Two unrelated stories to make me reflect further on gender in Zambia.
Story #1
This story also makes me reflect on myself, on how trusting I am, or how much I choose to see the good in people, because my reaction to a patient and reaction of Dr. Jack were very different.
I saw a patient on Wednesday. A man in his 40s, on ARVs for several years now. Has been doing fairly well, says he is adherent to his medications (but everyone always does). On this visit, we noted a largish drop in his CD4 count, not quite significant enough to consider assessing him for treatment failure, but it was a drop. But on exam he looked fine, he hadn’t had any recent illnesses or infections. I asked him if he was married, and then I asked if his wife has been tested, and here is the story he tells me.
Yes, she was tested in 2005 at UTH (University Teaching Hosptial) when she was pregnant, and the test was negative, but I don’t believe it. How could she be negative after all that time we were together?
So my initial thought about this statement was, he was worried about her. He really did feel she should recheck, that it could be a false negative, that since he’s infected it would be likely she is too. When I asked if he had suggested she test again, he said it wasn’t his place. Then he asked me this:
From 1991 until 2001, I was completely abstinent. Since that time, I have only had unprotected sex with my wife. Is it possible I could have been infected as long ago as 1991?
Again, my first thought about this statement was that he was really trying to figure out if his wife could really be positive and not getting treated. And I went into an explanation of the evolution of an HIV infection, and how it’s perfectly possible that he was infected back then, and he could have been healthy all this time as his CD4 count slowly went down.
So then Dr. Jack comes in, notes the large drop in CD4 count, immediately starts probing about how adherent to his medication the man really is. That’s Dr. Jack’s big thing, your CD4 drops, you’re having adherence issues. So he starts asking him about the situation at home, if there’s trouble with his wife, if he’s depressed. What Dr. Jack picks up on right away, and I did not at all, is that this man isn’t asking these questions because he’s worried about his wife, he’s asking because he’s blaming her. He thinks it’s her fault, that she really is positive and she infected him. It’s all about the blame game. Dr. Jack shares a story about another patient of his, a girl who got raped when she was 13, got a baby out of it, and then never had sex again (and he believes her). And 26 years later is when she was diagnosed with HIV because of multiple AIDS related infections. That is way above the upper limit of normal for how long it can take to develop AIDS, but it’s possible. For this man, 10 years is higher, but by no means uncommon.
The man started getting a bit uncomfortable and clearly didn’t want to be there anymore, kept looking at his phone, at his watch. He left as quickly as he could.
But there it is, I hear it all time, about men who refuse to get an HIV test, even when their wives come home from the pre-natal clinic found to be HIV+, even when their little newborns get diagnosed with HIV, these men blame their wives and do not think it could be themselves.
I’d like to acknowledge the fact that it could be his wife, maybe it was a false negative test and she did get HIV first. By no means am I saying it’s always the men. But if often is. And if they refuse to be equal partners in testing and prevention, if we can’t get beyond the figure pointing to the point of, well, we’re infected, what can we do about this now? we will never curb this HIV crisis.
Story #2
I went out to lunch yesterday with my supervisor Steph and Julian, one of the nurses who works with us at CIDRZ. We are the OPD-ART integration team, and we thought it would be nice to have a lunch together to acknowledge all the progress we’ve made over the last year. Over the course of the conversation, Steph asked Julian how she had met her husband, and she proceeded to tell us a wonderful story of serendipity.
Julian had been a nursing student at a hospital in the Copperbelt and her (future) husband had been a Ministry of Health official, visiting the hospital and met Julian because he stopped her in the hallway to ask for directions to an office. He had been enchanted with her, and later found her again to thank her. After that encounter, he wrote her a couple of letters, but she wasn’t really sure how to respond and she didn’t.
Two years later, she had graduated, and moved to hospital up in Northern Province. He had just taken a job there too, in the MoH office, although neither of them knew about the presence of the other. One day, he saw her name on a roster, and wondered if it was the same Julian. He asked that she be called in to the office to see him.
