Whiskey and Shake-shake

I spent last evening at a Caledonian society ball. It was an evening of tartans, dances with names like Strip the Willow, and a whiskey bar. And no, I didn’t just move to Scotland. Evidently there is enough of a Scottish community here to throw these types of balls several times a year. Bagpipes, piper, and two kinds of haggis flown direct from the motherland (fatherland? What gender is Scotland, anyways?). Besides tripping over my feet trying to do the Military Two Step, I spent a good portion of the night wondering about culture.
The contrast between Zambia and Scotland is pretty stark. I heard some “amusing anecdotes” of trying to teach a Zambian chef to make cock-a-leekie soup, or what a bungle the staff made of the chocolate mousse. The toasts to the Lassies involved the same worn laughs - man’s inability to understand women, communicate worth a damn, and apparently function without the support of a good female. The riffs and compliments were familiar to me – apparently American humor about the sexes really hasn’t been influenced by two hundred years away from the British isles.

A few days before, I had spent another evening at a play put on by a Zambian acting group. Essentially, the play made a farce of the infidelity that is rife throughout Zambia, by illustrating the battle between married women and the single girls who poach their husbands. There were such winning jokes as, “the wife is better than the girlfriend, because you can beat her and she won’t leave you,” or the father of a character advising his distraught daughter to go back to her husband because “even I had girlfriends! Go back or I’ll kill you!” There were jokes about Indians, rural traditions, alcoholism, murder, and materialistic women. The Zambians were in stitches. I alternated between being appalled and laughing from sheer disbelief. Women are apparently equally guilty as a bad wife for the inability to keep their husbands “on a leash,” and for being the “sluts” that tempt away the men. 

Yep, Toto, we’re not in Kansas anymore. You can bring your culture, your oatcakes, and your kilts to Lusaka, but it just reinforces how many miles away your countries really are.

Zanzibari Christmas

Zanzibar. The very name sounds exotic. The streets are narrow, jetting off at odd angles, strung with tattered flags. Men wear the robes and caps of the Muslim faith. Women wear full burkas, with only their kohl rimmed eyes showing. We are in Stone Town for 3 days, over Christmas Eve. The mosques are far more abundant than churches, and the call to prayer reverberates throughout sunlit alleys far more often than occasional carols heard from open shop windows. Everywhere is the smell of cloves, sweet and spicy and blending with the stink of meat left in the sun and the underlying odor of fish. The market itself is a riot of items, far more variety than we see in Zambia. There is dorean, a spiny fruit which smells of sulfur, has flesh the texture of (as one woman put it, unfortunately) “fat on meat,” and tastes like nothing so much as garlic bananas. Jackfruits piled high, as large as watermelon, drip sticky white sap. There are bags of vanilla beans, cumin, and chili powder next to tables with dried octopus (octopi?), stacked like pancakes. 

 The food is delicious; curries thick with coconut milk and fresh spices, prawns, grilled octopus, fish of all kinds, ice tea flavored with limes and honey, coffee brewed Arabic-style with real milk, coconut rice, spicy ginger gelato, Tusker and Sarangeti beer. Bellies full and bags heavy with scarves and spice packets, we head to Jambiani, on the east of the island. Our van blows a tire halfway there, and we wait by the side of the road for an hour or two while cars stop and men pile out to help our beleaguered driver. Finally, we arrive in the village, which consists of a number of houses (all, it seems, have crumbled on at least one side; apparently repairs become less urgent when the climate is balmy), around 5 restaurants, and a collection of beach bungalows for the mzungus. 

We have rented out the entire bottom floor of a large guesthouse, run by a cheerful, small Zanzibari man named Dude (doo-day) who sports Hawaiian print board shorts and Von Dutch tees, and pads around like a helpful house gnome delivering fresh bread and instant coffee. He takes us sailing after a few days in his mango tree boat (apparently, the wood lasts longer). It’s a catamaran with a sail sown of hand stitched tarps and rice sacks, and is constructed by deceptively simple engineering – lines and twine and random sticks all serve in place of the usual pulleys and cables.  He takes us toward the reef, and we weigh anchor long enough to snorkel. There are giant starfish and sea urchins the size of softballs, and hundreds of multicolored fish. In the evenings, we eat religiously at Coco Beach, a restaurant with amazing food and a sharp-tongued manager who at least once a meal manages to offend us. 

I spend most of our three days at the beach lying on the bench outside the house, with a fever and cough. It’s the most beautiful place to be sick, ever. By New Year’s, I’m back up, though I go to bed at a shameful 9 PM after eating dinner by candlelight on the beach. The next day, we catch a ferry to Dar es Salaam. The line to the ferry reminds me of a cattle drive, with everyone pushing to board the boat and secure a seat. Kate (who is about 5’ tall) says her feet didn’t touch the ground as she was borne along. The ferry makes us all slightly nauseous with the rolling, but they show Jackie Chan movies, which helps somewhat. When we arrive in Dar, we are amazed at the amenities. Chamomile tea! Gummy bears! Tabasco sauce! We stock our suitcases. Annie, Kate and I share a hostel room with Hank, an older man who works in the mining industry and comes to Dar monthly on business. He makes sweet, but awkward attempts at jokes, though clearly has lost the knack of talking to twenty-something females. He keeps a bow in a pair of cowboy boots in the corner, a plate of fresh chilies on the nightstand, and has four cell phones. After a blissfully air conditioned night, we head back to Lusaka. It’s been a good trip.

 

Getting in touch with your inner Neanderthal

Alright, digression to my undergrad years as a psych major... There’s a pretty well-known phenomenon in psychology about our ability to consciously express preferences. That is, people are capable of coming up with an explanation about why they like something, but that very act alters their preference. For instance, if you ask someone to pick their favorite book, they really love Harry Potter. But if you ask them to pick their favorite book and tell you WHY, they will probably realize that Harry doesn’t make them sound sophisticated or cool (unless, like me, you think Harry Potter transcends such paltry things as coolness), so they say that their favorite book is actually Zen and the Art of Motorcycle Maintenance. Then they can give a nice, clean explanation about why they love it. But they’re deluding themselves AND you, because admit it, they really, really love Hogwarts, and they’d be way happier reading Harry Potter over and over if stuck on a desert island. So, pretty much, if you want to get in touch with who you really are, you can’t think through your opinions too much, because then the rationalizing of just why you get all googly-eyed at Daniel Radcliffe ruins it. 

Interesting.

Now, for me, I’ll admit I’m a naval-gazer. Hence, the blog. Unfortunately, the above phenomenon guarantees somewhat that all my carefully thought-out opinions about what I think about the world, including thoughts on medicine, social justice, hobbies, relationships, and the like, are probably an attempt to make me into a person that sounds good to myself.  And that means that I could (and not even be consciously aware that I was) actually be someone who would prefer to watch Jersey Shore reruns and eat marshmallow peeps all day. Scary, no? So maybe I should go with my gut more, and stop thinking about all this life stuff, and I’d be way, way happier. Hmmmm.  Well, if you need me, I’ll be in my room listening to the Postal Service and reading the Chamber of Secrets.

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.