In the two weeks since I’ve gotten back from Cape Town, time has flown. Unlike the last time I arrived in Lusaka, in July, when everything was fresh and new and everything took adjusting to, this time it was like coming home after a vacation and all the good and bad that entails. It was both unwelcoming and comforting to slip back into the well developed routine-the early morning runs, daily greetings at the office, navigating transport arrangements and refreshment orders at work, evenings of cooking dinners, watching movies, reading, blogging, chatting and of course, weekend get togethers. I wasn’t so excited to get back to the crowds of Lusaka, the traffic, the exhaust, the burning garbage and always being on the defensive. But it felt good to get back to work starting from the place I had paused, rather than starting anew.
When I first arrived in Lusaka, each week was an achievement, another week here, another week toward some mark, one month, two months. Yesterday marked six months here, but I almost forgot it.
The first Monday back, there was already so much going on. The OPD/ART integration at Chazanga clinic is less than 30 days away. Matero Main Clinic will not be far behind. It’s amazing to think that nine months of planning went into integrating at Ng’ombe, the first clinic, and Chazanga will take us less than three. The really interesting part will probably be the information we gather from long term monitoring. More than a year’s worth of data about patient HIV testing, ART enrollment, overall numbers of clinic visits and patient waiting times will tell us a lot about the wider applicability of this integrated system. But for now, we plan, we implement, and we monitor.
The peer educator program at Chipata and George is headed towards the end of its pilot period. The September training feels like it just happened, but now they’re done with four and a half months. My (somewhat) daunting task is to complete an evaluation of that program in the next month. That way, by the official end of the program on February 28th, we will have an answer for them as to whether or not we can renew their contracts. It’s our program, but the ministry of health has to give the okay, and if they say the program goes, then it goes. From the way things look now, if the program does get stopped, it seems that it will be entirely a funding issue. They don’t want to continue programs that they will be expected to fund down the road.
That highlights the dynamic relationship between Zambian government funding of health programs and outside funding. There is a staggering amount of outside money coming into this country for health, specifically for HIV. If you look the annual national spending on health, about 10% of that comes from the Zambian government. The rest is outside funding, like PEPFAR and Global Fund money, most of which is directed at HIV. HIV treatment has massively dwarfed everything else, and while it’s great to have so many people being treated, the health infrastructure here was weak to begin with and has been strained even more so since PEPFAR.
So while the ministry of health is happy to have programs like peer educators working with TB-HIV patients, I don’t know how much hope there is for them ever funding it themselves. But I’m going to try and get them to agree, to at least let us continue this program for now.
I made a stop at George Clinic last week to pick up somebody on the way to somewhere else, and I ran into one of the TB-HIV peers. She’s the one I feel the most conflicted about, she’s the one I like a lot, but who takes advantage of me as much as she can, by telling me how poor and destitute her family is. The first thing she says to me after greeting me is, “Sarah, what have you brought us today?” There are so many snide, rude, angry, sarcastic things I want to say to her, because she never stops. Of course I don’t actually say those things, and I just have to smile and joke it away and say I don’t have anything for them.
I wonder if it would matter to her to know how hard I’m working to keep her current job, how even if the peer educator program doesn’t continue, I’m working on getting another job for all four of them within CIDRZ. Would that change her attitude toward me? Would it ever be enough? Or would she continue the emotional blackmail. She is poor and I am white (=rich) so therefore she is entitled to everything I have.
Working at an NGO has made me a bit bitter. It’s highlighted that very tricky, shady border between getting programs started and sustainability, and I think I might be losing faith that the sustainability part ever really happens. Not just in health, but in other areas as well.
Last night, as I was driving with a friend over a very rough, pot-holy road, in a nice neighborhood, that clearly hasn’t been repaired since it was built, I was reminded of one of my most vivid memories from Tanzania. I was with Johanna and Alea in the coastal city of Lindi. This is still a beautiful town in many ways, built along a sheltered bay on the Indian Ocean. It used to be the German administrative town, and there are many old, very solidly built buildings that were built and run by the Germans until they were handed over to Tanzania at independence. But rather than use and maintain these buildings they already had, they let them fall into disrepair. If you walk the streets of Lindi today, you will pass by big, solid, crumbling buildings, with newer, thatch roofed huts dispersed between them.
Somehow this turned into another sustainability rant, although I didn’t mean it to be so. But I think it highlights how every day here is a swing of emotions, between the satisfaction of accomplishment, the wonder and appreciation of another culture, and the stress and frustration at how things work here. But as they say, for all the good and the bad, TIA.
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