a complete list at the bottom of this post for those interested in more details.)

It was so amazing to see these animals in their natural environment.  Our guides were great and gave us all kinds of fun facts about the animals.  For instance, wart hogs and hyenas will share dens since one species is diurnal and the other nocturnal.  Water monitor lizards are the crocodiles worst enemies because they eat their eggs.  Crocodiles can live up to 120 years.  Giraffes spots get darker the older they get.  Hippos, though living in the water, eat only grass and when they defecate, they swirl their tails and their feces spreads out in the water to feed many species.

We saw thousands of impalas, they became quite common to us, but I became more and more fond of their elegant markings, they became one of my favorites.  We saw a two-month old baby elephant nursing and a newborn baboon (still with dark hair and bare pink ears) clinging to its mom.  We had a close encounter with an elephant who came to within 5 feet or our vehicle (their eyesight is not very good) before sniffing us, flinging its trunk, turning its head and walking off. Some of the most scenic sights were just looking out over the plains near the river and seeing hundreds of zebra, antelope, giraffes, wart hogs and baboons all mixing together or seeing in the distance long columns of elephants heading across the flat to the rivers edge in the heat of the day. We laughed at the giraffes getting a drink of water and were struck silent by the sight of several lions awakening from their days rest as the sun set and heading out for the hunt.

We saw a total of 13 lions in two different groups.  One group had a large male several females and a scruffy 2 1/2 year old male with only the beginnings of a mane.  The other group was all female. There were a couple elephant carcasses near our camp (closer than our guides let on), so we heard lions all night long calling with their deep guttural sounds. Thankfully there was a full moon so trips to the letrine during the night weren't so scary.  In the morning we drove to the elephant carcasses and the big male lion and one female were still feeding with many vultures waiting in the trees for the lions to get tired and go to bed for the day.  The lions ran away when we approached though the female quickly returned to feed on the baby carcass.  The male with his muzzle still bloody from feeding kept at a distance.  The female would keep an eye on the vultures and the adult elephant carcass as she was feeding on the baby.  Occasionally, just like a house cat, she would pull up short, settle down on her haunches and then bound towards them and chase them away.  Then she would return to the baby carcass some 25 yards away and continue feeding.

An interesting note of our safari participants is that we were largely volunteers.  Amy and myself from Macha, a Peace Corps couple from Botswana and a VSO couple from Choma. Both couples had adult children visiting them.  There were also two women in our group who were volunteering with a lion conservation group in Zambia.

Many of you have asked when would be the best time of year to visit.  If you want to go on safari and see the animals, September is best (perhaps August and October as well).  This is the dry time of year when the animals can't hide in the grass, and a time of year when most water sources dry up and they need to head to the river once a day for water.  Though other times of year would be good for the falls.  I have heard that Victoria Falls is one of only 3 or 4 places in the world where you can see a moon rainbow.  On a full moon night in the rainy season when there is plenty of water and mist at the falls, apparently you can see moon rainbows.

I must thank my friend Amy for some of the pictures in this post.  Her camera had a better zoom and better definition, so some of the shots are hers.

New Girls Hostel

Yesterday was a big day for the community of Macha. It was the official opening of the girls hostel at Francis Davidson High School. Unlike most high schools in Zambia which are boarding schools, Francis Davidson is a day school. The students who come from far away must find their own lodging, and this leaves the female students particularly vulnerable and their enrollment and academic performance are much lower than the male students. Also, their drop out rate (often due to pregnancy) is much higher. The teachers, students, church and parents have all expressed the need for a place for the girls to live for years. Typically this is not the type of project that MCC helps with, but they kept asking, statistics were produced and the female students wrote letters about their experiences and their need for a dorm. The funding was raised from three groups of people.  A large BIC church in Canada called The Meetinghouse, several BIC churches in Pennsylvania and friends in Winnipeg. The project was finished on time and within budget. The PTA made all the bricks locally in the community. You could sense the ownership of this new building.

Lots of government and church officials were present for the several hour ceremony. A tent was even rented for the guests of honour to sit under. Parents and teachers found shade under a few trees, but most of the students were out in the sun. There was singing, traditional dancers, many speeches, a ribbon cutting ceremony and a tour of the hostel. When it was all finished they served all the guests lunch. It was an exciting day.

There are still some finishing touches. The outdoor kitchen needs to be built for the girls to do their own cooking. A house for the matron needs to be built and a good water supply connected. Mattresses and curtains are still missing, but some of the girls are moving in on Monday. The entire hostel which will house nearly 60 girls (only three toilets and three showers to share amongst them all!) cost $40,000.

Over the last few weeks, as I have mentioned the opening of the hostel to people in conversation, several of them, especially women leaders in the community would comment on how needed this hostel is and what a benefit it will be for the girls. There are over 200 female students at the school. The girls had to apply for a place in the hostel and a committee of about 6 people (teachers and church leaders) chose the most needy (usually those from farthest away with no family locally to live with). Hopefully the benefits of this new hostel will be sensed soon, you can already sense sighs of relief.

Not a Good Patient

So, I was down sick this week, again. I think this is the third illness that has caused me to miss work since I have been here.  My co-workers are all very understanding and tell me I need to be home resting, but I have a hard time, sometimes listening to what my body needs. Thankfully, I am able to do some work at home on my computer since I am involved in a lot of data gathering and management. I had a cold that started about 10 days ago. Able to work the first couple of days, rested over the weekend, went to work Monday (a mistake) home Tuesday and Wednesday, back Thursday (sent home by my co-workers) and stayed home Friday. My energy is finally picking up today, Saturday. I guess it is just a whole new germ pool that I need to get used to and build up some immunity to. Mentally it is a challenge for me to be ill. A true test in patience and grace.

