Drama in the Streets

Ng’ombe health center has relatively small catchment area compared to most of the other health centers in Lusaka. But its facilities are relatively large. These are some of the aspects that made it a prime candidate clinic for the new OPD/ART integration program, the integration of the regular outpatient services with the HIV clinic, which until now have always been separate.

As of last Monday, at Ng’ombe, there is no difference between HIV+ and HIV- patients. They visit the same clinic building. They are seen by the same nurses and COs(clinical officers)/MOs(medical officers). They pick up their medication from the same pharmacy. Everyone’s patient folders are cards are the same color. This is the beginning of the great experiment here, can we integrate the clinics, can we centralize the services. This was the task given by the department of health to CIDRZ, on a shoestring budget, with no extra support staff. I arrived in Zambia at an officious time for this project. After a year of footwork, planning, IRB approvals, trainings and countless meetings, the pilot program began last week. I will be part of the evaluation. I will help with any modifications that need to be made for the next clinic that is being integrated in October. I will help with training and implementation. I am eager to see how it works out. If it does work, it will serve as a model for many more clinics to come.

You can imagine that patients who are used to showing up at their neighborhood clinic with a certain system in place may be confused if one Monday morning the clinic flow changes entirely. So preparing the community for the change in integral. As part of this preparation, CIDRZ hires acting troops to go out into the community and put on shows about changes. I went out with them today.

When we first drove into the Ng’ombe neighborhood, to me it looked much like several of the other compounds I had visited. But when I asked Linah, the nurse who was with me, about how the neighborhoods compare, she said this one was nicer. The houses are nicer and more people work in the city. Another hard look at the cinder block houses with glass windows, at the dusty roads between them, at the tiny shops, convinced me of this fact, surprisingly.

We chose a street corner. The actors piled out of the car. They unloaded bright costumes and large drums from the roof. And they began to drum and sing. The call to the neighborhood, a performance is about to begin. The children began to gather, excitedly. Young mothers with babies wrapped to their backs shuffled over. The drumming intensified, the actors called and swayed with the music. American women just can’t dance the same way, that focused, strong, rhythmic booty shaking. After several minutes of dancing and singing, the skit began. It was in Nyanja, one of the local languages, and so I relied on Linah to translate. But they threw in English every once in a while, like “ART/OPD integration,” and “You can’t tell by looking.” The parts of the skit I understood involved the characters coming into a shared waiting room, asking why they were sitting with the HIV patients, asking if they could be infected, taking their turn to see the HIV testing counselors, taking their turn to see the doctor. It was a humorous skit, but practical. The bottom line was teaching the new clinic flow. When it was over, there was more dancing and singing. Towards the end, one of the actors dragged me into the middle to dance. And so, in front of a crowd of about 100 or more, I attempted to shake my booty Zambian style, which certainly got quite the laugh. I was the only mzungu around for miles.

The actors did two of these performances, each in a different portion of the neighborhood. I got to know two particularly cute little 6-year-old girls, Patience and Sarah. They were clearly best friends as they had their arms around each other the entire time. They talked to me a bit after the first performance and then followed our car to the second performance to watch again. After the second performance, they were joined by a throng of children, who all surrounded me and wanted me to take their picture. They were all fascinated when I showed them the picture I had taken. I couldn't help but smile at their cuteness. But then one boy, probably 11 or so, who will surely be a ladies man in a short amount of time, gave me a wink and a smile and started asked me for money so he could buy a snack. It made him less charming and it actually irritated me a bit. I think I will find myself in that situation a lot this year, little children fascinated with the white girl, but wanting something too, probably from past experience.

That wanting something is not just the children. The staff meeting at Ng'ombe clinic yesterday afternoon gave me a better sense of what sustainability means. All of the NGOs, which trying to fix a problem, have also created a problem. In years past, CIDRZ has been willing to pay overtime to health workers to help implement the various initiatives. But that cannot go on forever, especially as the changes become standard of care. Yet some of the nurses still expect it, for even the smallest extra effort on their part. There was a tension in the air at the meeting, mostly surrounding the lack of resources at the clinic, for which CIDRZ is neither responsible nor can they provide. On the one hand I understand them. They are overworked, the clinics understaffed, and there are too many patients to see. But our job is to make the changes sustainable and enable them to continue themselves. Therein lays the challenge.