So there she is, working at the hospital and gets a message that she’s been summoned to the district health office to see the Director of such and such (but no name) and she has no idea why. She figures it’s because she’s getting fired. She said it was a long walk over to the office. Then when she told the secretary she had an appointment, the secretary asked why, and Julian said she didn’t know, and the secretary thought there must be some mistake, because why would such an (unimportant) woman be told to meet the Director of such and such if she didn’t even know why. But the appointment was confirmed and Julian was shown into his office, while he wasn’t there, to sit and contemplate her impending job loss.
Then he walked in, and smiled, and said, “Ahh, it’s you!”
She was definitely in shock at first, and didn’t know what to say, and felt bad for not returning his letters. But sounds like she got over it, because after 6 months of dating they got engaged.
I tell this story because it’s so cute, but the gender part relates to a statement Julian made after telling the story.
She said, “I really thank God for giving me such a truly good man. He loves me and he loves our children, and he supports us, and he helps take care of the children and the house, and I feel so lucky for such a good man.”
At first, hers statement made me a little sad, the fact that it meant so much to her implied to me that it’s not the norm here, and I’ve certainly observed that. Even some of the upper-middle class Zambian women I’ve met here tell me about how their husbands will come home from work, kick up their feet, read the paper, and expect their wives to do it all, they won’t lift a finger at home.
But then her statement also made me think about the way things are at home. Some of these things have become a given, at least in some parts of the country, men are expected to do these things-house cleaning, child care- and when they don’t, their wives get upset. Should they be so upset? Should they be more thankful, or at least, acknowledging of the help their husbands offer at home? Would more marriages be healthy and strong, from just those simple acknowledgments?
How different, really, are gender roles here and in the US?
Friday, February 27, 2009
Friday, February 13, 2009
Weeks'-End-Update and a Word about Food
It already feels like ages since that last uplifting entry and yet the weeks have flown by lightning fast, I can’t believe it’s already Friday again. But it’s all been rushing forward towards big things.
Next week is big, for both of my projects.
Monday is ART-OPD integration at clinic number 3, in a neighborhood called Chazanga. It's hard to believe it all happened so quickly. When I first got here in July, they had spent 9 months preparing to integrate the first clinic, Ng’ombe. Chazanga we planned from start to finish in less than 3 months. Something that makes this clinic unique is that they don’t yet have an ART program. ART will be starting next week as well. So not only are they initiating ART, but it is beginning as a fully integrated clinic, with ART just part of the outpatient department. It will be nice because we don't have to rework any of the established systems in the clinic, but it will be more challenging for the staff I think because they will just be learning how to work in an ART clinic. It's nice for the patients, because until now, they haven't had ART in their neighborhood clinic, and they've had to travel to other health centers to get their ARVs. Now it'll be close to home, and I think we're going to have a lot more people testing for HIV, since we've made (opt out) testing a standard part of any clinic visit.
My peer educator program evaluation moved along nicely as well. The interviews are complete. Let me tell you, it was a royal pain in the butt coordinating availability of my staff, who were conducting the interviews, with availability of the clinic staff to be interviewed, with availability of transport to get them there. But somehow (with a few extra visits to the clinics, why did we have to choose the furthest away clinics for our program) we managed to interview everyone we intended to.
Next week we're hosting officials from the local Ministry of Health, doing a site visit with them so they can see what the peer educators are doing, and then presenting them with the data we've collected. Overall there's been a very positive response to the program, from staff and from patients. And the concern that the people who volunteer at TB corner would be resentful of our peers getting paid to work at TB corner was somewhat founded, but doesn't seem to be too harmful overall. Everyone here is always looking for "motivation," incentives, snacks, transport allowances. I think the only thing holding us back from expanding this peer program will be available funding. I think our CDC funding is much tighter this year. Looks like if the MoH says yes, we will be able to continue the current peers at least for the coming year, but expanding it to other clinics looks uncertain. I’ll know on Wednesday if I can call this project a success.
Wednesdays have become my clinic days, and it's been really awesome. I've been going long enough now that I'm even getting to see some patients who return for follow ups. Yesterday I saw the little 8 year old girl who I first saw a month ago for her initial history and physical. If you look back to my January entries, you can read all about what a bad condition she was in at the time.
