The effects of loss

Zambia, like most of sub-Saharan Africa, has a shockingly high HIV rate. Estimates of the prevalence in Lusaka are around 22%. To put that number in perspective, when you ride the minibus with 20 other passengers, 4 of them have HIV. Anyone who lived through the 1990’s in Zambia saw HIV and AIDS sweep through the population like wildfire. Everyone has lost friends, children, siblings, parents, spouses to the disease. When antiretroviral drugs hit the mainstream, it changed the virus from a death sentence to a cumbersome, but workable burden.

You can get any of these statistics out of a textbook. What you can’t get are the individual stories, or an understanding of how this seems to tie into the psychology of the population. A coworker, Mr X, once told me about his own family. X was the middle child in a family of 6. His younger brother got sick in the early 2000’s. After his brother backed out of it for many months, finally his family forced him go to the clinic for an HIV test, but his brother returned to the family and told them it was negative. More time passed; his brother got sicker. Eventually, he came to the family and he confessed he had AIDS. He died a few weeks later. His children are now being raised by X alongside X’s children. As he tells me this story, about denial and fear, X’s anger at his brother is palpable. He is frustrated, and he slams the steering wheel with his palm as he makes his point. As we near our destination, X confesses that he is afraid for the future of his own children, who are growing wild and rebellious, skipping school and drinking. He worries they will catch the virus themselves, or not be able to work without an education.

Another evening, I am sitting, talking to a white man (we will call him Mr Y) from South Africa. He tells me that he believes AIDS is a disease of stupidity. Y says that the disease is the consequence of a society that fails to be disciplined, that has fallen prey to bad behaviors. I suspect that many Americans would agree with him, deep down. I ask about the culture that emphasizes marriage and children as the ultimate expression of womanhood for young girls, who get married at 15, 16, 17, and who are relatively powerless in their roles to ask their husbands to wear a condom (nor perhaps do they want to, as large families are desired almost universally across Africa). He scoffs at this. He tells me of South Africa, where the prevalence is as high as 1 in 2 people, when sex education presented the choice as a either a condom or a gun to your head.

So, what does this do to a culture, the slow, quiet terror of those years, the mass sense of grief? When 20 years ago, 1 of every 4 people died of a disease which still continues to cut down those around you? When you were raised in a generation that lost their parents? Combine this with an official unemployment rate of 70% and an abysmal poverty rate? You can start to see how the future might become an abstraction, with the likelihood of an early death being almost a guarantee. Maybe you start to live only for the satisfactions and distractions you can afford - driving fast, alcohol, sex. The prospects that drive other populations to work steadily and go to school, like retirement, devotion to a craft, or savings, these become nonsensical. 

Just think about that for a while.

On the meaning of purpose

I’ve been spending a lot of time in Africa thinking about what to do with my life. Lately, I’ve been reading some of the blog writings of a Buddhist physician (happinessinthisworld.com), which has been giving me a lot of interesting food for thought. In one of his posts, he discusses the importance of finding a mission in life, and how we might not even realize what sort of core mission we have, but there is something intrinsic that guides our movements whether we have actively selected it, or whether it is unconscious. I thought about these words all day, and during my run, I tried out his mind exercise for finding your mission. Strip away all of your explicit statements about your purpose in life, one by one. Determine your emotional reaction as you lose them.

In my last big effort to determine what I wanted to do with myself, I had come up with my personal philosophy: I want to help others achieve their goals, whatever those are. I believe (and I still do), that you are not able to pursue your personal goals if you are impeded by health. Cure the disease, and you free the body to follow the mind. These statements give me theoretical and philosophical motivation for my life. But do they give me that day to day purpose that he was speaking of? Not really. It’s hard to get up every morning motivated by a goal that is achievable only through years of work. So, what does get me out of bed? What will be enough of a push to believe in my work every day, when I’m tired, when I feel like crap, when my (hypothetical) family needs me? As I jogged along (don’t judge me, but listening to Shakira’s Waka Waka, which has been stuck in my head), I was forced to admit that what gets me going are two things. The first is an interest in other people. Understanding them, hearing their stories, becoming a part of their lives. After all, I was an anthropology-cum-psychology major years before medicine. Not in a voyeuristic sense, nor dispassionate observation, but directly related to a feeling of empathy. The “why” of a life is of great importance. Secondly, I believe in completing things (and doing so well). I find great satisfaction in this process. I feel this in medicine when I see patient through a visit through a hospital, when I write a paper, or when I finish a painting. It’s all the same sense of, “I played a role in that, and I made it better than it was before.” Self-centered? Maybe. But it works for me.

What do I take away from this? Well, I’m deciding on residency in a few months. I know that if the above are true, I need to hear your story, and I need to take an active role in your care. So, that rules out most of the surgical subspecialties, ER, pathology, radiology (stories being hard to come by in those departments), as well as referral-based care (e.g. family medicine or general primary care), neurology, and psychiatry (as seeing an illness completed and being active in care throughout is not as likely).  I have a feeling that either a medical or pediatric (or med-peds) subspecialty is coming my way. Anyone know of a job opening for a med-peds endocrinologist who does global health?