First week

The venturing out has begun. It was a whirlwind week of going out into the field to see all of the various projects that CIDRZ does. Each day, we went out with different teams from the various service initiatives.

CIDRZ has over 500 employees. While many of them spend most of their time in the office, there are many more who work in the clinics, in the hospitals, and even door to door. Each morning at 8:30 am, a fleet of minivans and SUVs fills with people, clown car style, and they head out in every direction towards the clinics. Most of these are located in what’s known as compounds, essentially slum neighborhoods. Some have electricity, some have water, some do not. The houses are placed haphazardly, some along the road, others back from the road, in clusters, all alone. Some houses seem to have been thrown together with whatever building material was available- some concrete here, some corrugated metal there, a bit of wood in places.

The roads to these compounds start out well paved, but as they reach many of the clinic areas, pavement turns into rocky, rutted, hard packed dirt road. Sometimes a marketplace will be placed seemingly in the middle of the road, yet the car will somehow makes its way through the masses, as if going for a browse through the market itself.

Driving through one of these is almost an over stimulation of things to look at. Little thatch-roofed stalls manned by women wrapped in their colorful chitenge. Piles of shoes for which you must sort, and would be lucky to find a pair. Ever wonder what happens to all those clothes you donate to Goodwill? They’re here. Wrinkled donated clothing from the states hanging on hangers placed every which way across the stall, sporting such sayings as “Everyone Loves an Italian Girl” and “Suessical the Musical.” Dust sprinkled vegetables, potatoes, tomatoes, yucca, and large green leafy vegetables of unknown sort sit in defined piles, marked with hand written price signs. Plastic buckets, brooms, and dustpans. There are extra dusty portions of the market selling packages of charcoal. If you looked hard enough, you could probably find almost everything you need there, at far more reasonable prices than the imported South African supermarkets. Weaving between these booths are the Zambians wearing most clothing like the ones for sale, the women with the added accessory of a baby wrapped tightly in a chitenge on their back, and a basket balanced firmly on their heads. The soundtrack to all of this was the bouncing African music the driver had blasting, with the added bouncing of the van itself along the rutted roads. The masses parted, miraculously, for our van, and on the other end was the sign for the Ministry of Health clinic.

The clinics remind me of the many clinics I saw in Panama. Yet there were differences too, some better and some worse. As in many developing countries, they are compounds of simple concrete and brick buildings, some with large waiting areas, some with cluttered hallways, but most all of them are filled with people waiting to see a health worker. CIDRZ has helped to revolutionize HIV treatment here. Many of the clinics now have new buildings devoted completely to ART (anti retroviral treatment), where there was no building, or treatment, before. It is really only since 2003 or so that such treatment has become so widely available. They streamline the process well. The hall of the ART clinic takes you down an assembly line of all the services offered. You start with the VCT area (voluntary counseling and treatment). Then there is intake, exam rooms, adherence counseling and pharmacy. At the end of the hall, there are always the CIDRZ data people, in rooms filled with computers where you would never expect to find a computer. Their teams works to document the massive amounts of data produced by the more than 150,000 on ARVs (anti retrovirals) for the ART scale up project alone, not to mention a comparable number of mothers in the PMTCT (prevention of mother to child transmission) and pediatric HIV programs. They keep tabs on every single CD4 count, who is failing treatment, who has not showed up for follow up appointments. At the very end of the hall, the community team helps track down those who have not come back. Floating between these rooms is the QA/QC nurse (quality assurance/quality control), who mentors the clinicians, does chart reviews, and follows up on patients failing treatment.

All of that is just the ART clinic area. Each clinic compound has a MCH (maternal child health) area as well, with an equally crowded hallway of waiting pregnant moms, and an equally if not more impressive computer system to keep tabs on them. Perry, the America doctor in charge of the PMTCT program, can sit in the CIDRZ office, and monitor via his computer exactly how many women were seen in any given clinic that day, how many tested HIV positive, and how many were sent to the University Teaching Hospital (UTH) for any obstetrical problems.

