A week at Bauleni

A week in the life of a clinic.

For the past seven days, I started my days at Bauleni Health Center, coordinating the patient waiting time survey in preparation for integration. The clinics open at 8, so I had to be there before that. Sometimes as early as 7 am, they begin to line up outside. Even when I arrived at 7:45, the waiting shed outside would be almost filled with people, waiting to rush in the doors as soon as they opened, to hand their patient cards into the registry, to be little further up the cue to see a doctor. They sit patiently though, for where else can they go, and what else is there to be doing? The chitenge wrapped babies make the occasional coo or hiccup, the toddlers waddle and wander, the women stroll back and forth, chat and laugh. The occasional elderly man or woman sits quietly, just watching. They make their way into the inside clinic waiting room when called, jam onto the benches, watch the loud Nigerian movies on the television. As the line moves forward, ever so slowly, they inch along the benches, one bit closer to the screening room, where they will have a doctor’s attention for perhaps three minutes. The registry staff works diligently. With Zambian music blasting in the background, while chatting politics, they take ID cards, fish through shelves of old files, stamp cards, mark times and weights, move the files forward. That’s all only the outpatient (OPD) clinic.

In the back, the ART clinic has an almost intimate feel. With its one short hallway, not nearly as crowded as OPD, it feels more private, more manageable. The staff knows them, because they return so often. There, too, they may sit for hours. But when they do get attention, it’s for longer. They have their vitals taken. They see the peers for adherence counseling. They see the doctor. They pick up their ARVs. They get health education talks while they’re waiting. In the back of the ART registry, a few patients each day spend a good half hour with one of the nurses, enrolling in the ART program. Space is at a premium though.

One day when I was in the one medium sized room of the ART registry, not only were the file clerks finding and putting away files, but one of the COs was seeing a patient, while a nurse enrolled a patient, while another very sick patient was being seen on the one cot/bed in the clinic.

Across the courtyard out back, the women crowd in masses at the doors of the MCH (maternal and child health) clinic. Some days are devoted to antenatal, others to under 5 pediatric visits. I could have sworn that every child in Lusaka was at the health center last Wednesday, and Bauleni is only a medium sized clinic. I couldn’t even figure out how all of the waiting patients could be seen before sunset.

In the building all the way to the back, women in labor push out new life, without making a sound, because it’s thought to be bad luck.

In the kitchen, the clinic cooks/cleaning ladies peel potatoes, scrape fish, boil beans, lunch for the staff and the women in Labor and Delivery. When I come to see what’s going on, they chatter in Nyanja, good heartedly laugh at my attempts and tell me they want to teach me to dance like a Zambian woman.

Patients like to come in waves. Even on Saturdays and Sundays, the masses start in the morning, and thin out as the morning goes on. By noon, it feels almost manageable again. But come afternoon, the waiting shed will once again be full. I usually leave by that time, completely drained by crowds, the heat, the effort put into my interactions. I imagine though, that only when the sun begins to set do the crowds clear out for good, at least until the next morning.

Adventure City

Lusaka never ceases to surprise me with all the western style things it has to offer. I mean really, what’s a good city without a water park? Adventure City is just that. Hidden away in the hills on the outskirts of town, it’s a lush oasis of sorts, winding paths between shady trees and thatched roofed shelters, and of course, swimming pools and water slides. These are not just any pools though, they are big, uneven shaped, lazy river type pools with waterfalls in the middle. The highlight is the two water slides. One of the curvy sort and the other of the straight, fast drop sort. They both descend from the same platform, into the same whirling pool. Unlike water parks at home, which hire bored high school kids to carefully regulate how many people climb up the stairs to the top of the slide and when each person can head on down, there is nobody watching. Children would push their way past me, running up the stairs. They’d go down two, three at a time, practically crashing into each other at times. Feet first, head first, backwards. Cheers would go up for some particularly daring leap down the slide. It was, interesting. But definitely loads of fun. I can’t remember the last time I darted down a water slide. I never imagined it would be here.

It got me thinking about what socioeconomic class somebody from Lusaka would have to be in to attend a place like that. With a K20,000 entry fee (about $6), it’s no Six Flags or Disney World, but for the cleaning lady at the clinic who told me she makes K260,000 per month for her and six children, a day at Adventure City seems very much out of reach.

Decision 2008, Zambia Style

The campaign is finally in full swing. Election day is October 30^th, which means the candidates have just over a month to convince everyone of their ability to be Zambia’s next president. Except that, from talking with most Zambians around here, that won’t matter much at all. The general feeling is that the election of 2006 was rigged, and that this one may be too.

