Workin' Late

I think you know you’ve been working here for a while, that you’re settled into your projects, that maybe you even really know what’s going on, when you start staying late at the office.
To Zambians, the concept of staying late at the office is totally foreign. The exodus at 5 pm is rapid and complete. Within the period of five minutes, the office goes from bustling to almost silent. The aircon gets shut off, the lights turned down, computer monitors go black. If you peak into the CIDRZ offices past 5, the only faces you’ll see are white.

It’s the same for lunch. Between the hours of 13:00 and 14:00, you can never expect that anything will get done. Even if you have a meeting that starts at 14:00, a meeting you’ve confirmed with many people, including the driver, that you need to leave the office early in order to make it in time and they all say yes, sure, no problem. Inevitably, at 13:45 when you’ve arranged your day to take lunch early and get back to the office and go, the driver will be lounging and just beginning his large plate of nshima. (The pharmacists here have a joke about nshima. The way you feel after lunch, after you’ve eaten a large plate of nshima, it’s like you’ve had nshimazipam.)

Up until now, I’ve managed to be fairly Zambian about my after hours working. Usually if I’m in the office after 5 pm, it’s to use the internet for personal reasons. But all of a sudden, everything is happening at once. The fact that I’m leaving on Wednesday means there’s at least four days worth of work to do before then. Today found me drafting IRB exemption forms for my peer educator evaluation, rewriting an abstract about the OPD-ART integration for a conference, and playing architect as I did a site visit at our newest clinic to be integrated, attempting to draft the entire clinic building layout with a pencil on plain paper (map not drawn to scale). I don’t think tomorrow will be any better. Drafting another clinic, finishing the abstract, submitting to the IRB, presenting data to the drama group on their performances. And oh yeah, packing. I’m going to Cape Town on Wednesday!

A morning of medicine

Just in time for all of that public health work to get busy, I finally got to spend a morning doing medicine too. Through CIDRZ, I made a connection to a semi-private clinic that sees only HIV patients. Last Tuesday morning, I was given my very own room and my very own patients. Okay, they weren’t totally my patients. But Dr. Jack let me see as many as I wanted, and spend as much time as I wanted, and then bring him in to teach, explain, agree, sign off. It felt so good to be back, stretching my medical brain, dusting it off, and learning a whole lot in one day.

The nerdy side of me is excited to tell you that I saw Kaposi’s Sarcoma, lipodystrophy, chronic pelvic inflammatory disease and two people failing their HIV treatment. Of course none of those things are good things, but I learned what they looked like, and what to do for them. Each patient is a lesson for the next time. “I remember the time I saw….and we did….”

I’ll remember the look on her face when we told her that she’s failing treatment, that her CD4 is rapidly dropping and she continues to insist she’s been adherent to her medications. And Dr. Jack insists, she’s been on the same regimen successfully for 4 years, one of the original clinic patients, why is she suddenly doing so poorly now? She barely spoke, barely acknowledged us in the room. She stared into space, lost in thought. What was she thinking of? Of that one dose she forgot? Of the person who infected her, now long gone? Of what comes next? To give up or to go on? The last I saw of her that day she sat stiffly on the bench by the lab, waiting to get her blood drawn for a viral load. At home, viral loads are done all the time, certainly part of an initial workup for a newly diagnosed person. Here, they take two months to come back, and they aren’t even offered unless there’s indication of treatment failure. Qualifying for a viral load here is usually a bad sign.

Because of the fact that HIV is at the forefront of all the clinician’s minds when seeing patients, chronic disease is the largely ignored and very real issue here, for anybody who makes it to middle age.

One of my patients was a 50-year-old woman who, back in the states, may have been older, but she was the quintessential lonely older woman who comes to the doctor to talk, hypochondriac, somewhat depressed, but really cheery too. One minute she was crying and telling me about her friend who died, and the next she was smiling and joking. She must have answered yes to every symptom question I asked her on the standardized ART visit form. She had the same long history that primary care docs at home see on a daily basis-high blood pressure, obesity, history of deep vein thrombosis, uterine fibroids, dysmenorrhea. If only she knew how many medications she’s missing out on, how many medications she could potentially be on if Zambia had a healthcare system like the US. For better or for worse, most of that is largely ignored here, or barely managed. And oh yeah, by the way, she also has HIV. But in her case, it just kinda fit in with all her other chronic diseases.

I was proud of my diet and exercise discussion with another obese woman with high blood pressure who had never been told how she could try to bring her blood pressure under control. She seemed like she really wanted to know.

The morning flew by. I almost forgot what it feels like to be on my feet all morning, forgetting if I’m hungry, forgetting if I need to go to the bathroom. Gotta keep going, there’s always more to see. But that morning got cut short, because there was busyness back at the office. When did I get so busy?

I hope to go back on a weekly basis. More patient stories to come, hopefully.

Pictures up!

After a two week long saga, I finally managed to get some more pictures posted to picasa.
For your viewing pleasure....

Canoe Race in Siavonga
Kasanka and Mutinondo (apologies for duplicate pics, I can't deal with it right now)
Holiday decorating

Click on the link on the lower right hand of the page

I will not miss...

Despite the touching and saddening previous entry, when I reflect on the reasons I’m happy to be here seeing all of this, even if it’s difficult, I’ve got to write this next one. I’ve been saving it up for a long time.
Here are a list of things I will not miss about Zambia.


I want my anonymity back. This includes:

-I will not miss being honked at, numerous times, by every taxi driver who goes by. Partly it’s because this is how taxis drivers find fares, they honk at likely people walking. People don’t often flag down taxis here, they flag you down. But my whiteness makes me a more likely fare, and thus the higher incidence of my being honked at. It becomes particularly obnoxious when I’m physically in the driveway of the shopping center, clearly walking to it (as opposed to away from it). I just want to scream out at them:
“Why the hell would I want a taxi when I’m here?! I’m clearly going here, and here I am, and just leave me alone.”
But I don’t do that.


-I will not miss not being able to walk past a bus stop without being heckled by every call boy who comes within 20 ft of me. Like cab drivers, call boys get passengers for the mini buses. Usually the get off the bus at each stop, run up to pedestrians, every one a potential passenger, “Town madam? Town?” The drivers honk wildly, in case anyone didn’t know they were already there. Sometimes their passenger recruitment is to such an extent that they will drive off the main road, onto the side streets, honking repeatedly as the call boy slides open the door and shouts at passersby, even if they clearly have no intention of getting on a bus. Don’t you want to get on a bus? Surely you do, how could you not? We’ve got one right here! And never make the mistake of getting on a minibus that isn’t full, because you’ll likely sit there at the stop until it is.


-I will not miss being stared out, hissed at, shouted at, sneered at, or even genuinely greeted, by every single person I pass on the street. I think there’s something to be said for that cold Northeastern exterior. I don’t want to know everyone on the street. I don’t want to be approached by every man and get comments like, “Hello, you seem nice, I really want to know you, give me your phone number!”


-On that note, I will not miss Zambian social norms. Here, it is completely normal to have a less than five minute conversation with someone and ask for their number. Zambians really like to meet each other. To us, who tend to be somewhat reserved in that sense, in seems super foreign. I get tired of having to constantly figure out how to tell someone I don’t want to give them my number, I don’t want to tell them where I’m staying (where do you stay means where do you live), and I don’t know how to help them with whatever business or charity scheme they are planning, no matter how genuine they may be.