I got a tour of the labor and delivery wings at many of the clinics as well. While many women probably deliver at home, many deliver at the local clinics. It is far fewer who deliver at UTH. In Panama, my impression of Labor and Deliver compared to the states was certainly barebones. But this, blew all of that away. In one clinic, we were brought to a simple room with four bare stretchers. One woman lay wrapped up in a sheet, the only sheet I saw in the whole room. She looked barely 14, but she was all alone. The midwife said they don’t allow any family in, and encourage them to go home in fact to cook food for the mother once she is finished delivering. There are certainly no monitors. A shortage of gloves. I am not sure if I saw oxygen. The stethoscopes were the old fashioned megaphone looking contraptions, which you place directly on their stomach and place you ear to. This was for listening to fetal heart sounds. This is birthing as it has been done for centuries, perhaps even slightly better.

My clinic visit on Friday led to my taking the unexpected role as pediatric ART clinician for the morning, with some help of course. There are very few doctors. Every clinic has at least one clinical officer (CO), which is the equivalent of our PAs back in the States. Together with the nurses, they run most of the care. The doctors spend most of their time in the regular outpatient services side of the clinic, and are only called in for very complicated cases. After our clinic tour, we were invited to watch one of the COs see the pediatric ART visits. After a couple of visits, he asked me if I wanted to try. So suddenly, there I saw, sitting at the desk, pen in hand, flipping through the file, asking a little two year old girl’s mother about which medications she was on, how she had been feeling, doing a quick physical exam and making a plan for follow up. I didn’t know when I started the morning, but now I do. Using percentage CD4 count rather than absolute count for children, first line pediatric ARVs, how to dose them (there’s a useful weight chart on the wall), other supplementary medications like septrin, multivitamins and iron, and when to make follow up appointments. One 10-year-old boy came in with a plan to start ARVs that day. He had been seen two weeks previous with a falling CD4 percentage and had various labs drawn in preparation for beginning meds. During the history his mother mentioned that he had developed a dry cough. I’m not sure that his lungs would have been listened to if I had not been there, because I’m not convinced that the CO had a stethoscope. His physical exams were short at best. But I took a listen, and his lungs sounded junky. So together, we made a plan to get him a chest xray, throw him on some regular antibiotics and start his ARVs. What’s common is still common, the most common causes of pneumonia in HIV patients are the most common causes for the general population. But I wonder if we’ll find that he has something more complicated, like PCP pneumonia or tuberculosis.

Disclosure of HIV status to children is another issue that left me thinking. Part of the regular counseling is asking if the children understand that they have a chronic disease, have HIV, what it means. I did not meet one who did. Many of the children I saw were young, ranging from babies to 10 years old. The mothers stated that none of them knew, that they thought taking pills was the norm. There was one 13-year-old boy who came by himself. We asked him if he understood why he was taking pills, why he came to clinic, and he said no. We asked him where his parents were. Mother dead, father at work. We asked him to return to his next appointment with his father, so that we could begin the delicate topic of disclosure with the counselors. But really, how could he be 13 and not understand his status?

The “what’s going on?” moment of the morning was with a 7-year-old girl, who came in with a woman and a baby. We always inquire after the mothers when the children come in, because they too should be enrolled in the ART program. We asked this woman if her baby was okay, she smiled and said yes, we asked if her husband was okay, and she said yes, we asked if she uses condoms with her husband, to which she shyly replied no. At this point, we thought we would have to get into a counseling session. And then she said she was HIV negative, to which all of us responded “huh?” But the question, “is this your daughter” quickly clarified that this little girl was in fact her niece. Her parents are dead, and she is one of the millions of AIDS orphans. Now I know not to make any assumptions.

My mind is chock full of these experiences, these impressions. It’s only the first week. I have not even begun my project yet. This is just a taste of all that is going on here. On Monday morning, I will begin to learn about my project. From what I know now, there are two clinics that are piloting the integration of all services- regular outpatient services with ART and tuberculosis care. Up until now, they have been very much separate, if only because the massive amounts of funding which have come in the past few years for AIDS in Africa led to the rapid creation of the self standing ART clinics. Now we are trying to integrate those services with everything else.