Right after I saw her in January, she was initiated on anti TB therapy and given various antibiotics and antifungals for her opportunistic infections. She definitely looked better yesterday than the last time I saw her! For kids we do CD4%age instead of absolute CD4 count. Her %age was, get this, 0.4%! Anything under 25% is considered getting low. Her CD4 count was essentially nothing. We initiated her on ARVs yesterday, it was really interesting for me to see how we go about doing that, choosing which drugs and which doses, based on her co-infections and other medications. Concurrent ARVS and TB treatment can be tricky. Of course just this morning I read an article about IRIS, immune reconstitution inflammatory syndrome, a serious condition patients can get after initiating ARVs while already on TB treatment. Now I keep thinking of her and hope I don’t see her in a few weeks time with that too. It's hard to see kids like that, but I really enjoy the overall experience too, the medicine, the interaction, the support, the learning.
I have to say though, working in an HIV clinic makes is not helping me remember my non-infectious disease stuff. I saw another patient a few weeks back, a friend of someone at the clinic who just needed to be seen for malaria like symptoms, HIV negative. Long story short, I totally wanted to work her up for SLE (lupus) after talking to her for a long time. But sadly, a simple ANA is hard to get and very expensive too. And it wouldn't have been worth it for her, she's not doing all that badly. And then who would manage it? Maybe for me it would just have been the thrill of making that kind of diagnosis, in a place where usually people never know they have those types of conditions.
It’s going to be another busy weekend as usual. 8 mile run. The return of Stitch n’ Bitch Lusaka, first one for 2009. Birthday party for one of our friends, with Thai lady catering. Sadly, the boat shipment did not come in, and there will be no Pad Thai due to the lack of noodles.
Curious what food items are available and not available, and when. I shouldn’t complain. Before I got here, I expected no availability whatsoever. I pictured myself eating onions, tomatoes, eggplant and carrots all year. But once I’ve been given the opportunity to buy an item here, it makes me sad when I can’t.
Cilantro
Red chili paste
Couscous
Balsamic vinegar
Granola
Chickpeas
Celery
Canned diced tomatoes
Tahini
Sweet corn
Usually when they’re out of a particular item, they’re really out of it. Like a totally empty shelf, you reach all the way up to see if maybe one is left all the way at the back and come back with a dirty hand, and no more in for weeks. I don’t think I’ve ever made a grocery trip without not being able to find at least two of the items on my list, items that are usually there. We like to come home saying, “Gosh, there’s a run on lentils and popcorn this week!” This week I really wanted parsnips, and they actually almost always have them. But they tried to be sneaky, they put Chinese turnips on the shelf instead, long and white and root looking yes, but not really the same thing at all. Celery is just luck of the draw. Zambians don’t really do celery. But they know mzungus like it. Sometimes they only have little milk cartons instead of big ones, or small trays of eggs instead of large ones, or only instant coffee, or no instant coffee. Good thing there hasn’t been a run on toilet paper yet.
Next week is big, for both of my projects.
Monday is ART-OPD integration at clinic number 3, in a neighborhood called Chazanga. It's hard to believe it all happened so quickly. When I first got here in July, they had spent 9 months preparing to integrate the first clinic, Ng’ombe. Chazanga we planned from start to finish in less than 3 months. Something that makes this clinic unique is that they don’t yet have an ART program. ART will be starting next week as well. So not only are they initiating ART, but it is beginning as a fully integrated clinic, with ART just part of the outpatient department. It will be nice because we don't have to rework any of the established systems in the clinic, but it will be more challenging for the staff I think because they will just be learning how to work in an ART clinic. It's nice for the patients, because until now, they haven't had ART in their neighborhood clinic, and they've had to travel to other health centers to get their ARVs. Now it'll be close to home, and I think we're going to have a lot more people testing for HIV, since we've made (opt out) testing a standard part of any clinic visit.
My peer educator program evaluation moved along nicely as well. The interviews are complete. Let me tell you, it was a royal pain in the butt coordinating availability of my staff, who were conducting the interviews, with availability of the clinic staff to be interviewed, with availability of transport to get them there. But somehow (with a few extra visits to the clinics, why did we have to choose the furthest away clinics for our program) we managed to interview everyone we intended to.