-I will not miss having to retreat indoors as soon as it gets dark. I will not miss that as soon as it starts to get dark, it makes it okay for men to start talking inappropriately to you on the street.


-I will not miss having women tell me on a weekly basis that I have a stomach. Zambians are dead honest. And I’ve yet to figure out if they’re insulting me, or complimenting me, or just telling it like it is. But there’s no taboo against telling someone they are fat. I adore the nurses I work with at CIDRZ, but they sure do know how to make me feel shitty about myself when they reach out and pat my stomach for no apparent reason. I don’t think they mean to be insulting. I think they don’t realize there are. I think there’s a double standard though. In traditional culture, it’s a positive thing to be fat, because it means you have money and are well fed. But with encroaching western culture, it’s probably not a good thing. So I have no idea where they are even coming from.


-I will not miss the utter disregard of drivers for anybody else except for themselves. I don’t think it’s only drivers, I think in general there isn’t the same sense of courtesy on the street as there are in other places, but here it manifests most obviously on the road. Think of all the places where people say, “Oh drivers are crazy there!” Massachusetts drivers, for instance, who have gained themselves the nick name of Massholes. Then multiply that by 100.
At home, it’s not uncommon to see some guy speeding down a neighborhood street, and you kind of just watch them pass and feel mad and give them a dirty look. But it certainly doesn’t happen every day. Here, it’s the rule rather than the exception. People race down neighborhood streets at highway speeds as if there was nobody else there. And if they see a pedestrian or biker that could potentially be in their way ie walking on the side of the road equivalent to the sidewalk here, rather than slowing down, they honk obnoxiously, speed up and give you the dirty look. And when car accidents happen here, they are bad. People speed around corners, lose control, and fall into the deep drainage ditches. It’s not uncommon to see two back wheels and the rear end of a car sticking up from the side of the road. I try not to think too hard of what the front of the car looks like.


-I will not miss the number of drunk men walking down the street on any given day. Unemployment -> idleness, depression-> drunkenness-> spread HIV-> depression -> drunkenness. Yeah, you get the picture.


-I will not miss having people expect that because I’m white and working for an NGO, that I’m bringing them something. If I have to hear one more in appropriate request (complaint…whine) for refreshments and transport reimbursements, I will scream.


-I will not miss having to extensively greet everyone each morning, and if I don’t, being thought rude. Sometimes I’m in my zone, and all I want to do is go to my computer and start my work day without the niceties.


-I will not miss people trying to sell me things. I’ve never been a good bargainer. So when it comes to techniques that some people use to drive down prices while bargaining, I use them in a sincere way.
For instance, I’m at the Sunday crafts market, looking for something very specific. I’m examining a carved wooden bowl. It’s not exactly what I’m looking for, a bit smaller, not the greatest paint job. And the salesman keeps asking me how much I’ll pay for it. And I keep saying I’m not sure I want it. I say this because I really mean it, I’m not sure I want it. But to him, that’s my bargaining technique. He won’t even let me put the darn thing down. I have to move away from him, set it down and essentially run away to get away from him. And of course, as I leave his stall, every other shop owner wants me to enter his, “Madam, come look, looking is free!” while shoving the same old kitchy knick knacks in my face and all I want to do is run away. Being obnoxious to people doesn’t make them want to be your customer. Or maybe I’m just no good at this stuff. Businessmen are businessmen the world over.


-I will not miss the literality with which people think. The lack of critical thinking, of thinking outside the box, sometimes utterly amazes me. Or maybe I take for granted how I’ve been taught to think critically and creatively. Even some of my Zambian colleagues at CIDRZ cannot read something over, give a presentation or think about something above and beyond what is written on the page. And if it’s written, then you have to read it. Meetings can last hours longer than they are meant to, because people will take the time to read every single word of a protocol, out loud, together, rather than having prepared it before hand, or skimming it, or speaking about the gist of something.

The TB-HIV peer educators, who I sometimes love dearly, are great in so many ways, but most of them cannot think outside the box. I have redesigned my monthly reports several times to most accurately reflect what they are actually doing in clinic. And I get their feedback and input, and we go through the questions over and over again. And they say it makes sense, they say they get it, they helped me design it! And then the next month’s report comes in, and they’re still answering some of the questions not really how I wanted/expected. They take the most absolute literal meaning of the question, one I didn’t think of because it was, perhaps, too obvious. It’s a lesson for me in how to word things, at how words can have so many meanings, but I also wish they just thought about it a bit harder. If they did, they’d realized that they way they answered didn’t really make sense in the context.

I think a lot of it stems from the standard system of schooling here, of a large room full of students, repeating back word for word what the teacher says. I don’t mean to be overly critical in this respect, we have issues with our education system too, and there are surely many children in the states who can’t think critically either. But it’s a daily challenge, and time sink.


-I won’t miss being seen as the boss just because I’m white. I’m not the boss. I’m here to work with them, to learn from them. Once again, the peer educator Mary illustrates this. I went to meet with her and Dennis at the clinic one afternoon, and when we were through, I was waiting for transport to go back to the office. She insisted on waiting with me, even though she was done for the day and I told her she should feel free to go home numerous times. So I just saw it as a courtesy, really nice of her to wait. But then, when her phone rang, she mentioned in the subsequent conversation that she had to stay at work “with my boss.”
I hate being seen that way. I am here to help, to mentor, to make things sustainable for them yes, but I’m also here for me, to learn, to experience, and certainly not to boss anybody around.

But there’s no hiding from my skin color. Everywhere I go, I am mzungu, whether or not it gets verbalized (though it often does). And on some level, no matter what I do, people will never see past that and give me a chance otherwise.



So I yearn for my anonymity. The freedom to put on my hood against the brutal Boston winter wind, keep my head down, plug in my headphones, stay in my own little confined world, and not be expected to acknowledge anyone or anything, and not have anyone want anything from me, all the way from the door of my apartment, through central square, to the T, through the streets of Chinatown to my school. I want that unwritten, unspoken, separation. I want the harsh northeastern coldness, if only for a little while. Friendliness if overrated.