10 lessons for living and working in Zambia

Coming up on the halfway point, it’s a good time to summarize what I’ve learned during these months.
1. How to speak Zambian (trust me, it’s English, but you say the same thing in American English and you’ll only get blank looks):  

• Add inflection in the middle of a sentence. Then pause. Then answer your own question-that’s-not-a-question. For example, on how to ask a group how to treat pneumonia, “And we have learned that the right drug is?...Erythromycin.” This also applies to less sensical sentences, such as, “Shoprite closes at 18 hour on a? Sunday.” Really.
• Add an “EY” sound (like the EY in key) to everything that ends in a consonant. It applies to all sorts of words: with (with-ey), have (have-ey), and so on.
• Say EEsh! instead of sounds like Aww, or similar expressions of sympathy and frustration. This one is going to be hard to get rid of when I go home.
• Multi-purpose mmmmm’s are useful when listening, asking questions, denying a possibility, or responding in the affirmative. Change the note = different meaning.
• Unexpected shortened verbs: I hope to chance him at the office later = catch him in his office if he’s there; I’ll pick you at sixteen = I’ll pick you up at 4 PM; we are used = used to it.
• Use “these guys!” as an expression to cover all manner of annoying, slow, or frustrating people.
• Start sentences with “me,” despite later use of a clear subject, as in, “me, I like to eat cheese.” 

2.        When arranging for a meeting, you must never, ever, ever forget to include tea break with biscuits and softies (10:00 – 10:30, and potentially 15:30 – 16:00), lunch (13:00 sharp to 14:00 (not sharp)), per diem or lunch allowance for out of area visitors (even for half-day meetings), respect of protocol (acknowledge all important persons in the room), opening prayer, and election of the chair to lead the meeting. Oh, and don’t forget that softies require giving the vendor empty soft-drink bottles to reimburse the deposit paid on glass. No empties, no softies. And that’s a big problem.

3. Medical decisions are relatively easy in the clinic when you generally have no drugs, no diagnostics, and no referral options. Pneumonia? Penicillin. Mastoiditis? Penicillin. Sepsis? Yep, penicillin. Oh, and deciding between things like malaria and pneumonia? Just count the respirations, naturally!

4. If you want to really sound like an asshole, tell someone you don’t like nshima or don’t go to church. See how long it takes until you’ve been reported to Immigration for being a person of suspect character (which can get you kicked out, you betcha)

5.  A 12-passenger minibus can fit over 20 people, easy (highest I’ve heard is somewhere in the 30’s).

6. Goat is cheaper in Luangwa than Lusaka, and makes an excellent gift for your wife or mother-in-law.  

7. It is perfectly acceptable to wear fishnet stockings, red peep-toe 4” heels, miles of cleavage, and a pencil skirt to work, but showing your shoulders makes you a hussy.

8. Even if things seem a little ridiculous to all parties involved, challenging the status-quo of a situation is Just. Not. Done. Bleeding from the neck and told to wait in the queue of patients? Of course! Meeting with someone who is 45 minutes late? Sit down, it’ll be a while. Need a stamp on a form but it’s past lunch time by one minute? Sorry, see you at 14:00.

9. When you ask if someone has something, you have to be very specific that you actually want the thing in question. Usually the exchange goes like this, “Do you have sliced bread?” “Yes” … Pause…. “Um, can I have some?” “Yes”…. Another pause…. “Um, okay, I want to give you money and buy one.” “No problem” (hands over bread).

10. There is nothing funnier than a Muzungu in gum boots, riding a bicycle that is too small for them. Yeah, yeah, it’s a riot.  

Reaching out

The holidays always seem like a time that you shouldn't be away from family. You should be tucked up in your childhood bed, with a cup of coffee and a book. When you're a million miles away (in space and context) you create family wherever you are. In keeping with this, I've been writing emails and cards instead of blogging, preferring the connection of home to the mass format. It's funny to think about what family means in my home, when I live in a country where the concept of family means something else entirely. In Zambia, the extended family, the power of blood, is of the utmost importance. Here, your fortune means your family's fortune, and children are the shared responsibility of the aunts and uncles, even grandparents, who are as equal authorities in the upbringing as the parents are.

In my little world, however, everyone is just about as independent from their families as it comes in the West. Those who choose a life abroad aren't exactly the type of people who are afraid of the world beyond their front doors. Moreover, the transitory nature of Lusaka, a virtual revolving door of young faces, means you are constantly forming bonds and saying goodbyes. It's an interesting place to be for the holidays.
So, wishing a big happy Christmas to my loved ones in America, and to my Lusaka family alike.

Thoughts on a year.

        I expected Africa to be different than the US. Clinics filled with HIV-positive patients on ARV day, elephant sightings, strange bugs, ridiculous rain leading to ridiculous pot holes, bargaining at the market, red dirt that gets everywhere… I expected all this. Well, maybe I couldn’t have predicted how much I actually like nshima, or learning to cook all sorts of plants (pumpkin leaves in peanut sauce, anyone?), or clinics that lack drug A through X (and tape, and sutures, and whatever) and are entirely run by the maid, or regularly wearing chitenge to the office, but more or less I expected things to be different.

