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.

South Africa

It has been over a month since I last posted, and much has happened. I was able to visit South Africa. MCC hosted its regional retreat for Southern Africa just outside Durban December 13-19th. Currently MCC has workers in South Africa, Lesotho, Swaziland, Zimbabwe, Mozambique and Zambia. Those of us at retreat came from 13 different countries on 5 different continents, our ages ranged from 3 months to 60+ and I can't begin to count the number of languages spoken between us. We would have bible study and workshops half of each day and then free time the other half. Most people spent their free time at the beach. There were a handful of us who were birders and went to a local golf course/birding area nearby several times. We all went to a local community Christmas caroling event one evening. The odd thing to me is how often I hear songs with cold and snow mentioned in them over here in Africa. In the evenings we would play games or watch movies. The last night we had our own services of carols followed by communion. It was good to step away from the grinds of daily life and reflect on the reasons we feel called to service. I shared a room with four other women, so there was not much personal space, but it was good to compare stories with others dealing with similar challenges and struggles that come with working and living in the region.

Prior to retreat, I traveled to Cape Town for a few days of vacation. That was lovely. There was so much to see and do and I had only three full days. I climbed Table Mountain and visited Robben Island where Nelson Mandela was imprisoned for 27 years. I visited the V&A waterfront and the Kirstenbosch botanical gardens. There are inexpensive tour buses (with headset commentaries in 9 or so different languages) that take you all about town and beyond. You can hop on and off at different sites as they run on a schedule and pick up at designated sites like a city bus would. I also walked along the shore line several times. Cape Town is a beautiful place with lots of history and a friendly feel. To me it felt like a wealthy version of Havana (shore line, historical architecture, political history of struggle, diversity of people) with a sprinkle of Portland's community spirit (taking care of the earth, sensitivity to homeless people, local cultural events). Considering that less than 20 years ago black Africans could not even vote and political apartheid and was still the norm, it is amazing where this country is today. I hope to get back to Cape Town again and see and learn more.

I returned from South Africa (with a head cold) in time to celebrate my birthday in Lusaka with this year's four SALTers (one year service workers in their 20s). Traveling on the buses around the holidays can be hectic, and with my cold I didn't know if I was up for the task, but I wanted to be back in Macha for Christmas. Thankfully my trip back went smoothly and I was able to settle in to my own space and see friends over the weekend before starting back to work on Monday.

Christmas day I went to church in the morning. It was raining hard, and people must walk. I was 15 minutes late and the second person there. An hour after the service was to start, we were posting notes that the service was cancelled when people started coming. So into the church we went to hold the service. An hour later we actually started with two men on the altar, two men and five women in the pews along with 30 or so children (our choir and skit producers).  By the end of the service an hour and a half later, there were perhaps 50 adults and 50 children. It was a small service, but full of heart.

That afternoon I gathered with 7 others. There were 4 from the US (one Jewish), three from the Netherlands and one from Zambia. We had a wonderful potluck feast and then some stayed around to play games.



I hope your celebrations with family and friends are blessed this season.

Flying Termites! Yum!

There is an interesting phenomenon this time of year in Zambia. After a big rain, the termites sprout wings and fly to any light source they find. They will sneak through any crack around a window or door and land in your food or the sink or on the floor.  If you manage to keep them outside with a strong porch light, it will be hard to get in or out without getting them in your face, hair and house. Overnight their wings drop off and they head off in pairs to mate. I swept up quite a pile one morning just on my 3'x4' front porch. You end up tracking in the wings like you would leaves or pine needles. People eat the termites themselves. It is a good source of protein. They put buckets of water under lights and let them collect and die. Then they spread them out to dry. Another neighbor has a whole counter full drying (these are just the ones that got into her house). You fry them up and eat them. At our recent MCC meeting here in Macha we tried it out. We had smores for dessert but said no one could have chocolate until they tried out the inswa (the Tonga word). At first the boys balked, but once all the adults ate some (they taste like popcorn to me), and the 20 somethings teased them, they gathered their courage and tried them.

So, if you come to Macha this time of year for a visit, you too can give them a try!

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.