The Hidden Face of HIV

To me, the face of HIV in Lusaka is every face on the street. It’s the young guy strutting along the side of the road, in his baggy, wrinkled, second hand clothing, wishing me a good morning in his ever so cool and suave sort of way. It’s the businessman in his suit headed to town for work. It’s the woman at the clinic, chitenge wrapped baby on her back, another child at her feet, clutching her white ART treatment card and waiting patiently for hours to be seen. It’s the callboy shouting at passersby to get passengers for his bus “town madam, going to town!” It’s the uniformed lady working the register at Shoprite. It’s the woman in the power suit, in the corporate office, in the tallest building in Lusaka.
But one face of HIV I never saw, until today, is that of the babies. Some of them are infected themselves. And others are the face of HIV because HIV has left them without parents. But these children, thousands and thousands of them, live in the orphanages all over Lusaka, the lucky ones do anyway. Today we went to the Mother Theresa Orphanage, on the other end of Kalingalinga (as you may recall, one my least favorite neighborhoods, though my most favorite to say), to visit some of these children. As we first stepped into the complex of buildings, we found ourselves in a courtyard, filled with children from about 4-12. As soon as they saw us, they began to sing, in perfect unison, a song of welcome and thanks. I have begun to believe that Zambians are born with perfect pitch and perfect voices, for on so many occasions- piled on the backs of trucks going to a funeral, shouting out of cars in a wedding procession, at the maternity clinic in the morning, on the school bus, harmonious, uplifiting songs can always be heard. It was no different for these children. You would have thought they’d been rehearsing for days, in anticipation of our arrival, a welcome song finally sung to its recipients, instead of just on the fly.
I don’t know if their clothing was the result of large donations of identical outfits of similar sizes or a true dress code of sorts, but it seemed that each age group/gender had on the same clothing. Most striking were the 5-ish to 8-ish year old girls in bright red, tafetta and gauze party dresses with gold trim. A Christmas gift perhaps? After our welcome song ended, we found the sisters and went to visit some of the tiniest residents of the orphanage.
The room had 25 cribs, lined up in three rows. They were little rolling cribs with short sides rather than proper large cribs, almost like larger versions of the plastic rolling baby carts they use in the hospitals back home. In each one sat a toddler. They all looked at us as we entered the room. 25 pairs of eyes that had probably only been looking at each other and at the Christmas tree in the corner for most of the day.
It only took a quick hello to a couple of them to fall in love. Those large smiles. Those reaching hands. That desire to be held, that willingness to hold on. I thought of the power of touch, and how much it means to be hugged, to know that someone is there. I thought of all the people who loved me when I was that age, of all the songs people sang to me, of all the games they played with me and I wanted to give all of that to them. In a whirlwind tour, I sang “Itsy Bitsy spider,” “open shut them,” “this little piggy,” and “patty cake.” I thought of all the stimulation we give our babies at home, of the little brains watching and absorbing and making connections, and how mostly, these babies just sit and just watch each other.
One little girl, probably a little older than a year, wore a dress I probably would have worn for a family portrait- a yellow and white striped sailor dress with a large white collar. She happily listened to my songs and held my hands and swung them with me.
Her crib neighbor, whom she would crawl over and visit every once in a while, was probably my favorite. In his smart blue striped shirt, he won my heart with his charming smile and his delight at my spinning him around.
After a bit of play, it was time for them to eat. The women who worked there expertly carried two toddlers at a time to the miniature dining hall, the low benches with divided chairs for each child, the baby sized tables, to go with the baby sized bowls of nshima and stew. I checked in on them periodically and got a big, nshima smeared smile from both of them.
I managed to spend some time with some of the older children too, although that was equally overwhelming in a different way. Imagine being the focus of attention of everyone in the room, instantly on arrival. As soon as I stepped back into the courtyard, I had no less than five little boys and girls glued to me- on my lap, on either side of me, tapping me, pulling my arm, making excited declarations in Nyanja that I wish I could understand. And of course, since children will always do what you don’t want them to, I had quite the time keeping them from reaching into my bag with my water and phone.
Towards the end of our visit, when the toddlers had made it back to their cribs (in a seemingly random fashion, for I found neither of them where they were before), surprisingly clean after such a messy meal, I went to find my little friend. I could just feel his need for affection. He was quite the snuggle bunny. I must have held him for half an hour, just held him, and when I had to put him down to leave, he cried. And that’s my final burning image of the orphanage for the day. This is country full of children just like them. And what will happen to them all? Who will survive? Who will grow and thrive? Who will go on to opportunity, health and love, and who will set out at 16 with no job prospects, nothing to do and nobody to care? Just to think of them all is so overwhelming and so sad.
This week we’re holding a Christmas party for them. With the loudest, funnest toys you can think of, and the saltiest, crunchiest, most artificially colored snacks you can imagine, it’s going to be a blast.

Batfest 2008

There is life beyond the boundaries of Lusaka, thank goodness. The extra long Thanksgiving vacation time allowed us to go find this out. This past weekend, nine CIDRZ mzungus set out northeastwards in 2 Land Rover Defenders, affectionately named The Green Machine and The Beige Beast aka Bubba aka Short Bus, outfitted with refrigerators, cooking utensils, chairs, tables, stoves and roof tents. At about 5 am on Thursday morning, Batfest 2008 began.
Kasanka National Park is one of the smallest national parks in Zambia, located in the northern part of central province, almost on the body of the Zambia butterfly shape, if you will. It’s heavily wooded, with a river and some lakes. It has its share of antelope species, birds and crocodiles, but it’s not particularly known for any of its large game. What it is known for is the annual bat migration. Each year, from November to December, millions of gray fruit bats, upwards of 10 million to be exact, descend on Kasanka. Biologists aren’t even sure where they all come from. They don’t all come from the same place, some are in different stages of the gestational cycle than others. They know that some of them go to the Congo in December, but where the others go is a mystery. Yet somehow, each year, word gets out in the bat community about the Kasanka bat convention, a family reunion perhaps, and do they ever come.

There is a particular grove of trees where they like to roost. I heard some statistic that the weight of the bats in the trees is comparable to some ridiculous number of elephants, like several hundred. Each evening, at dusk, the bats begin to stir and prepare for their nightly hunt for food. As we approached the grove, with a quickly darkening sky in the background, we saw some flecks of black in the air, flying above the trees. But soon the flecks became clumps, and then more and more until the entire sky above the grove was filled with bats, as if mud had been spattered all over a window between you and the tree. In large groups they would fly off in each direction, but just as fast as they could fly away, more would ascend from the trees to fill the air space the others had left behind. We lay there on the ground, watching them fly above our heads, until the crowd thinned out, and it was too dark to see them anyway. Then, in the early morning, when we peeped our heads out of our tents at first light, we looked up, and there they all were, flying back to the very same grove.

The morning viewing was even better. It takes them quite a long time to settle down for the evening. They settle on a branch, fly up again, settle down on another. They crawl up and down the tree branches, clean themselves a bit, do some more crawling. They like to sleep in clumps, rather than spread out on the branches. Is it for the warmth, the comfort? Do bats know the bats they choose to sleep with?

The park has built tree houses, hides, way up in the trees. In the early morning light, we climbed to the platforms to get a better look, a closer look, at the settling down. And every once in a while, if something scared them, a huge mass of bats would fly startled up into the air, scurry round and round for a bit, and then settle down again. New sleeping clumps or old ones? By the time the last few stragglers finally settled down to sleep, there was another Kasanka treat to be seen.

The elusive situtanga, a type of antelope. But unlike the ubiquitous puku, lichwe and kude, the situtang are few, and hide in the marshlands in the early morning. From our tree hide, with the help of binoculars, we caught glimpses of them through the marsh grass, large rears in the air, heads bent down in search of food, tails constantly flapping the flies away.
And if you look even closer, even smaller, there are countless species of birds and insects, including the longest and brightest millipedes I have ever seen.

So distracted were we by the fabulous morning wildlife, and then by a flat tire, that we were late for our canoe rides (as if we hadn’t gotten enough of canoes recently) on the other side of the park, a good hour’s drive. But that way okay, because, darn, we had to sit under a thatched roof by the river for several hours, lounging and eating lunch, before we could go out in the canoes in the afternoon. And unlike the choppy waters of Lake Kariba, this river was calm, and the soft, silent gliding motion of our canoes across the water, with the rhythmic splash of the paddle as it plunged, lulled me into a thoughtful trance. One thing that came to mind was how close I was to the Congo border at that very moment, and all the poor people who are suffering there, and how here I was, in this beautiful forest, on a calm river, soaking in all the beauty.

