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.