         What I didn’t expect was how much I think this year marks a transition in life for me. When I think about where I was last year, and where I am now, it’s pretty unfathomable. Exactly 12 months ago, I was a full time med student, sporting scrubs through my 30-hour shifts in OB/GYN out in Boise, Idaho, fitting in 6-8 hour breaks (include sleep, eat, shower, in that order) between stretches. I was loving the OR, especially surgery with the super cool DaVinci machine, wielded by a rockstar Gyn/Onc. Kings of Leon playing while we whipped through a para-aortic dissection of lymph nodes invaded with cervical cancer. Dinner usually consisted of cafeteria pudding, coffee, and wilted salad or other unidentifiables. All of my shopping, I hate to say, was at WinCo, which was a convenient 500 meters from the apartment. My favorite run took me out in the desert, past scrub and flowering grasses, where mountain bike trails criss-crossed over streams and steep rocks turned red and sandy gold at sunset. Once, I took a risk on a slowly progressing patient and went for a run while on call. Of course, my pager went off. Twice. I convinced a passing rollerblader that I needed to borrow her cellphone (saying hospital is like a free pass), and set a personal best for the miles home.

          Looking back on the past year as a whole, my life was full. I was set to graduate in a less than two years from medical school, had just signed a lease on a great apartment, and had a fantastic boyfriend. I applied for a few fellowships on the off chance they would deliver, thinking that it was the time to do these things before residency, buying a house, maybe getting married, and the other milestones that one expects at that point of life (heck, I was toying with the idea of a pet!). Now, one year later, I have walked away from all of that for one reason or another (don’t worry Dad, I am going back to med school!). It seems Africa, and her promises of adventure, has a way of coming to call and staying for a lifetime.

This all begs the inevitable: Now what? And that is a darn good question.

Meeting expectations

It’s come up a lot recently that my photos and blog posts aren’t always living up to people’s expectations of Africa. Before I left, I’ll be the first one to admit that I had pretty firm ideas about what I would encounter while I was in Zambia, even though I tried not to. When I told people about my upcoming year, I got responses ranging from “Cool! You’ll see lions!” to “What will you eat?” Now, I think about how I prepared for a year here, I think in some ways I was right on target, but in others I was way, way off base. For instance, I packed about 5 bottles of bugspray, 2 rolls of floss, a headlamp, and a bag full of random medical supplies. All useful. My preconception that I would spend many, many days near a toilet with various stomach bugs, that I would be deprived of Thai food, and new movies? Not so valid. 

You can find parallels between African and American everywhere you look, or you can note the chasms that separate the cultures. This is what often gets overlooked when thinking about a foreign place before you visit – how similar, not how different, things will be. I expected to stand out in a crowd, to find the food unusual, to feel awkward when I made social gaffes. I didn’t think as much about how teens here still buy the Zambian equivalent of Cliff Notes and SAT prep at the market, or how the majority of patients present not with exotic parasites or HIV (though lots do), but with banal complaints of headache and fatigue and the flu. 

The thing is, Africa isn’t only the place that exists in National Geographic-like stills, with mud huts and hippos and little kids with flies everywhere. I can’t even vaguely pretend I know the first thing about how it is to live here, really, but I can say that it’s complex. It’s a place where rural (really, really rural) life meets huge cities and urban progress, and where the same things that impact society in America, or China, or Argentina affect life in Zambia. All these are facets of one existence here: the dusty rutted red roads and the village chickens; the kids without shoes playing with a ball made of plastic bags; the urbanites in patent leather heels and pantsuits; waiting for oxen or elephants to cross the road; the laboratory at Kalingalinga with uber high tech automated sorting machines; a minibus towing another minibus to the gas station with a length of rubber; ladies carrying everything from suitcases to water buckets on their heads; cops asking for bribes; huge superstores; tin-roofed shacks at the market; nshima; fine Italian wine; guys reading statistics books next to little old ladies reading the bible… This is not an incongruence or a dichotomy. Life here is one blend of all of this. So to note some single strange aspect and say aha, look, this is Africa! is impossible. Unusual, familiar, old, and new – it’s all part of the same raucous, wild, sometimes beautiful, often smelly, fantastic place.

Whirlwind update (no reflections here, sorry!)

Been out of touch for a while. It's been a combination of lots of weekend trips and really, really bad internet at home (and at work, unfortunately). October has flown by in a blur... I'll do the highlights of my last three trips:

* Sinkholes (October 9 - 10), near Ndola. Good swimming (great swimming), good food, good people. Need I say more? Oh, I guess I should mention that someone heard that maybe there was a python swimming in with us, but we didn't spot him. And as everyone knows, if you don't see giant snakes, they can't hurt you. Matt gave a bunch of Zambian teens a kick by boarding their floating log and playing around with them - probably the most entertaining thing a mazungu has done in the sinkholes aside from getting eaten by a python. We did get a bunch of stuff knicked, which was our own fault, but still was a bummer. We balanced this out by filling up the back of the car on the way home with pumpkin and onions and other veggies from the roadside vendors...Yum.