After we’d had our fill of the bats, it was time to move on to waterfalls and whalebacks. We piled into The Green Machine and Bubba and continued heading north. First we stopped off at Kundalila Falls. Ilse Mwanza, the loud tough old German woman we met at the Busanga Plains camp, the one married to a Zambian man, wrote a book about little known waterfalls in Zambia. Kunkalila Falls is one of her favorite. It was worth every kilometer of the bumpy dirt road to get there. Seeing the falls requires hiking down into a gorge, with breathtaking views of the landscape along the way, a landscape I’d never associated with Zambia before-granite hills, denser, greener, taller trees. There were even trees with red leaves here and there, so you could almost imagine you were looking at an autumn landscape in New Hampshire. Once you begin nearing the floor of the gorge, you get your first glance through the trees, to massive and tall jets of water falling from above. Hike a bit further down and you see both streams tumbling into a large pool below, and then to a smaller cascade, and into a quieter pool. There was very little time between arrival on the rocks, removal of shirts and shorts, and taking the plunge into the delightfully chill water. This watering hole had already been discovered that day by a group of 10 Peace Corps volunteers, celebrating Thanksgiving. There was plenty of space to share. And once again, with a little talking, we were reminded how small the Zambian expat community is. You always run into people you know, or people who know the same people you know.

I could have spent all afternoon at the falls. But sadly, we had to move on, to get to our camp in the Mutinondo Wilderness, a good three hours away, before dark.
Northwards once again. Through the small roadside villages with their colorful mud huts, past the stands with ladies selling piles of tomatoes and onions, past the children selling mushrooms at least 12 inches in diameter, strung on sticks. It’s mushroom season and this part of the country is known for them. We had an interesting conversation about whether the rather extensive ditch digging along the side of the road was for water drainage or related to telecom. Both seemed equally likely. The most developed buildings around seemed to be the schools. There was at least one in every village we passed. When it seemed that the sun might in fact beat us to our camp site, we reached the turnoff for Mutinondo. Another 25 km down a dirt road, and we indeed found ourselves in a wilderness, a lovely, wooded, hilly wilderness.
One of the most distinct features of the landscape are the whaleback, these narrow, steep hills that you could almost imagine to be the back of whales plunging out of the earth. Another distinct feature of Mutinondo is the fact that there really aren’t any big game, and it’s privately owned rather than a national park. Both of these things mean that it’s okay to hike and wander on your own, and wander we did. It was so refreshing to be able to just walk around on our own, and really really walk far, without a guide. Our wandering brought us to a small river that connected a series of small waterfalls, one of which was perfect for lunching, relaxing, swimming, and even using an inner tube to float down the falls. There were also whirling deep pools of water, crevices in the rock carved by countless years of falling water. There were ledges perfect for sitting beneath the falling jets, good for a head massage of sorts. Even after hours of frolicking in the water, I’m not sure any of us were quite ready to leave the river. Except there was horseback riding to do. And dinner at the lodge, as a treat for having made ourselves dinner three nights. And a morning jog/hike up the top of one of the whalebacks, in time to watch the sun rise and reflect across the totally human-empty, tree-filled wilderness.
Another illustration of just how small the expat community is here. At the lodge at dinner (8 hours from Lusaka), we met an Australian man and his son on holiday, traveling around the world, literally, from Sydney to Africa to Europe to the US to get back to Australia. A couple of days later, back in Lusaka, we ran into them in the grocery store.
It was not enough time. I want to move CIDRZ to that part of Zambia. I want to hike more hills and play in more waterfalls and eat more mushrooms and see more village life. But somehow it was maybe all just enough. Despite the 12-hour ordeal getting back to Lusaka (there were some car issues with poor Bubba), I arrived incredibly relaxed, refreshed, ready to get back to work. And it’s only 3 short weeks until I go to Cape Town for the winter holidays.

Three short weeks to finish my work plan for my peer educator program evaluation and begin preparing for integration of ART and OPD services in another two clinics. Sometimes it feels like things happen very slowly here, or perhaps the amount of work that gets done on any given day is small, but the parts add up quickly. I’m going on 4.5 months now. In some ways it feels like I’ve been here forever, and in others, I can’t believe how quickly the time has gone by.

Thanksgiving

Even far away from our families, I think American expats all over the world find special ways to celebrate Thanksgiving, albeit a bit early in our case. Due to our upcoming Great Zambian Batfest Road Trip 2008 on Thanksgiving itself, we declared the Sunday before to be Thanksgiving. With a little organization, I managed to get people to volunteer to make all the dishes you’d expect- turkey, stuffing, mashed potatoes, sweet potatoes, green beans, pumpkin pie, cranberry sauce and lots of non-traditional things as well. With over 30 people gathering at McMansion for the event, it was a dinner to almost rival the years of Alum Thanksgivings at pika. We set up extra tables and chairs all around the house, and covered each with a colorful chitenge cloth and candles stuck in wine bottles. With jazz playing quietly over our satellite TV radio, it felt like some fusion of a romantic restaurant and a college café lounge type place.

It was a grand success. There was plenty of food for all, and everyone commented on how nice the house looked and how well coordinated the food was.

I think for me, the best part was at the very end of the evening, when everyone else had gone home, and it was just the four of us, sipping wine on the front stoop, in the chilly night air, and Liz made a toast to all of us, to our Zambian family, to the family we’ve made here, despite all being so far from our true families. And indeed, I am thankful for so much…for the opportunity I’ve been given to be here, for the people I’ve met, for all the things I’ve been able to do and see while I’m here, for all that I have learned and hopefully what it can add to my career and my ability to better serve my patients in the future.

James Bond comes to Lusaka

Yet another event held by the Environment and Wildlife Conservation Society, a gala event for the premier of the James Bond Movie. They rented out the whole room of the theater. There was a cocktail hour before hand. We all got dressed up in our finest, or the finest we could throw together here anyway, without having brought any gala type dresses myself. Stu, one of the other interns, who ran the James Bond fan club at his university, even made a bowtie for the occasion, observe. Perhaps the movie itself wasn’t so great, but the evening was a blast.

Canoe Race in Siavonga

I know you’ve all been waiting eagerly over the weekend to hear how it went.

The race consisted of 15 clues, stopping points along the way from the starting point on an empty beach several kilometers down the lake shore to the finish line at our lodge, Eagle’s Rest. Each stop was worth a different amount of points. Rowing a figure 8 around 2 large rocks in the water known as “the pimples” was worth more points than running to the bar at Lake Kariba Inns with a large fish tank. Sometimes we had to figure out clues and aquire things, like buying a smoked fish, or picking up a stone off an island. At the end, they put together our finish times and the cumulative number of points to declare the winner.

The press boats followed us the whole way. That’s right, representatives from ZNBC, Radio Phoenix and various newspapers were there the whole way to watch and record the whole thing. I’m famous now in Zambia. People are stopping me in the streets saying, “You’re that chick from the canoe race!”

Okay, not really. But it is going to be broadcast on TV tomorrow morning and again on Friday evening.

The winning team was a team of three locals who have essentially been rowing for their entire lives. They crushed everyone and won by 20 minutes or so. But coming up into second were my two supervisors, Steph and Jennie, who rowed amazingly well and solidly beat the Fogarty intern Jen and her husband Ben, who we affectionately refer to as “The Bionic Couple.” (In any given conversation with them, you might hear something like, “Dude, that time I did the 24 hour triathlon on Palau, I was totally stoked!”)