There are three main candidates, but two front runners:

Rupiah Banda. He was President Mwanawasa’s Vice President, he’s serving as the current acting president. The general feeling, at least around Lusaka, is against him. There have been corruption accusations. The national TV station, ZNBC, is being accused to covering Banda more than the other candidates. The politically independent newspaper The Post is reporting that Banda wants to stop them from speaking out against him.

People say that in 2006, when he and Mwanawa were running for re-election, that the highest population areas, Lusaka and the Copper Belt, all voted for the opponent, Michael Sata. The votes that reelected Mwanawasa and Banda all seemed to come from remote areas of the country. Those votes took days to travel into Lusaka, and the numbers of votes coming in seemed inconsistent with how many people could reasonably be registered in any of those places. So their entire administration is questionable, and people don’t seem excited to continue it. On the extreme end, I’ve heard that if Banda wins, people will again say the election was rigged, and there may be protests. In addition, his opponent is the very person who they say he stole the election from two years ago.

Michael Sata. He was Minister of Health in the 1990s and people say he was able to bring about change. At multiple health centers, I’ve heard stories of him coming on his own, just to spend time at the clinic and see how things were going. People around here really seem to have faith in him. I have yet to talk to a Zambian in Lusaka who is not voting for Sata. On the most extreme end though, I’ve heard that he would almost go the way of Mugabe in Zimbabwe and kick out all the non-Zambians. But most people have explained that he just wants more Zambians running business, and he would not go so far as to kick out NGOs or aid workers and such.

I suspect as the campaign goes on, the claims of corruption will increase. It should certainly be an interesting month.

To reassure all of you a bit, should you be worried, the US embassy is not overly concerned about the elections at this point in time. More updates later.

Kalingalinga

Kalingalinga is probably my favorite neighborhood in Lusaka. Well, not really my favorite at all, but the most fun to say. Say it, Kalingalinga. My theory about why it’s called that:

Kalingalinga is the place to go if you need a large metal gate for the wall around your house, a wooden bed frame, an overstuffed couch or a pile of rocks. That’s right, apparently the entire gravel industry of Lusaka centers around the rock hammerers of Kalingalinga. Drive through at any time of the day, and for blocks and blocks, people sit by the side of the road, under the hot sun, making the sound, “Kaling! Kaling!” as they monotonously hammer rocks into gravel. Old and young alike, they sit on the ground and hammer. Sometimes they even have the little babies wrapped around them while they hammer, perhaps to accustom them to that “kaling” that will be the rhythm of their lives. The children who are old enough to sit and hold a hammer can break rocks too. Imagine being born into a rock hammering family.

It’s actually not a very nice place at all. It’s busy, it’s dusty, it’s hot, it’s dangerous at night. One of my fellow interns has a good Zambian friend she works with who lives in Kalingalinga. She was recently staying there at night. Even though there were bars on the windows of the house, they can’t keep the windows open at night for safety reasons. And the power was out, so there were no fans. So she lay awake all night, sweltering in the Kalingalinga heat. Recently though, I have found its saving grace.

In the past few weeks, the Jacaranda trees have been in bloom. Tall, branching trees alive with a rich purple flower, a sort of opposite of an autumn maple alive with reds and oranges. The Jacarandas, which cover the trees like the leaves, are a beginning instead of an end. They are the kind of flower that you just want to look at in awe and appreciate. That you wait all year to see. All around me, people say, “Look, the Jacarandas are in bloom.” And people who are not here, but who have been here in the past will write to me and say, “I imagine the Jacarandas must be in bloom.”

These beautiful trees grace even the dustiest, hottest and most unappealing neighborhoods. Under the Jacarandas, even Kalingalinga looks inviting. Almost. But do let me know if you need some of the finest gravel in Lusaka.

A weekend in Chirundu

For the first time in a month and a half, I managed to get out of Lusaka for the weekend. Much like at home when Boston starts to wear me down and I feel that pull towards the mountains and wide open freshness of New Hampshire, I just had to get out of the city. In this case, the destination was Chirundu, a town to the south, on the border with Zimbabwe, on Zambezi River.

Chirundu is hardly New Hampshire. In her book Don’t Let’s Go to the Dogs Tonight, Alexandra Fuller describes Chirundu as “possibly the hottest, least hospitable, most malarial place in all of Zambia.” Sounds lovely huh? Well actually, I didn’ t remember having read that before I went. I went because I was promised a weekend of camping, relaxing, wildlife and tiger fishing on the Zambezi River, and that’s definitely what I got, although it certainly was hot.