* Lake of Stars Music Festival (October 15 - 18), Mangochi, Malawi. 15 hours in a car each way. Awesome bands ranging from the Noisettes (No Doubt meets Amy Winehouse) to a school for orphans performing hip hop to a guy playing a gourdophone (yeah, that's right, like a xylophone, but with gourds). Right on the beach, housed in a resort with white sand and poolside drinks. Picture lots of young, sunburned, and hungover white kids inside the fence, with lots of equally young Malawians trying to peer through. That was the weird part, it was like crossing from Africa to Fort Lauderdale when you walked through the gate. Also, we got a ticket on the way home. For having an expired road tax sticker. In Malawi. For a Zambian road tax. Explain that to me, Mr Officer. Oh well, he did issue us a receipt. The drive was definitely the most harrowing part - chockerblock full of goats/little kids/potholes bigger than your car/guys parking their semis in really, really inappropriate spots (e.g. blind curves)/narrow shoulders and guardrails that rusted off the side of the highway. Mom and Dad, I AM trying not to get killed, I promise.

* Livingstone (October  22 - 25). Home of the natural wonder, Victoria Falls. It's pretty darn wonderous. You could see all of the rock formations as it was the dry season, and the depth and breath of the waterfall is spectacular. Easy to see why Livingstone had such a verbose response to the sight. Went white water rafting and may be a total junky if I kept that up. I think I made this noise the whole time: AHHHHHH -WHEEEEEEE - HAHAHAHA (repeat ad nauseum). We capsized once, on a class 3. Thankfully, we didn't go over the class 6, which resembled a sheer cliff with some water shooting over it. I also went for a swim in the Devil's Pool at the top of Victoria Falls, which was definitely worth the chunk of change to be sheparded along through the guided chute. A few minutes in a pool at the top of the falls - feeling the tug of the water going over the edge... Awesome. Livingstone was, all in all, a place to indulge (for example, the Royal Livingstone hotel, complete with flute players and tame zebras roaming the lawn) and a place not to think too hard about your existance in Africa by losing yourself in the maze of tourism.You could be shuttled around from bus to hotel to packaged tour and back without ever lifting a finger or making a decision beyond choice of safari hat.

Small Lives

I'm not sure how to reflect about today. The patient's death seemed so quiet, so mundane in the setting of the clinic, that not many people looked up from their routines. The mother's cries were a shift from the pattern of the minutes before, but other than that, we all drifted out of the room and back to our tasks with little more than a pause to consider the tiny body on the bed.

I had started writing about her death, about the small spark of life and how quickly it went out after her arrival at the clinic. But putting the words down made it seem so much more the spectacle, so much more than the passing of one life, among thousands that die every day in this continent. And that is really what I felt when I was watching her life go; how her story was so very, very common. Even while I grieved this baby I did not know, it seemed she was just an infinitesimal statistic in Africa. You could throw your entire being away here, you could pour every drop of energy, money, effort, into this parched soil, and it would hardly change the waves of lives being lost through lack of IV needles, through lack of sanitation, through people walking miles to reach clinics where no one can care for them, through mothers who bear children too young and too often, through oceans of shit and sadness and loss.

Zimbabwe

Elephant!

The road at sunrise...

Walking with Elephants

The day seemed so promising when the four of us started off from Lusaka. Within two hours, we had collected two separate police tickets (one for speeding, one for passing illegally) and we started to suspect luck wasn’t exactly with us. At the border of Zimbabwe, we ran into more trouble. Such-and-such form, blah-blah-blah, and 2 ½ hours in a hot customs office later we were allowed through. The day just got better - after pulling out of customs, an officer waived us to the side... there’s a penalty for overtaking a parked semi (seriously?!). Thankfully, we badgered him with logic and indignation, and he let us off. As the sun started to sink, we floored it on to the park entrance, where we barely squeaked past the gate at closing time (with the help of some well placed chocolate chip cookies). We made it just in time for about half of the welcome remarks of the annual Wildlife and Environment Zimbabwe game count at Mana Pools Park, in Chirundu. There was an assembled crowd of about 150 members, most of the retirement age, who were veterans of the count. Most were white Zimbabweans, with jaw dropping camping set-ups – we had multiple offers of food, shelter, and firewood, as we clearly didn’t have our heads on straight to only have pop tents and a little camp stove, while they reveled in multi-room palaces, fold-up camper top trucks, expanding trailers, camp chairs as numerous as weeds, and griddles, pans, and grills as propane powered assembly lines for the meals that seemed more suited to full restaurants than a camp site. After making friends with a group next to us, we ushered into the majestic camp chair circle and dined on dinners of beef stew, salad, and jam tart, and full fry-ups of buttered rolls, sausage, ham, bacon, eggs, tomato stew, and real coffee. It was a pretty stark contrast to camping á là America (especially to contrast with our first nights dinner- kerosene soaked pasta courtesy of a leaky Jerry can).