Well, I didn’t come in 1^st or 2^nd or even 3^rd, but 13 isn’t bad considering we capsized about 2/3 of the way through the race and lost our clue sheet and the smoked fish. At least we didn’t come in last. Perhaps it was appropriate that we were team “Capital Fisheries.” It seems that we were embracing the spirit of the water. Although from looking at the jazzy shirts they gave our team (see picture), they might have thought we were going to a golf tournament instead.

Other than the race, there was plenty of time for rest and relaxation. Siavonga does not have the advantage of elevation like Lusaka does. It was HOT. The bright sun and intense heat had us all awake by 6 am each day. I think I spent more time in the water this weekend than I did sleeping or eating. But when I was sleeping, I got to sleep on a houseboat, on a bed on the upper deck outside, with just a mosquito net between me and the breeze off the lake, which was pretty darn neat.

The evening after the race, we had dinner and an awards ceremony at a different hotel in town, one that had also sponsored a team in the race. It felt a bit like the Club Med experience I never had, and certainly like nothing I’ve experienced in Zambia. We ate dinner by the swimming pool, large grill with fresh fish, reggae music blaring, surrounded by palm trees, with the waves of Lake Kariba crashing in the darkness below us. There was a definite vacation/holiday spirit, with people dressed up, dancing. I could almost imagine it was a seaside town. Something I’ve definitely been missing in this landlocked country. Post dinner dancing turned into people being hot, which turned into some of the guys jumping in the pool in boxer shorts, which turned into more people being pulled into the pool in their clothes, which became an in-pool clothed dance party, as we listened to a live performance from Crisis, “the best rapper in Zambia,” or so he says. With lyrics like, Damn look at your body lookin’ all blown out, nice titties, beautiful eyes and nice thighs I can really see what he’s talking about.

Like many resort towns by the water though, move a little away from the hotels and it’s a different world. It felt much more like the little villages we passed on the three hour drive south from Lusaka. The cinder block homes, some with thatched roofs, look particularly inadequate compared with the fancy lodges, inns and hotels across the road. The landscape down there is generally brown, dusty, dry, steep hills with patches of green desert plants. The lake makes it humid. Despite the beauty right on the lake, the combination of the heat, dusty hills and humidity would definitely lower it on the list of places I would want to live.

Despite the heat, it was still an enjoyable weekend and as always, when I leave Lusaka for the weekend, I wasn’t particularly in a rush to come back. But compared to the heat over the weekend, Lusaka felt delightfully cool when we returned.

Next Conservation Society Event: A James Bond movie premier gala evening.

Canoe Race for Wildlife & Environmental Conservation Society of Zambia

It's going to be a fun weekend...

http://www.siavonga-zambia.com/newsandevents.htm

Not only is CIDRZ representing with 12 teams, that's 24 people participating in the race/scavenger hunt, but it's going to be on national TV! And viewers will be able to text in to support which team they think will win. I don't know if there will be any footage online, but if you are so inclined, take a look around the ZNBC website or the Radio Phoenix website. The only catch is having to advertise our respective teams' corporate sponsors. I might be representing something like Barclays Bank, or perhaps Total Petrol or even better, Zambeef. But at least they're putting their money towards a good cause.

Weekend summary and pictures to come on Monday. A winner's trophy perhaps?

Integration Implementation and Lusaka Loves Obama

After months of planning, it has begun. As the doors of Bauleni Health Center opened on Monday morning, there was no longer separate ART and OPD departments. There is just the integrated OPD clinic. 3 days in, it’s going surprisingly well. Even on Monday morning, Steph and I left the clinic by 11 am, because there was nothing to do, they didn’t need our help, they had it all under control. In the first three days of operation, Bauleni is at a point that it took Ng’ombe at least a month to reach after they integrated in July. Everybody who works at Bauleni knows where they are supposed to be and what they are supposed to be doing. The waiting area is quiet and orderly. Every patient is having vitals taken. Every patient is being offered HIV testing. Every patient is being seen by a clinician. On day 1, already, an inspiring story about the integrated system improving clinical outcomes:

One feature of the integrated clinic is that every patient who comes to the clinic is offered the opportunity to get an HIV test, every time. Because the national HIV rate is close to 20%, and even higher in Lusaka, knowing somebody’s status is essential to correctly diagnosing them when they present with certain symptoms. On Monday, a healthy appearing young woman and her 3-year-old son were offered (now) routine testing. She had come to clinic because her son had passed a worm in his stool but his health history (and hers) was otherwise unremarkable. She agreed to test, with a why-not- it’s-just-part-of-my-visit-now kind of attitude.

I’m not sure that she was expecting the positive result for both her and her son. From what my colleague Julian tells me, she took it surprisingly well. In fact, while most patients who receive a positive test result usually take some time to absorb the news and return for enrollment in the ART program, she calmly asked, “Well, what do I need to do next?” and then went directly to the enrollment room.

And there it is, our integrated clinic identified two HIV+ people who may otherwise have not been diagnosed until much further on in their disease, when they began to be symptomatic. Will this improve clinical outcomes? We believe it will.

On a totally unrelated note, there were an amazing number of tired Zambians this morning, even more tired than I was. While I only woke up at 4:30 am to catch up on election returns, many Zambians I spoke with had stayed up all night long watching. This morning, at work, on the van, at the clinic, there was a palpable excitement in the air. If there was any discontent in this country about their own election outcomes just days ago, this one certainly left everyone a bit happier. When CNN showed clips of the election party happening in Kenya, they could have just as easily turned the camera to O’Hagan’s Irish Pub here and seen just as wild a celebration. Indeed, it is a happy day in Lusaka.

And the winner is...

Banda, by about 30,000 votes. Forget waiting two months after election for inauguration, Banda was sworn less than two hours after the official annoucement of election results, complete with visiting heads of state, fighter jets flying in formation overhead (the entire Zambian airforce?) and a 21 gun salute that we could hear from our second Stitch n' Bitch Lusaka over in the Showgrounds yesterday.

The results were somewhat surprising, if only because Sata was ahead for a good 2/3 of the counting process. Was there vote rigging? A lot of Lusaka residents think so. But who really knows. Despite his promises to incite violence if he lost, Sata hasn't and things here have been surprisingly quiet. This morning, the workday went as usual, the CIDRZ nurses went out to the clinics, CIDRZ transport got us all there the normal way, and driving through the neighborhoods was like driving through on any other day. It seems that even if people aren't happy about the results, they are accepting. Much in the way that even if they didn't like Mwanawasa, they were respectful of him, in his sickness, in his death, and in his mourning.

It might also help that people here are looking forward to the US elections tomorrow. Everywhere I go, people ask me about Obama. O'Hagans, the Irish pub here, is even having an all night party and breakfast on Wednesday to watch election results. If Obama was running for president of Zambia, he would win by a landslide.

Election Update

Elections were held Thursday. In anticipation of any potential civil unrest, we got off from work Thursday and Friday. Things here are still quiet though. The votes are making their way in from around the country to be counted, but there hasn't been a winner announced yet. Once again, the public access quality of the national TV station ZNBC keeps me laughing. Yesterday they had a very serious report from election headquarters, explaining how results from polling stations were being faxed in from around the country, how results were "pouring" in. The camera then pans to a line of fax machines, and every once in a while, one sheet of paper would come slowly through the outlet. Then they talk about these women whose job it is to sort through and verify, and they show some heavyset women sitting right next to the fax machines, picking up the papers from the outlet baskets and putting them into piles. Very official I tell you. Those reports are then intermingled with specially made music videos of Zambian men and women dancing outside various government buildings, singing about the wonderfullness of Zambia. It's enough entertainment to keep you going through the days and days it takes to count all the votes, should you want to watch election coverage for that long.