My week of understanding life as a Zambian a little better ended with life once again as a mzungu. After work, there was happy hour (which turned into happy three hours) at the fancy South African bar/restaurant at the Arcades Mall, with about 20 expats from CIDRZ. Seeing a bill for 780,000 kwacha made me laugh. The evening continued with the new Batman movie, opening weekend here, only one week after the States. Impressed? It was a little bizarre standing in the movie theater which could have been any Loews back at home, meeting a friend of one of the CIDRZ people who was also class of 2004 at MIT and lives in Boston. Once again, I had to remind myself where I was.

This morning I joined in to the ultimate Frisbee games that happen every weekend at the American School outside of town. Another mzungu event for sure, but a great way to meet more people. Made me miss my ultimate buddies back in Cambridge, but it was a great game and a great workout.

Corrected phone number

Please note the correction to the phone number I posted earlier. This is everything you have to dial from a US phone. I'm six hours ahead. Call me. I can get/send text messages too.

011 260 966 934 700

First reflections

First weekend in Zambia and already a party. Emily turned 30, and it was reason to celebrate. Less than 24 hours after she arrived in the country, we managed to throw together a potluck between the two intern houses. Two o’clock in the afternoon found the four of us zipping along Addis Ababa Drive in a taxi, together with our little charcoal grill, pasta salad and three trays of oatmeal raisin bars.
Food prices are somewhat shocking here. We couldn’t find any canned goods for less than $1. Toilet paper and paper towels can be more than a $1/roll. Even grains are more. At least vegetables and fruits are somewhat more comparable. Perhaps it’s because we happen to live near the most expensive supermarket in town, Superspar. I always thought Shoprite was the expensive African supermarket, but apparently it’s the budget place around here. Perhaps it’s also because my budget this year will be teeny, and while I am living rent free, food and transport is going to add up fast. So I think cooking will get creative this year. We’ve already replaced $30 bottles of olive oil with olive oil cooking spray (garlic flavored!) Our pasta salad came out surprisingly well, considering it was dressed with the cheapest salad dressing they had, a $3 bottle of somewhat neon yellow colored Greek dressing.
Our first party in Zambia was a smashing success. The other intern house, while not quite a McMansion, has a beautiful grassy yard. With our satellite radio blasting via the TV and through the open windows, all the dining room furniture moved outside, and a table covered in tasty food, it was a great afternoon to get to know each other. My first Zambian beer, Mosi, was nothing to write home about, but was refreshing nonetheless.
Night falls fast on Lusaka. As soon as the sun dips below the horizon, the city is blanketed in a thick blanket of darkness. And while there are streetlights in places, there are by no means enough. As a result, it’s not safe to be out after dark, and in fact I’ve heard there’s technically a curfew. Since it’s winter season right now and we are somewhat equatorial, it means that by 6:30 pm, we are driven within the walls of our protected compounds. But on Sunday night it was okay being stuck within. As the sky darkened, we melted candles in old wine bottles, and continued our lively conversations of all the places we have been, and all we’ve yet to do. It took a reminder that tomorrow was our first day of work to finally get us to stop talking, call a cab, and make our way home.

It’s funny, but after only three days here, I’m already feeling like I live here. On a trip to The Arcades (that’s the strip mall) on Sunday morning for groceries, we encountered a massive throng of young Americans, probably college students, converging on the money exchange. I stared at them thinking, “Who are all these people, why are they here, why are they taking up all this space and being such loud Americans, I live here!”

Today was our first day of work. Like any new job, it was a day of orientation, one of those painful but necessary days of talk after talk from every department in the company. We had extensive lectures from facilities, IT, finance, acquisitions and security. I now know more than I could ever want to know about reimbursement for expenses both below and above 300,000 kwacha. It wasn’t all boring talks though. The morning was full of presentations from all the different research and service groups here- antiretroviral treatment scale up (ART), prevention of mother to child transmission (PMTCT), HIV/TB integration, pediatric HIV, cervical cancer and community outreach. Each talk made me more excited about the work that’s going on here, how incredible it is, and how much I can’t wait to be a part of it. The highlight of the day was probably the presentation by the community members, who sang for us, wrapped us in traditional fabrics and made us dance. That was followed by a traditional Zambian lunch. The nshima (maize paste used to pick up food) and various vegetable stews were okay. I was a big fan of the sweet potatoes with a peanuty sauce. I skipped the fried caterpillars, despite their encouragement that I try it.