The game count itself was a twice daily trek through the park. Each team of 4-6 was assigned a ½ x 3 km strip of land with coordinated start times (0700 and 1500). We headed off the first morning with a ranger, but the subsequent treks were on our own, armed with our eyes, ears, and a GPS. The game was astounding – we spotted crocodiles, zebra, hippo, impala, troops of baboons, eland, kudu, waterbuck, bushbuck, nyala, vultures, warthog, hyena, storks, Sharpe’s grysbok, mongoose, buffalo, and elephants. And not just a few; On one walk alone we had 353 impala, 22 buffalo, and 16 elephant (among other species). Thankfully, we never came across a lion, despite Jes’ prayers to the bush gods (maybe balanced by my prayers to the opposite?). Our camp site was equally popular with the fauna. We had nocturnal visits by hippos wandering up from the river, a curious bunch of baboons who disassembled our tents for us while we were out, a sleeping trio of buffalo about 40 yards from our site, and a young elephant who stubbornly hung out between our tents and the bathrooms. At night, the hippos rumbled and there were unnervingly loud lion calls. This was not camping for the faint of heart. Tales had already gone around the WEZ gossip circles of the coordinator who was recovering from a buffalo goring, the group that had been nearly trampled by a herd of buffalo, and the group that had an elephant charge them. Just a small chance of death by wildlife, nothing to worry about. Sure. On Sunday, I thanked my lucky stars that for being physically intact, counted my tsetse fly bites (6), and headed home to the much tamer destination to the north.

Balancing Act: A Work in Progress

Things I love about Africa: Boababs. Goats. Kids getting SUPER excited to say hi to you. Getting called Momma. Loud ZamPop on the minibus. Mosi lager. Bouncing around in a Land Cruiser. Hot sun. Knowing a little bit about how it's done here. Feeling my issues like promptness and efficiency begin to erode. How little stuff perks me up (coffee, salsa, itunes). MEAT!. Laughing about everything. Not worrying about how the little pieces will come together, because they all seem to. New plants. The possibility of seeing elephants cross the road. Feeling even a teeny bit competent. The hustle. The bustle. Saying hello and how are you to every single person. Little babies in shawls. Not being able to instantly peg people into socieoeconomic classes by appearance. Appreciating life in the US and losing some of the distain for my country. Saying "isn't it" instead of "right". How every word is spoken in up-going lilts like questions. Hanging with good people. Did I mention meat?. Chickens being everywhere.

Things I miss about home: Getting in my car and driving whenever. Camping. How beautiful the Northwest is. Trees (big, green, lush trees). Mountains. Breezes. Talking on the phone for cheap. Recycling. Thin aluminum cans that don't make me wince. Cheap fruit that's not oranges, bananas, or apples. Dark chocolate. Good olive oil. REI. Farmer's markets. The ocean. Coffee!!. Stoplights. Traffic laws. Relative public safety. Going out after dark. Not having flies everywhere. Not getting stared at. Short skirts. Bakeries. Running outside. Having more than 3 pairs of shoes. Pizza. My bike. Old fashioned doughnuts (yes, really). Stationary stores. Mac and Jacks beer. ANY good beer. Good bread. Cheese. Driving on the right. Clean air. Carrying my ipod without thinking it'll get stolen. TVs on treadmills. Not being certain that the police, the health, and the legal systems are totally bogus. Dog parks. Glimpses of Mount Rainier. Menus that are consistent with the actual food. Fixed prices without bargaining for everything. Wifi. Snap top tupperware. Public expectations for body odor. Gas efficient cars. Reusable bag trends. Hiking. Trader Joes. Crystallized ginger.

Dirt Roads, A Dead Goat, And ABBA (Naturally)

Finally, feeling like I'm meeting Africa, and she lives in the small town of Luangwa. Minimal power (generators supplement the frequent outages), minimal running water (though the kindly hotel staff deliver boiling water in buckets at 0700 to your room), and lots of goats. My kind of place.
In Luangwa, I am occupying the clinic's labor ward (aka, a bed with neatly folded wool blanket and sterile delivery tools at the ready), doing chart review over the first month of the project's work. It's tedious work, and can be frustrating when you realize that a patient who has a constellation of symptoms unnervingly familiar to TB has just been sent home with a prescription for Penicillin. Moreover, like so many clinics in Sub-Saharan Africa, the staff are shorthanded to the extent that the maid runs the clinic here (there is a clinical person, but he is rarely in house), prescribing and dealing with patients and stray chickens equally deftly. However, the staff is dedicated to their work, and the clinic runs smoothly for some place that has neither power nor water, nor batteries for appliances such as the quasi-defunct hemoglobin machine in the corner. The charts that have more serious concerns are flagged, and a community health worker stealthily tracks down the patients and asks them to return before the day is through.I do my summary reports from the hotel bar (which hosts the only free electric socket in town, evidently), where a generator fuels really, really loud ZamPop and village men gather to drink Mosi beer and try to chat me up despite my clear focus on excel spreadsheets.
I go for a run outside for two of our five days, running through herds of cattle and being followed by small children on bicycles or barefoot. I am grateful for the (mostly) clean air, next to Lusaka's smog and dust. There are boabob trees everywhere, their monstrous trunks disproportionate and startling compared to their tiny branches. The joining of three countries and two rivers is here, with a place in town that you can see the banks of Mozambique to the East and Zimbabwe to the South, across the rivers.
On our trips around town, driven by our good humored Andrew, we blast Abba, Kenny G, and Gospel music from the Land Cruiser. I'm sure the village appreciates Andrew's taste, as I do.