We probably won't know who the next president is until Sunday or Monday. To keep you occupied until they announce the winner, instead of ZNBC election coverage, you can enjoy my pictures from Busanga that just went up. Click on the pictures link to the right. Enjoy!

A weekend on the Busanga Plains

(Just a note about pictures on picasa, I'll upload the who lot from the trip as soon as I can, internet has been a bit slow, hopefully I can get into the office this weekend and just let 'em all go up. But for now, here's a few to go with my entry...)

Life on safari is a different pace. It accommodates, and sometimes even takes the shape of, the lives of the animals themselves. When they wake, we wake. When they eat, we go to watch. When they laze in the midday sun, we laze. And eat, and eat, and eat. Now that I’m a safari lodge expert, having stayed at two different lodges, I’ve realized that the formula is always the same: Wake at 6 am, morning game drive at 6:30, return around 10:30, brunch/lunch at 11, nap and relax, small afternoon snack and tea at 4, afternoon game drive at 4:30, including sundown drinks halfway through, usually on some hill overlooking a hippo pool, or herds of puku and lichwe, candlelit dinner at 8, sit by the campfire till you can’t keep your eyes open anymore. Life on safari is difficult I tell you.

As I walked through the front door of my house after returning from the airport on Monday afternoon, it felt odd to be inside. I realized that since I stepped off our tiny 6-seat charter plane on Thursday (we flew with Fly Mission, a charity organization that runs mission hospitals in the bush), I had not been inside since.

After a bit of a turbulent plane ride, as well as landing first at the wrong airstrip and being redirected to another, Rodney was waiting at Lufupa Airstrip for us. I could not have been happier or more excited to see him smiling and waving from the safari truck, our long awaited trip to the Busanga Plains had begun.

Kafue National Park itself is giant, about the size of Israel. the Busanga Plains are situated in the northwest corner, just a tiny piece and yet the plains feel vast. The flatness of it all puts the horizon at kilometers and kilometers away. Distances there can be deceiving. What seems like it should be a short walk can turn into an hour long journey, especially while trying to walk across uneven surfaces of trampled grasses and undulating mud hills shaped by the forces of water. These are the flood plains, and for many months of the year, completely under water. It is only during the dry season that we get the opportunity to visit the plains at all.

The nice thing about driving through Kafue National Park is that even if you’re not on an official “game drive,” even if you’re just driving to a destination, there are still animals to be seen. Our three-hour drive north through the forest and to the Busanga Plains included elephants, various types of antelope like puku, lechwe, kudu and oribis, in addition to countless birds. We drank beer and watched the sunset along a bend in the Lufupa River known as Crocodile Corner. In the darkness, it began to rain, the first heavy rain of the season on the plains. It made for an interesting final hour of the drive to the Plains Camp, in an open safari vehicle with only a canvas top. The glowing kerosene lamps of the camp in the distance welcomed us out of the wetness, to our home for the coming few days.

http://www.mukambi.com/?section=busangaplains

The camp itself is situated on an island. It’s not really an island as you would imagine it. In the dry season, sometimes it’s just a narrow, deepish, damp ditch separating it from the land around it. Nevertheless, once the rains begins, the water can surround it fairly quickly and so there is a long footbridge, a boardwalk of sorts, to get across to camp from where the vehicles park. The camp is delightfully small and intimate, with only four sleeping tents as well as the dining area. When I say tent, I mean a large safari tent with an additional canopy over it, complete with rugs, wooden four-poster beds, cushioned chairs and canvas- draped armoires. The bathrooms are found down bamboo-lined walkways, toilets and sinks with real plumbing, paradoxically outside. Sit on the toilet, brush your teeth, take a shower and watch the antelope graze in the distance. The dining area is a canopied deck overlooking the picturesque plains and two fig trees. There’s a bookcase tucked into the corner, built from an old wooden dugout canoe turned on its side with shelves added. There are books on wildlife, issues of Africa Geographic magazine, books by local authors.

On our first evening, in the dark, in the rain, I could not appreciate any of this. But there was candlelight, and wine, and good food, and friends, and laughing late into the night. I slept well.

Over the next four days, I went on several game drives and saw countless animals. The animals up and about on the morning drive can sometimes be completely different than those you start to notice at twilight. There are numerous types of antelope- puku, kudu, impala, lichwe, roan, and oribis. At first they are exciting to see, but soon become so common that you hardly notice them at all. It was interesting to learn the distinguishing features of each though. We saw crocs and hippos and elephants. We saw civets, ganets, and the elusive honey badger. Wildebeest, zebras, warthogs, bushbucks, waterbucks and my favorite name, the Lichtenstein Hartebeest. We saw countless, numerous birds, an ornithologists dream, I wish I could remember them all, but they include cattle egrots, saddle billed storks, kites, secretary birds, African fishing eagles, vultures, guineafowl, wattled cranes, crowned cranes, dikkops, grass owls, the lilac breasted roller, the cinnamon roller and honey guide. I think my favorite name is the Francolin. After a while, it was fun starting to combine names, like the scarlet breasted warbling cinnamon roll. An interesting fact about several of these birds is that they mate for life.

But the highlight of the animal viewing was the lions, especially since I hadn’t seen any on my last trip to Kafue National Park. There are two prides living in the area of the plains camp, the Busanga pride and the Papyrus pride. From Rodney’s stories, we had already heard that the Papyrus pride of six lions has taken a liking to the plains camp and visits fairly often. He’s even come to his tent on occasion to find them waiting for him by the door. This weekend was no exception. We were lucky enough to have many encounters with the lions, some perhaps a little closer than we expected.

The first encounter was at twilight, we passed another game vehicle who told us where to find them, and we came upon them lazing in the grass, cuddling and playing and rolling on their backs. In that setting, you can almost imagine them as large housecats, they certainly act that same way. In the safari vehicle, we could get fairly close, perhaps about 15 ft or so. They don’t have much reason to bother us if we don’t bother them. We all sat in silence for quite some time just watching.

The next evening, we again went looking for them at twilight, but we couldn’t find them. As true darkness set in and dinner time neared, we decided to give up our search and head back to camp. As we approached the road leading up to camp, there she was, in our headlights, the lioness sitting solidly in the middle of the road, blocking our way. Where there is one, there are more. Some quick assessment of the situation with the help of our spotlight identified the other five lions, off to the left, almost lined up single file, each further back into the field than the one before it. It seemed we had interrupted some lichwe stalking. Sometimes it can take them hours to situate themselves around a target, use one of them as a decoy and create a trap for some unsuspecting animal, about to be dinner. The lioness leading the hunt looked at us for a long time, then began to make some low grunting noises and stalked off to the right, then back, around the vehicle. Was she hunting us? Or just moving along? The other lions followed her, slowly, deliberately, taking time to plop down, rest, wrestle, play. We continued to count them. Six lions in sight. Six lions in sight. Eventually, after what seemed like a long time but was probably less than half an hour, our road block had cleared and we returned to camp.