Next week we're hosting officials from the local Ministry of Health, doing a site visit with them so they can see what the peer educators are doing, and then presenting them with the data we've collected. Overall there's been a very positive response to the program, from staff and from patients. And the concern that the people who volunteer at TB corner would be resentful of our peers getting paid to work at TB corner was somewhat founded, but doesn't seem to be too harmful overall. Everyone here is always looking for "motivation," incentives, snacks, transport allowances. I think the only thing holding us back from expanding this peer program will be available funding. I think our CDC funding is much tighter this year. Looks like if the MoH says yes, we will be able to continue the current peers at least for the coming year, but expanding it to other clinics looks uncertain. I’ll know on Wednesday if I can call this project a success.
Wednesdays have become my clinic days, and it's been really awesome. I've been going long enough now that I'm even getting to see some patients who return for follow ups. Yesterday I saw the little 8 year old girl who I first saw a month ago for her initial history and physical. If you look back to my January entries, you can read all about what a bad condition she was in at the time.
Right after I saw her in January, she was initiated on anti TB therapy and given various antibiotics and antifungals for her opportunistic infections. She definitely looked better yesterday than the last time I saw her! For kids we do CD4%age instead of absolute CD4 count. Her %age was, get this, 0.4%! Anything under 25% is considered getting low. Her CD4 count was essentially nothing. We initiated her on ARVs yesterday, it was really interesting for me to see how we go about doing that, choosing which drugs and which doses, based on her co-infections and other medications. Concurrent ARVS and TB treatment can be tricky. Of course just this morning I read an article about IRIS, immune reconstitution inflammatory syndrome, a serious condition patients can get after initiating ARVs while already on TB treatment. Now I keep thinking of her and hope I don’t see her in a few weeks time with that too. It's hard to see kids like that, but I really enjoy the overall experience too, the medicine, the interaction, the support, the learning.
I have to say though, working in an HIV clinic makes is not helping me remember my non-infectious disease stuff. I saw another patient a few weeks back, a friend of someone at the clinic who just needed to be seen for malaria like symptoms, HIV negative. Long story short, I totally wanted to work her up for SLE (lupus) after talking to her for a long time. But sadly, a simple ANA is hard to get and very expensive too. And it wouldn't have been worth it for her, she's not doing all that badly. And then who would manage it? Maybe for me it would just have been the thrill of making that kind of diagnosis, in a place where usually people never know they have those types of conditions.
It’s going to be another busy weekend as usual. 8 mile run. The return of Stitch n’ Bitch Lusaka, first one for 2009. Birthday party for one of our friends, with Thai lady catering. Sadly, the boat shipment did not come in, and there will be no Pad Thai due to the lack of noodles.
Curious what food items are available and not available, and when. I shouldn’t complain. Before I got here, I expected no availability whatsoever. I pictured myself eating onions, tomatoes, eggplant and carrots all year. But once I’ve been given the opportunity to buy an item here, it makes me sad when I can’t.
Cilantro
Red chili paste
Couscous
Balsamic vinegar
Granola
Chickpeas
Celery
Canned diced tomatoes
Tahini
Sweet corn
Usually when they’re out of a particular item, they’re really out of it. Like a totally empty shelf, you reach all the way up to see if maybe one is left all the way at the back and come back with a dirty hand, and no more in for weeks. I don’t think I’ve ever made a grocery trip without not being able to find at least two of the items on my list, items that are usually there. We like to come home saying, “Gosh, there’s a run on lentils and popcorn this week!” This week I really wanted parsnips, and they actually almost always have them. But they tried to be sneaky, they put Chinese turnips on the shelf instead, long and white and root looking yes, but not really the same thing at all. Celery is just luck of the draw. Zambians don’t really do celery. But they know mzungus like it. Sometimes they only have little milk cartons instead of big ones, or small trays of eggs instead of large ones, or only instant coffee, or no instant coffee. Good thing there hasn’t been a run on toilet paper yet.
Subscribe to:
Posts (Atom)