Oh, and our drive home from Luangwa? 1 Land Cruiser, 5.5 hours, 6 passengers, 1 driver, 1 box of computers, 6 bags, and 1 butchered goat bleeding on top of the car. Apparently goat meat is cheaper in Luangwa. Who knew.

Mosquito Attack!

Officially think I'm one walking mosquito bite, and am having a really, really bad reaction to them. I have thirty on my legs, from one evening in a skirt at dinner outside. New best friends = DEET and my mosquito net! And yes, am taking antimalarials. I feel slightly in some sort of state of eternal punishment, as they are keeping me up at night with the itching.
It's only kind of funny, but my co-workers seem to think I'd been smacked in the face on Friday, due to the quail-egg sized protrusion from my temple (yes, one mosquito bite). My roommate saw me and cracked up saying it was like a cartoon lump.

Morning

My cellphone bleets out the African drum song to wake me up at 6:15 AM. I have been dreaming, like usual, of far-away places (last night I was driving through the desert in Nevada). I kill the alarm and disentangle myself from my sleeping bag, which I sleep in under my blankets as a deterrent to the creepy-crawlys that frequent my bedsheets. I duck under the mosquito net, which I belatedly put up in the middle of the night last night after being awoken by that characteristic wheeeee of a mosquito – and I have a nice bite on my temple to show for my procrastination. After doing my morning toilette and getting dressed, I lock up my little house (a bedroom and a bathroom) and head over to the big house (which holds three more bedrooms and the main living quarters), shouting Good Morning to the baby-faced but smiley night guard, Moses, who waves back a cheerful Morning Madame! The smell that is everywhere in Zambia is thick this morning, a mix of burning leaves, trash, and something that reminds me of peanut butter, no doubt from the piles of street trash and lawn trimmings that are burned daily in the gutters and sides of roads. A common third-world waste solution, when no infrastructure or real area to dispose of trash exists. I take care to avoid stepping on the red ants nests on the little path between the two houses, and note the garden bed is looking a little dry since being watered a day ago. I really need to get in a second bed, else it’ll be lettuce and beet salad forever, but there’s so much broken glass and random electrical parts in the dirt that digging takes a lifetime. In the big house, I make some Jungle Oats! oatmeal and tea and grab my lunch (salad today, can’t do nshima five days a week!). It’s a ten minute walk to the mini-bus station. On the way, there are schoolkids in uniform, shoving and giggling when they see me, men sitting by the side of the road who yell My Sister! Hello!, and boys vending fried dough balls and cellphone talk time cards. I make a brief pit-stop into the gym, where I greet Sara the desk girl, who shakes her head at me. She knows why I’m here. I nod at Shaun, the white South African dwarf who runs the place, who just glares. It’s okay, he always glares at everyone, and sports an identical scowl as he flexes glossy, short limbs in his body building photos that line the wall. In the locker room (it’s the room under the taxidermied large fish on the wall – another Shaun accomplishment?) I spot my shoes, which I had left here yesterday. I grab them and make my escape. Sara says, Forget something again? on my way out and I shrug at her. The day before yesterday it was a pair of sunglasses. Before that, a book. I’m an absent-minded regular, evidently. At the mini-bus stop, the conductors see me and shout LET’S GO! LET’S GO?! Cheston! Arcades? LET’S GO, Madame! And swarm around me, each trying to pull me into their half-full bus. I ignore them and look for the fullest bus, as they will not leave until packed to the gills, and I have no desire to sit around in the fumes and smells of the station any longer than necessary. I see a good candidate and hop in, squeezing four or five to a row in the bus (which is really more like a VW van). I dig out my 1,500 ZKw to pay (about $0.30) for the 7 minute ride. This bus has Virgin Mary stickers and a particularly odd “Girls used to cook like their mothers, now they drink like their fathers” slogan over the driver’s head and ZamPop/Gospel music blaring from the stereo. The conductor gets a running start and jumps in to the moving vehicle. Inside, he snaps his fingers and says Ndrama! At each new passenger, who will hand the bills in a folded pile to him individually. He counts, separates, and repeats the finger snap for each of us. At my stop, I unfold myself, wishing again that deodorant was a more culturally acceptable/affordable item (it’s about $5.00 - $10.00 a stick in the store, obscenely expensive like most toiletries). I cross the street looking left-right instead of the right-left I’m used to – that one took me a full month to master, and several near-misses! It’s a four lane highway, so it requires pausing between car lanes as well as at the meridian if you don’t want to wait for a rare synchronized opening. I step around the begging women at the station with an apologetic smile, and walk across a parking lot, over a field, and through an impromptu car-wash station before turning into the fence surrounding the office. It’s just another morning in Lusaka.

Pattering with Ex-Pats

Well, I guess I am starting to find my footing. Work is busy as all get-out, with a pile of clinical guidelines to transform into wall charts, and the upcoming month of September shaping up to be entirely in the rural districts (including an 8 day stay in a village about 4 hours outside of Lusaka).  An American co-worker, who will go with me for part of it, was asking a Zambian colleague about what we might do over the weekend while we’re there. The conversation went something like this: “So, what is there to do on Sunday?” “Church.” “Oh.” “Are you Baptist?” “No.” (Silence).