As we were sitting down to dinner, they announced that the lions had been seen stalking across the footbridge towards camp. They were somewhere on the island. This would definitely be a good night to make sure you get an escort from the dining area back to your tent. The thought was there, but not at the forefront of my mind. A much anticipated dinner came, we dined, we enjoyed. As we were finishing dessert, Rodney suddenly raised his hand, shushed us all, and pointed a flashlight off the deck towards the campfire pit. There, less than 10 ft from the deck, was a lioness with several others not far behind her. In the distance, to the far side of the deck, our flashlights revealed a lichwe. It seems we interrupted yet another stalking/hunting session. She gave a decided growl and almost a mock charge, which sent several of us leaping further back into the dining area. It certainly gave me a bit of a rush. But I couldn’t have expected its effect on some of the other guests. A large, long-haired, older German woman with a boisterous, in your face personality, who had lived in Zambia for 40 years and was an old hat at safaris, sat hushed and dazed- looking in her chair, puffing away at a cigarette, tightly holding the hand of her small, mild-mannered Zambian husband.

After having most decidedly established their dominance, the lions didn’t stay long. They soon wandered away from the dining area, toward the sleeping tents and then around to the other side of camp, in search of another target. Minutes later, the staff reported the lions once again crossing over the bridge, leaving the island. This was not to be the last encounter however.

A couple hours later, Sarah K., Rodney and I were sitting by the glowing campfire, chatting, taking in the fabulous starry sky. Most of the camp had already gone to sleep. Quite suddenly, we heard a low grunting and a rustling in the grass. As had seemed to become the formula for the day, Rodney turned on the flashlight and there she was, the lioness in the grass, probably less than 20 ft away, watching us. “Alright,” he said, fairly matter-of-factly, “get over to the deck.” In one synchronized motion, Sarah and I were over and up onto the deck in about two large leaps. The lioness didn’t come any closer. Sarah and I sat crouched on the deck, recovering our breaths. In the light from the flashlight, she turned slowly and stalked away once again, back around the camp and presumably, off the island. That was the last we saw of the Papyrus pride for the night.

As we packed our bags on Sunday, with a strong wind blowing in across the plains, shaking our tent (Oooooooooklahoma where the wind comes sweeping down the plains…), it felt too soon to be leaving. None of us were excited to head back to the smog and traffic of Lusaka. Somehow, through the wonders of spotty email access and miscommunication, we got our wish. We were meant to fly out of an airstrip that was closer to our camp, but the message never got through to the pilot. After nearly an hour and a half of waiting with no planes in sight, it seemed that our ride wasn’t coming. And if fact, as we found out later, once again, the pilot went to the wrong airstrip. I can’t say any of us were too disappointed to turn around, drive back through the forest and once again see the glowing kerosene lamps of the camp welcome us back to our home on the plains for one more night. So I had another chance to sleep in an amazingly comfortable bed, in a beautiful tent, under a marvelous night sky overflowing with stars, with the whistling wind lulling me to sleep. One more chance to brush my teeth while watching the grazing puku. It’s times like that when I think I should just go open a bed and breakfast somewhere far away and fabulous.

Alas, this time we managed to meet our pilot, and return to Lusaka, and come back to real life. Seems as if HIV and TB hasn’t really become a problem yet among the lions of the Busanga plains. But if it ever does, you better believe I’ll be one of the first people out there ready to lead any public health initiatives they may come up with.

Some Tuku, a bike ride, a book shop and a Stitch n’ Bitch

After three months here, my weeks have become routine and sometimes my weekends feel that way too. Sleeping late, ultimate frisbee, lounging by the pool, out to dinner, get togethers and potlucks, movies, big weekly food shopping at Shoprite. With limited forms of transportation, limited funds, and limited things to do in Lusaka, it’s hard to switch things up too much. But this weekend, with a little creativity, we managed to make it feel totally different.

It started off with a concert at the International School, given by the great Oliver “Tuku” Mtukudzi, a musician from Zimbabwe who sings Shona music. I can’t remember the last time I heard music performed in a high school gym, but it was easy to forget the setting when they finally came on stage. It was a night of clapping and dancing and fabulous music, late into the night.

Mary is an older, White, British woman who owns a house and property a bit outside of town, to the southeast, way down (and up!) Leopard’s Hill. From the entrance to her driveway at the top of the hill, indicated by the simple, hand-painted sign, you can just make out the two “skyscrapers” of Lusaka far off in the distance. They seem delightfully far away. This lovely, shaded, verdant piece of land is not only her home, but home to Mary’s Book Shop as well. She specializes in selling used books out of a large shipping container turned into a walk in book display area. Her range of books would amaze you. From historical classics to dime store mysteries, travel guides 15 years old to poetry anthologies, cook books, how-to guides, recent New York Times bestsellers, even old Jane Fonda exercise VHSs. I found a book about “Modern Israel” published in 1965. She also throws in the occasional new/unused book and novelty items. The Christmas season has begun, as I’m sure it has back in the states, and Mary had a full line of traditional holiday crackers (those large, paper wrapped, cardboard candy looking things with surprise toys inside) direct from England.

We wanted to get some books as a gift for Rodney and for the guest library at the Busanga Plains Camp we’re going to visit, and so it seemed like a good excuse for a visit to Mary’s and a nice long bike ride to get there. The physical distance from our house is probably not that many miles, but riding on a heavy, squeaky, partially-broken-gear Zambike, on the rough unevenness of the side of the road, alongside trucks chocking thick smoke, first through the craziness of Kalingalinga and then over the many hills of Leopards Hill (clearly misnamed), under the intense midday sun, it made for a good 1.5 hour adventure.

But we made it. The little signpost, the tree lined driveway and the little children selling bunches of flowers could not have been a more welcoming sight. In order to get to the actual shipping container/book shop, you must first walk through a tented, seating area, nestled alongside a grove, where old, white, expat couples sip tea and eat little cakes and biscuits. The whole setting felt so decidedly un-Zambian, I really had to remind myself where I was. Perhaps we stuck out just a bit in our sweaty athletic clothes and bike helmets. For most people, this is a leisurely weekend drive. If nothing else, they were impressed with our hard work to get there. “Where did you bike from?!”

Two hours later, stomachs full of our brown-bag lunches and Mary’s chocolate cake, bags full of books, feeling much revived, we ventured back the other way. The ride home was definitely easier. The good part about having gone slightly uphill the entire way out there was getting to go slightly downhill on the way home. The only adventure on the way home was attempting to buy bottles of water from the roadside shop, which turned out to be a bar, with many Zambian men hanging about who apparently started happy hour at least 6 hours early. It really got me thinking and wondering about mental health services and rates of alcoholism here, but that’s a discussion for another time.

This weekend also marked the first ever Stitch N’ Bitch Lusaka. What is a Stitch N’ Bitch you ask? Imagine those old groups in small towns, when women would sit around and quilt together, late into the evenings, away from their husbands. Now move that outside, to an Italian restaurant by edge of the polo fields. The women are younger. Most of them are knitting, but there was needle point and even some quilting too. They’re all sipping cold drinks under the hot sun, like iced coffee, beer, and pina coladas. And they just happen to be in Lusaka, Zambia. But no matter where it is, stiching and bitching will always be the same. I’ve learned how to knit. I finished my very first project, an iPod cozy, something no iPod should be without.

Amazingly, we are already halfway through this week. Friday is a holiday, Independence Day. Tomorrow we leave for our long awaited safari to the Busanga Plains. I can't wait!