There were some good things that came out of the week. I was able to read most of two books. Shake Hands with the Devil, about the Rwandan genocide and failed international/UN attempt at stopping it. Not light reading, but an eye opener. Then I am almost finished with Unbowed, the autobiography of Wangari Maathai the late 2004 Nobel Peace Prize winner who started the Green Belt Movement in Kenya. She has lots of perspective and insight into the Africa of today and what has contributed to it's state in today's world. I had known of her briefly for her environmental work, but she is an all around inspiration of peace and justice in the world. In seemingly simple grassroots ways, she connects all the important pieces of the puzzle to the complex world we live in today.  As one of the first African women to receive a Phd, she used her opportunities for the betterment of her country and the world and stood up nonviolently to some pretty powerful people and institutions along the way. What a loss to this world her premature death was. I highly recommend this easy read. Fun fact for those of you from Kansas City, Wangari went to undergrad at Mt. St. Scolastica in Atchinson, KS in the 60s and worked at the lab in St. Joseph's hospital in Kansas City during the summers.

I also was home one day when Bridget, a woman from the village of Lupata stopped by selling her beautiful hand made baskets. The quality was excellent. I couldn't believe when she told me the price of just under $3 US. These baskets would have sold for $60 or $80 in the States. She understood enough English to tell me where she got the grasses/reeds (from two different neigboring towns) and to tell me that it takes her two days to make each one. Once my Tonga is better I hope to visit her at home and learn more about basket making. I paid more than the asking price for the basket I bought.

I also have been cared for by my neighbor Jaeron who has been bringing me food here and there and just checking in on me.Which is very sweet of her considering she has to listen to my coughing all night ( she and her husband share a duplex and a bedroom wall with me).  One day, she hollered through my window "Lisa do you want to go on an adventure?" She had a big butcher knife in her hand and led me to the banana grove in our backyard. She had spotted a bunch of bananas that the birds were getting to so she had me do the honors of cutting down the whole plant to get to the bunch. They have ripened beautifully and I am sharing them with friends.

Maria, Patricia and Racheal

I want to tell you about three new faces for me. I will start with Maria. I was taking a walk one evening through the dry brush near the water tank when I heard pounding and conversation so I turned off my path and found Maria and Naomi sitting on the ground with legs out in front of them pounding away at white quartz rock turning it into piles of golf ball sized pieces to try and sell. They had old feed sacks wrapped around their chitenges (colorful wraps women wear here as skirts) to protect them from the flying rock shards. Both Maria and Naomi had to have been in their 60s. Luckily Maria's English was pretty good, she even pulled up from her memory the word slab when I asked her what the rocks were used for (the concrete slab which a house is built upon). I have also seen them used in landscaping/mud removal or prevention around buildings. The rocks are natural in this area, sticking out where erosion occurs and just needing someone to dig down and break off big pieces or pull up large rocks.  Maria worked at the hospital for 27 years before retiring. She was using a sledge hammer and Naomi was using some old piece of metal from a vehicle of some sort that had a heavy head. I shivered to think of the shock their hands, wrists and arms were absorbing which each blow of the hammer against the rock. Maria told me it took them three or four days to make a heap and they could sell it for about $12 US. I thanked Maria for answering all my questions and let them get back to work. I keep meaning to go back (with my camera) and visit again, but I have not made it.

Patricia is a 12 year old seventh grader who loves to read! This is a rare thing in Macha. She quickly moved on from the children's story books I have and is borrowing some old children's encyclopedia's that were in the house when I got here. She borrows one at a time and usually brings them back the next day. While here, she often picks up some of the adult books on the shelf and browses through them asking what certain words mean. Winter, precious and souls are a few that come to mind. She also likes to look at my map of the world. She seems to be a sponge for new information. Patricia is the youngest of three girls I also am one of three girls. From there our similarities part. Patricia's father died four years ago, her mother three years ago. I am assuming from AIDS, but I have not asked. Patricia was raised in the Copperbelt an area in the Northwest of the country where the primary language is Bemba. When their parents died, the girls were split up. Her oldest sister now 17 is in Kitwe with friends. Her other sister 15 is with an uncle in the town where they grew up. Patricia was sent here to live with her grandmother. It is just the two of them in their home. She says they get along. I have not met her grandmother yet, but hope to soon. Patricia seems to mentor some of the younger children around and so far is a young twelve, not trying to grow up too fast. I look forward to getting to know her better these next few years.

Finally I want to tell you about Rachael, the most vibrant one year old I have seen yet in Zambia. Rachael's mother has hiv, and we had called her in because her last CD4 count was under 350 indicating it is time for her to start full HAART, a three drug regimen that she will be on for the rest of her life. Because she is still breastfeeding Rachael, this is even more important. As the head ART nurse was talking to mom and explaining her lab results and the next steps, little Rachael was wiggling and smiling and clapping and flirting with me.   Rachael has been taking Neveripine daily since birth and a daily dose of prophylactic antibiotic since six weeks of age. She was due for her one year hiv test.  I carried Rachael next door where the testing takes place with mom close by. Thankfully she tested negative. I just could not get over how active and engaging Rachael was. Most babies that age are pretty stoic and observant around here. Rachael's love of life was contagious and we were all laughing at her at some point. Mom is not married, but you could tell this baby was getting lots of love. I asked the nurse to ask mom who all lived in their house. Sure enough, mom still lived with her parents. So this little one had three adults to love her up, and it showed. So many kids have stressed out parents with many to take care of, you could tell this little one had lots of one on one attention. I hope I get to see more of her.