My roommates and I are slowly developing our routine. We started the morning off with some cardio, another Billy Blank’s Bootcamp session. I managed not to laugh at myself quite as much today as I did yesterday. After getting home from orientation today, we made dinner together. Now we’re all sitting at our large, square dining room table, quiet music playing in the background, all lost in our own worlds of writing the days reflections. I think as we all settle into our projects, we won’t spend quite as much time together. Probably by the end of this orientation week we’ll be tired of each other anyway. But we promised to try and have one family dinner per week.

Call me!

So here's my Zambian cell phone:
011 260 966 934 700
I haven't sorted out call forwarding yet, so you can call a calling card and call me on this number. Can't wait to hear from all of you.

Finally home!

My house

As the plane landed on the simple one lane runway, I felt a pull towards the familiar. Not home, exactly, but to a place I knew in a sense, a place to be comfortable, and a place to hopefully call home soon. The dry brown landscape faded green scrub brush and thin plumes of smoke from burning garbage in the distance. Hand painted advertisements next to the airport building touted the wonders of both competing cellular companies. Arriving in Zambia was very much like arriving in Tanzania, the one room concrete arrivals area, with booths marked off for Zambians, permit holders, foreigners, and VIPs/Diplomats, and border guards stamping passports at a snails pace. Why rush? What else is there to do today, but stamp some more passports? The one baggage conveyer belt was fed by luggage handlers we could see through the doors, dropping bags one by one. People crowded the belt, removing bag after bag, barricading themselves in a fortress of packages and completely blocking the belt, leaving no room for others to get even near the rotating bags.

But somehow I managed to grab mine, get them onto my trolley, and walk neatly through customs, to the driver from CIDRZ (Center for Infectious Disease Research) holding a sign with my name. Nixon introduced himself, helped me to the white Toyota SUV, and with that, I had arrived in Lusaka. He drove me down well paved, clean, tree lined boulevards towards town. As I remembered from Tanzania, there were dozens of bicyclists zipping along the sides of the road, women wrapped in brightly colored fabrics, carrying baskets on their heads, school children running. He pointed out landmarks- a health clinic, the University of Zambia, the Manda Hill shopping center with Shop Rite supermarket, the Arcades shopping center closer to my home. He drove me to one of the CIDRZ offices to pick up my house keys and a Zambian cell phone. Like most houses and important offices in any African city, the office can almost be called a compound, hidden behind high concrete and electrified wire. We pulled up in the driveway, beeped once, and a guard came out to slide open the gate. The office was surprisingly nice, a large carpeted house, chock full of desks and computers, and people busy at work, both Zambians and ex-pats.

It was only a short drive to my home, the compound on Thabo Mbeki road, the Spanish cycle hacienda hidden behind walls and wire, guard at the gate. Some people at CIDRZ call it the McMansion. As the gate pulled aside and we drove into the driveway, I almost felt like those people on “Extreme Home Makeover” must feel when their new house is first revealed to them. This? This is my house? I’ve never lived in such a nice house in my entire life. I come all the way to Zambia to live in this house? As I walked in, I admired the stone and tiled floors, the 12 ft ceilings with molding, the kitchen complete with microwave, stove, oven, toaster and washing machine. And oh yeah, the pool, there’s a pool outside. Check it out:

The past few days have been a slow acclimation, to time zone, neighborhood, and people. Figuring out where we are on the map of this sprawling city. Figuring out where to get necessities, like milk, eggs and toilet paper. Where the buses run, how to catch a taxi. Rearranging our furniture, sorting out the kitchen. All of things we do when moving into any new house that really make it a home.

As for who is living here with me, numerous sources have decided that we should henceforth be referred to as “Real World Zambia.” There are nine of us in total, four at my house and five at the other. My roommates are Valerie, Liz and Sarah. Valerie is boisterous, spirited, talkative MPHer most recently from University of Alabama. She can talk up anybody and be best friends within a matter of minutes. It’s hard to be around her and not be happy. Liz is a family nurse practitioner from California who specializes in HIV treatment. She is friendly, outgoing and laughs a ton. When her and Valerie are in a room together, the energy level kicks up a notch. The other Sarah is a quiet but free spirited southerwesterner. There are five others, some of whom I met at the other house today. All in all, I’d say it’s an incredibly accomplished and totally fun group of people. I can’t wait to get to know them all.