Although  while work has been hard, we’ve been finding time to play hard as well. This week should be labeled, “An introduction to Ex-Pat life in Zambia.” I spent Wednesday evening playing pub quiz at the local hostel, which is a regular activity for what is becoming my social circle (a group of co-workers and their friends). This was populated with far, far too many alcohol-sodden 19-year-olds on gap year. It was also distinctly different than quiz nights in the US, where I often feel the point is to be able to answer questions. Evidently, the point here is to stump your audience (What year was the first rowing race between Oxford and Cambridge? Or, How many points is a blue circle on an archery target worth?). Over the weekend, I also took part in the Hash House Harrier’s. Totally new experience, but very much enjoyed it. Running through the African bush, trying to dodge the branches covered in 2” thorns, and falling into cattle-holes at top speed while looking for little piles of trail marking confetti – awesome. Not to mention the cold pints at the end!

While I am loving the new faces and aspects of life, I was a tiny bit unnerved by the whole thing. I found the vast majority of the Ex-Pats friendly, interesting, and well meaning. On the other hand, I was surprised by the casual way some people talked about strategies to not get the hired staff to steal, or the “laziness” of the population, or the inability to get good cheese here (okay, I sympathize with that one).  I also felt strangely disconnected all week from the point of my being here. It would be too easy just to transfer a life in the comfortable US for an almost equivalently cush life here in Zambia, and forget all about the principles that push me to do this. I can’t forget the statistics that seem to get buried in the luxury of the Ex-Pat scene; that for the 200,000 or so middle or upper class people in Lusaka, there are 1.8 million others who live in the slums and struggle to live on pennies a day. Though it may be fun every now and then to wander through the Dutch Farmer’s Market, or to take a run with the Harriers, I also need to keep myself grounded in reality. Just remind me of that next time I’m grumping about some nonsense that doesn’t matter.

A Groundbreaking

     Today we broke the ground for the new Community Center and site of CIDRZ campus in Lusaka. The building will be built over the next several years, with principle funding from USAID, the Mary Fisher Foundation, and several other partners. The ceremonies opened with a dance and theater group from Eastern province, who stamped and swayed and sang songs of the loss of their friends and relatives to HIV/AIDS. The epidemic swept through Zambia like wildfire, with almost every person knowing someone or losing someone close to them. Now, the time has come to transition from the state of emergency and control of the virus, to learning to live with the virus in the aftermath. The flow of anti-retrovirals to Zambia has ensured that through treatment, people can live full lives. The new Community Center will play a role in helping women learn vocational trades, and will bring together education, research, and treatment.
     After the theater group, we heard from several key government and agency representatives from Zambia and the US, exemplifying the partnerships that CIDRZ has worked to create, as well as the willingness of diverse groups to come together for HIV.
     Mary Fisher's speech was impassioned, moving, and full of grace. She told her story of being HIV positive herself, and her journey from the isolation of carrying the virus, to the redemption she found in realizing that there was a global community who would welcome her regardless of serostatus, race, or nationality. She spoke of the ties that bind individuals infected with HIV, and of the necessity of overcoming stigma, ignorance, and the pain of feeling as if you are alone in the world. It was a fantastic speech.
     I thought of the patient I had seen in a rural clinic the day before, who was in her mid-twenties and had four children under the age of 8 (two in infancy, twins). She had been diagnosed with HIV during her pregnancy. Her husband had left her while she was in her last trimester, and she had no way to earn a living other than selling food items on occasion. Her older children carried the twins on their backs, and she alternated them to nurse throughout the clinic visit. She had not yet started her anti-retrovirals and was breastfeeding, meaning her twins had a 40% chance of being HIV+ themselves. This patient, and her children who stared at me and giggled shy smiles behind their mother, give faces to the meaning of the battle of HIV.

Welcome to Zambia!

The Community Group welcomes the new interns (the HIV Corps interns and I) to Zambia with a song and dance series, showing off some sweet drum moves.

The Basics...

Alright, I realize belatedly that I didn't address the basic questions that I've been getting asked from those back home.

1. What am I doing here, exactly?
I'm working as a... um, I don't know for sure what my title is. Nor, really, my role. But, in generally I will be helping with the clinical team's work as we push through a 5 year long project called Better Health Outcomes through Mentoring and Assessment (BHOMA). This is the second year of the project, the pilot phase. The intervention is primarily 1. clinical mentoring (as the name implies) with one-on-one work with clinic staff, and 2. community health outreach, with training a number of addtional community health workers and incentivizing them to refer patients to the clinics. We are also working with traditional birth attendants to help get improved maternal and neonatal health, and with neighborhood health committees to improve community involvement in the health care system.

2. Where am I?
I'm based out of Lusaka, the capitol city of Zambia, in Sub-Saharan Africa. I will be doing a bunch of regional work at the areas around Lusaka, at three different district sites. Lusaka is a big city, around 2 million people. It's spread out, with lots of small buildings and residential areas extending in all directions. There are few to no major highways, so the city can get pretty congested. All in all, it's a thriving African city, with the pollution, traffic, pedestrians, open markets, and general bustle you'd find in most countries on the continent. It's relatively safe, but has enough pickpockets and general crime that keep most people off the streets at night.