Some thoughts on NGOs, incentives, sustainability and making a difference

I went to visit the TB-HIV peer educators for the first time since the training back in September. They’ve been on the job for more than a month now, submitted their first monthly reports, and it was time for a check in. After two afternoons and two dusty, bouncy, sweaty SUV rides along unpaved roads to two clinics, I am drained. I love them, but they drain me. Their hard work, creativity and proactiveness has inspired me and defied my expectations. They work hours well beyond what’s expected of them, and they are paid the same stipend regardless. They stand as proud role models for their peers, opening accepting and discussing their own HIV status in hopes of inspiring patients towards successful treatment. I almost can’t imagine reaching the point of acceptance and empowerment they have found, if I found out that I was HIV infected.

All on their own they have come up with additional projects to do. Stephen, one of the peers at George clinic came up with the idea to do an outbreak mapping of sorts. He mapped all the smear positive cases of TB in the community and determined where the clusters of active disease are. Then he organized teams of treatment supporters to go out to these neighborhood clusters to encourage further case finding and enrollment in TB care. This is certainly not in his job description. They also took it upon themselves to schedule the first meeting of a TB-HIV support group which we had vaguely discussed with them but about which we had never finalized plans. The first I heard about it was last week, when they told me it would be happening this week. They have been truly wonderful.

Despite all that, they have also lived up to the stereotypes of locals pushing to get as much as they can, from the NGO, from the mzungu, and I almost want to hate them for it, for the way they manipulate me and the way they make me feel almost guilty for who I am, where I come from, and what I am privileged to have.

To fully understand what’s going on here, you have to know a bit more about the history of NGOs in Africa, because I know at least a bit about that now. Over the years, new programs, new initiatives and new work to be done led the NGOs to create initiatives for people to do them. They range from larger initiatives, like overtime pay for nurses, to smaller things, like transport reimbursements for attending a meeting or training, and refreshments. Sure, throughout the world, everybody appreciates refreshments at any event. In school, it’s a lunchtime mantra, a guide to choosing which meetings to attend during lunch time, “Free food!”

But for people here, its importance has become to excess. It has come to the point that people will complain if there is none, or not enough, or even if it’s not what they wanted. After a perfectly satisfying, free lunch one day during the peer training back in September, where we had given them “chicken & chips,” they said to me, “Sarah, why did you give us chicken and chips? We wanted nshima instead of chips. Next time give us nshima!”

Here’s a lesson I’ve learned about tea breaks during meetings. If you put out a plate of biscuits, theoretically enough for everyone in the room, they will most likely be gone before everybody gets some. That’s because people will pile biscuits onto their plates like these are the last ones they’ll ever have. They’ll be more biscuits on their plate than you can imagine them comfortably eating in one sitting. And if, by some huge chance, there are any leftovers on the tray at the end of tea break, they will soon disappear into purses and bags. I know we’re not really that different at home, we still crowd and hustle for food, and take leftovers away, but maybe not quite to this extent, or perhaps with this much disregard for those around us. And if the food is gone, it’s gone. We don’t usually complain that there should have been more or that we didn’t approve of what was ordered, or that we’ll never come back because there wasn’t any food. So, if you don’t want your tea break biscuits to disappear before equitable consumption, what you need to do is this: prepare pre-wrapped, napkin covered packets of little piles of biscuits and hand them out, that way, everyone gets one.

Getting back to those incentives. I think I’ve written in the past how going to trainings is a big deal here. That’s partially because they do in fact teach people skills they do not have. For example, nurses who have never been trained to care for HIV patients get a fully paid for opportunity to learn how to do so. But it’s tricky. Because while we’re not paying them to attend per se, we give them money as lunch reimbursements, as travel reimbursements, which is often more than they would really spend on those things. Sometimes, they’ll go without lunch, just to be able to keep more of the money. It’s seen as an added income source. I’ve heard of people managing to get themselves into trainings in various topics, on a weekly basis, as a source of income, not because they really want to learn whatever the training is about.

The NGOs have shot themselves in the foot. We create these programs and incentives to do them, then we talk of sustainability and enabling local organizations and government offices to take over, and because of that, the incentives cannot continue. And when the incentives stop, so do the people who were willing to do these things before. Nurses paid overtime to help fulfill our TB/HIV integration of care initiatives have helped those practices become Ministry of Health standard of care, but the nurses still don’t consider it to be so. You take away the overtime pay and they won’t feel any obligation to do those jobs.

Alright, so what does all that have to do with the peers? When the peers informed me of support group meeting they planned, it was almost their demand that there be refreshments provided. I got a mouthful from both the peers and the TB corner nurse about this issue and I felt thrown to the lions.

“The first meeting is very important you know Sarah, people will not come again if there is no food. They come in the morning for their treatment, and they have to wait all afternoon until 2 pm for the meeting, what will they eat?!” This led to a discussion of the peers themselves, and what they would eat on any given day for lunch, whether they would bring it with them or buy something near the clinic. Apparently the peers do not eat lunch. And this is where they really pulled my heartstrings, this is where they left me almost crying but feeling so manipulated it hurt.

“I do not eat lunch Sarah. How can I? I have four children to feed. I only make XX kwacha per month. How can somebody live on that?! There is the rent to pay, and the school fees. I do not eat until dinner! My second child is 7 years old and HIV positive. She doesn’t understand it. How can I explain it to her? And if I tell her she got it from me, she will hate me. And my oldest child started feeling sick, and I brought him for VCT (voluntary counseling and testing) and he is also HIV positive. And why haven’t we been paid yet? And why are they taking so many taxes out of our pay. Tell me Sarah, how are we supposed to live?”

Yes it’s true, poverty is rampant, they are not paid enough to really live on, they are not always paid on time and they probably do need more food than they have. Those are all things beyond my control. If I could fix them all I would do it in a heartbeat. Yes I feel for them and the more time I spend here, the more I am so grateful for all I have been blessed with in my life. But they played it all up because I came alone to see them, because I’m mzungu and must therefore be rich and therefore they are entitled to what I have. They would never have made such a stink if my Zambian colleague Lillian had been there.

They made me feel guilty about drinking from my water bottle. And when it ran dry, and I was parched, they were very forthcoming about the fact that there were drinks for sale in the TB clinic. But that was likely because I couldn’t sit there, after having heard them talk about how they hadn’t eaten all day, and buy a drink and drink it in front of them, without offering to buy them one too. And so, I bought three drinks. They were each less than a dollar, totally meaningless in the grand scheme of my spending. On the one hand I was happy to do it, something little I could give them that day. But on the other hand, the more I think about it, I feel so conned and manipulated into having done it that’s it just the principle of it that makes me so mad.

There are around 40 people expected at the meeting. 40 people! At the first meeting! How fabulous and exciting is that, that there seems to be such interest and such a need for it. Just the thought of it makes me so excited about this project and its potential. And all of those people said they would come without being promised refreshments.

The fact of the matter is, none of the regular HIV support groups have refreshments. People come because of what it means to them. And I truly believe that if the TB-HIV support group means anything to these patients, they will come regardless of a napkin wrapped pile of biscuits. But I’m starting to lose faith that this rampant cycle of expectations and handouts can ever be broken. And we have a damn long way to go before we even begin to understand sustainability.

After work, I will go home to my walled in McMansion, with my swimming pool, my Western style kitchen, my satellite TV and a fridge full of food. And I’ll think about necessities and excesses. But I will not be made to feel guilty for who I am. I am here in Zambia, living so far away from everything and everyone I know, to do my part, but it’s such a tiny piece, I wonder if any one person could ever feel that impact. Or ever appreciate it.