So this is my world within the compound. Living in this isolated, protected place is this strange contrast to the world outside. Our first day after arriving, we stepped outside our gate, looked around and said, “Now we’re in Zambia.” We walked down yet another seemingly familiar African road. We passed trucks packed with men hanging off the sides and spewing black smoke, calling to us and waving as it passed. We passed bicycles, and men selling bags of nuts by the side of the road. Many of them greet us, perhaps out of wanting to sell us something, or curiosity, or maybe just friendliness

But after that bit of what Africa should be like, we hit the strip mall, which, if you squinted your eyes a bit, you might believe was in southern Florida. Large parking lots, palm trees, tile lined walkways and fountains, upscale stores and restaurants. This is the Lusaka of the mzungu and the Zambian aristocrats. But this is not the Lusaka of countless others. I am eager to begin my job on Monday, to work with real Zambians, to visit real clinics, to see what it really is that makes this country tick.

I’d best go to sleep, I have a date with my roommates in the morning to do the Billy Blanks exercise video. Getting exercise here will be quite different than at home. Running outside draws quite a bit of attention. And the gym that attracts mostly whites is actually more expensive than my gym back at home. But I discovered the ultimate frisbee games and will be certainly attending the next one.

One more day to settle in and relax before the real work begins.

Expect the Unexpected

I could not have guessed when I woke up yesterday morning that 12 hours later, I would be on an airplane bound for London. Suffice it to say, never use Expedia and if you do, don't book a flight on multiple carriers.

I was supposed to leave on Wednesday morning. Mentally, that was my departure point. Tuesday was supposed to be this day of recovering from the boards (which went better than expected), tying up all the loose ends, and enjoying the company of my parents on my final day in Boston. But things don't always happen as we expect them to. And so this year long adventure began a day early.

So here I sit, outside Heathrow airport, being extremely thankful for the free WiFi. It's a cool sunny morning and I'm enjoying the fresh air after 5 1/2 hours in a stuffy cabin. The red eye flights are rough though. My body barely settled down for the night when the faintness of dawn seeped through the windows of our plane chasing the sun. The sunlight and the coffee-cup-and- crisp- newspaper morning bustle has tricked my body into thinking it needs to be awake again, but I know this will catch up with me later. With this fresh new day comes a more solid feeling that all this planning is finally over, that I'm really going, and I can't wait to get there.

Perhaps my day yesterday set the tone for the year. Hopefully not always quite as stressful, but certainly unexpected.

Contact information

I know all of you probably have images of me living in a little mud hut with a thatched roof in the middle of a village, bringing buckets of water on my head from the river, hunting animals with spears and all that. But amid all that, I'm actually going to have a telephone, and internet, and email and skype, and a postal address too. That means that I want your phone calls, emails, letters, and packages (hint hint). I want to know how all of you are doing.

So here's all the info:
Email: sgottfried@gmail.com, and gchat is a good way to talk

Skype: My skype name is sarah.gottfried If you're not familiar with skype, you can download it for free, and we can talk for free via our computers. Just make sure you have a microphone.

Telephone: I bought a skype phone number. It's a local US phone number, that you can all dial from your regular telephones, and I'll pick it up on my computer, or I can even forward that to my Zambian cell phone.
Telephone number is 617 381 4221
I will also have a cell phone once I get there, and you can call that number too. Calling cards are pretty easy to pick up these days. I've gotten great rates from a company called Viapin (www.viapin.com), you can buy the calling card online.
Time zone difference is currently 6 hours, and when we go off of daylight savings time here, it will be 7 hours.

Mailing address:
For flat mail-
Sarah Gottfried
c/o CIDRZ Zambia
1500 6th Ave. S.
Room CRWH 370
Birmingham, AL 35233

For real packages-
Sarah Gottfried
c/o Centre for Infectious Disease Research Zambia (CIDRZ)
PO Box 34681
Lusaka, Zambia

Some Zambia background

Because you've all been asking...here are some fast facts....