3. Where do I live?
I'm living in a CIDRZ-owned house in a neighborhood close to where I work. There's a giant wall around our place, barbed wire, and a full time guard, like most houses in the neighborhood. I live with three other American girls, with a fourth coming in January. They are serving as the HIV Corps interns, a separate program at CIDRZ.

4. When am I coming home?
Tentatively, June 2011.

5. Can you visit?
Heck, yes!

Hope that helps! I'll try to get some pictures up soon.

Down a dirt road, and off to Kafue

We are bouncing down a rutted, red dirt road outside of Kafue. The driver, Lawrence, is a pleasant man, but at the moment he is pounding the steering wheel in fervor at the Celine Dion CD that we are hearing now on repeat for the third time. I am more or less ready to throw myself from the Land Cruiser and hoof it back to Lusaka. This morning, Lawrence picked me up and drove me to Kafue, about 30 or 40 minutes outside Lusaka. We collected the district team members one by one, and deposited them at the two rural clinics out of Kafue, where we will be holding the 3-week long trainings for the community health workers in the area. They are learning (or re-learning for those with experience) basic skills such as taking blood pressure, recognition of STIs, and how to properly sanitize water. One of the district nurses is amazed when I tell her I will not go home to the States for a whole year. She asks how I can stand to be away from my mother (I know, mom, it's hard) and invites me to her home to learn to cook nshima and okra with baking soda (hum). Her boys are 2 and 5 - the same as my youngest nephews. I hope this will happen at some point. At lunch time, the health workers disperse into the village, and come back with plates piled high with starchy nshima and bowls of relish- the leafy dark green rape, and the infamous "village chicken" (chicken chased down by the diner and killed for lunch). A colleague teaches me to roll the nshima in one hand to form a column, which is dipped in sauce, and pinch bites of rape and chicken between my thumb and the fistful of nshima. It's messier for me than him, but I'm getting the hang of it. I spend a few minutes watching a team nurse administer a rapid malaria test (which is, I'll admit, new to me). The nurse's role is to work in the clinic for the next 6 weeks, giving one on one mentoring to the local staff, while clinic supporters help take up some of the workload and free up the regular staff for the additional time of mentoring. At afternoon break, I wander outside to the clinic courtyard, where I find Lawrence perched in the Land Cruiser, chewing sugar cane. He hands me a stick, and laughs at my attempts to pull the fibers off the outside of the cane with my molars. I find it delicious, but hard work. I think this is the Zambian equivalent of sunflower seeds - a pain in the rear, but good entertainment in the hot sun. At the end of the day, the health workers, stuffed full of family planning, malaria, hygiene, and the rest of the days topics, climb on their bikes and pedal off. I eye the Land Cruiser with reproach and climb in.

Caterpillars for Lunch and the Start of the Project

After being oriented nonstop for the past month, I feel fully prepared to take on... nothing. The set-up of the upcoming year is more or less a complete mystery, and I'm practically re-learning how to tie my shoes in Zambian. I've spent the past several weeks being given lectures on how to conduct international research, use online databases, act in culturally sensitive manners, stay safe abroad, and understand the structure of the research organization. With such excellent preparation, you wouldn't expect that within three days of my feet touching African soil, I have had something lost, something stolen, have put my enormous feet in my enormous mouth, gotten turned head-over-rear about how to use the Internet, and have failed entirely to understand the basics of research concepts. Yep, batting a big 0.0 right now.

Despite this, I"m actually enjoying myself immensely. My colleagues are very kind, and have been generous with their time and patience. I've tried some new foods, including nshima (the polenta-like staple of the diet), fried caterpillars, fish heads, trotters, anchovies, and what might have been either wart-hog or hippo (depending on who you ask). I haven't gotten sick (yet). I have a fantastic house and great housemates. I managed to track down a very, very long game of ultimate Frisbee (I'm blaming the altitude for my windedness). Doing alright, indeed.

Today, I'll be done orienting. It'll conclude the 3 weeks at the NIH in Washington, DC, 3 days in Birmingham, AL, and the 1.5 weeks here in Lusaka. I'll join my research project full time tomorrow. Here we go!

Growing Ideals

"Grow into your ideals so that life cannot rob you of them." - Albert Schweitzer

My hope is that this year will cultivate those seedling ideals which I already hold. I have always believed in the basic principles of social justice, equality, and the right to health. One personal goal for these months is to take my nascent beliefs and turn them into the kind of lifelong core values that are forged through experience. I would like nothing better than to be marked irrevocably by what I have set out to do, and I hope that I walk away from this year wearing its marks upon my skin.

I will spend the next 10 months of the year living in Lusaka, Zambia, in the southeast of Africa. I will be serving as a Fogarty Scholar, a program which takes around 30 U.S. students in various professional programs and pairs them with an international 'twin,' working in international clinical research projects. My particular work will be carried out at a well-known non-profit research organization, called the Centre for Infectious Disease Research in Zambia (CIDRZ). I will be assisting with a project that is focused on improving Zambia's existing primary care clinic services and community health. During this year, I will be on leave from my stateside life as a medical student at the University of Washington. Feel free to contact me through email or via this blog as my year progresses... I'd love to hear from you!