Population: 11,227,000

Capital: Lusaka; population 1,394,000

Area: 290,586 square miles (slightly larger than Texas)
Language: English, indigenous languages (73+)

Religion: Christian, Muslim, Hindu

Currency: Zambian kwacha

Life Expectancy: 41

GDP per Capita: U.S. $800

Literacy Percent: 81

A landlocked country in central Africa, Zambia occupies an elevated plateau, flanked in the south by the Zambezi River—and Victoria Falls. There are more than 70 ethnic groups, and most of them live in Lusaka, the capital, or in the cities of the Copperbelt—the two largest, Ndola and Kitwe, have more than 400,000 people each. It is one of sub-Saharan Africa's most highly urbanized countries.

Endowed with huge copper reserves and fertile farmland, Zambia looked to the future with optimism after independence from Britain in 1964. But copper prices plummeted in the mid-1970s, and transport costs soared. The economy has been in decline ever since, and copper, vital to Zambia's economy, suffers from declining prices.

Farming will become increasingly important; only a fifth of the arable land is cultivated. Thundering Victoria Falls and other power sources bring self-sufficiency in hydroelectricity.

The territory of Northern Rhodesia was administered by the [British] South Africa Company from 1891 until it was taken over by the UK in 1923. During the 1920s and 1930s, advances in mining spurred development and immigration. The name was changed to Zambia upon independence in 1964. In the 1980s and 1990s, declining copper prices and a prolonged drought hurt the economy. Elections in 1991 brought an end to one-party rule, but the subsequent vote in 1996 saw blatant harassment of opposition parties. The election in 2001 was marked by administrative problems with three parties filing a legal petition challenging the election of ruling party candidate Levy Mwanawasa. The new president launched an anticorruption investigation in 2002 to probe high-level corruption during the previous administration. In 2006-07, this task force successfully prosecuted four cases, including a landmark civil case in the UK in which former President Chiluba and numerous others were found liable for USD 41 million. Mwanawasa was reelected in 2006 in an election that was deemed free and fair.

More than 70 percent of Zambians live in poverty, and unemployment is a serious problem. Zambia depends on copper for most of its foreign earnings so the economy suffers when copper prices decline. AIDS is blamed for decimating the cream of Zambian professionals, including engineers and political leaders. It kills around 100,000 people each year.

Economy
Industry: copper mining and processing, construction, foodstuffs, beverages.
Agriculture: corn, sorghum, rice, peanuts; cattle.
Exports: copper, cobalt, electricity, tobacco, flowers.

Sources:
http://www3.nationalgeographic.com/places/countries/country_zambia.html
https://www.cia.gov/library/publications/the-world-factbook/geos/za.html

10 Days Till Departure

I just returned from a weekend of backpacking in the White Mountains. It would have been a weekend like countless ones before it but this one seemed different because it's the last time I will hike there for a year. In ten days from now, I'll be on an airplane headed towards my new home, Zambia. Each view into the familiar valleys, each summit I hit, each cozy night in my tent, with good friends, on top of a beautiful mountain was made more bittersweet by the thought that all that is coming soon in unknown.
My emotions vary wildly on a daily basis. One moment, I'm immensely excited for all that is to come. The next moment, I feel this questioning, this hesitancy, did I make the right decision to do this, to give an entire year of my life? As I watched my car drive away last week, it hit me especially hard. It's no longer my car. A years worth of driving to hospitals way too early in the morning, NPR blaring, coffee stains and breakfast bar crumbs are all that remain. It will not carry me to my fourth year adventures, to more hospitals, to my journey of figuring out what kind of doctor to be.
Tomorrow is the first day of fourth year for all of my classmates. They will be waking up early, heading to new hospitals, ready to work hard and impress for one of the most important rotations of fourth year. Instead, my week will be full of studying and packing. Packing up my room, putting away all the things I will leave behind, trying to fit all the things I will take with me. How do I efficiently pack a years worth of life into two suitcases?
And there will be many goodbyes. I don't know if I want to say so many goodbyes. But I have chosen my path. Take a deep breath, twende (well, that's Kiswahili but close enough for now), let's go!