Although travelling in large groups can be challenging, the good thing about traveling with nine people was that we were able to charter a minibus all to ourselves. Yes, there was the adventure of going to the City Market bus station, and having every minibus driver there gather around us to find out where we were going. But it helped having a Zambian friend who came along, and he managed to haggle us a deal, not only did we get our own bus down there but we got driven directly to the camp at Zambezi Breezers (www.zambezibreezers.com). Having our own bus, we were also able to avoid the constant stops, the overcrowded, packed the brims, sweaty, stuffy, fish/live chicken filled experience that it could have been. Within a half hour of arrival at the bus station, we were speeding southwards out of Lusaka. The crowded, traffic ridden city starts to thin out, and then it’s gone. Then nothing but clusters of thatched roofed huts, little one room markets, cinder block structures adverising pay toilets for 500 kwacha (that’s about 15 cents), and dry bush on a dusty plain with hills in the distance.

I also discovered on this ride that Lusaka is indeed at elevation. Eventually we started heading down, some roads with a surprisingly steep incline, nestled between rubbly/sandy/dusty hills. I think it was the wind through the open windows that helped us not to bake under the sun. Chirundu itself is nothing special, a border town, a truck stop. Lines and lines of trucks on their way to somewhere, carrying fish norwards to Lusaka, goods southwards to Zimbabwe. With my mind stuffed full of HIV programs, I couldn’t help but think of all the truckers right there at those crossroads, an important target population. But it was the weekend. Our minibus turned off the main road, up and down the rough dirt road. Past the occasional cinderblock house, turned right at the goats, around the bend at the fish farm with its large concrete tanks, and up to our camp. All along the ride, the theme for me was dirt, dust and hot.

Happily, Zambezi Breezers is a haven from the inhospitalbe dustiness. A narrow oasis along the river. Sprinklers scattered drops of rainbow catching water along a soft green lawn. A small, kidney shaped swimming pool glistened in the sun. A large, thathed roof cabana caught breezes off the river and enveloped them in shade. Down in the river, halfway across, what looked at first to be a cluster of large boulders soon revealed itself to be a large group of hippos. And beyond them, Zimbabwe. Not surprisingly, it didn’t look much different than Zambia. A flat plain with those stereotypical low, branching African trees of paintings, large termite mounds, and some hills in the hazy distance.

I set up my tent on a grassy, tree shaded nook with a view of the river. It was the first time I haven’t set up a rain fly over a tent for as long as I could remember. I haven’t seen a drop of rain since I got here.

For those who know anything about fishing, tiger fishing is a well known sport. People travel to the Zambezi River for miles to have a go at catching them. A blackboard at the cabana proudly announced that Diane had caught the biggest tigerfish of the year there, back in June, at a whopping 7 kg.

The nine of us rented a boat for the afternoon. First, our driver Robin took us speeding down the river, close to the Zimbabwe side, where we saw several groups of elephants, hippos, and even a crocodile. The nice thing about being on the boat was that we were able to slow down, double back, and get much closer to the elephants than I had at Kafue National Park. They glanced at us briefly, seemed to give it some thought, and went back to rustling through the trees, stuffing clumps of brush into their mouths. From the middle of the river, the hippos continued their loud, grunting calls. They always sound closer than they actually are. At one point in the middle of the night, I had to peek out of my tent to make sure they weren’t standing right there.

The second half the boat ride was dedicated to fishing. We each had a go at reeling out the bait, which in itself could have been a fish worth catching. At one point I felt a tug at my line, it seemed that I may have caught something, and we even moved the boat in pursuit. But I came up with an empty line, hook broken off. We’ll never know if it was a fish or if it just caught on the bottom. In the end none of us caught a thing, but we enjoyed an afternoon out on the water, the breeze and the sun, some cool animals and cold drinks. At several points, we passed by other camps and lodges along the Zambian side of the river, which looked much more luxurious, and I got little panks of missing Mukambi Lodge where I went in Kafue. But our camp was a no frills (=cheap) kinda place, and that’s what we were going for. One of the girls who came along, who doesn’t work for CIDRZ (!) is spending the week in Chirundu, staying on the river in one of those very structures, doing research at an Italian mission hospital with some nuns. Seems like a lovely way to spend the week.

Besides the boat ride, it was a lazy weekend of lounging, by the pool, by the river, under the cabana, reading, chatting. We took a walk down the road to a banana farm, watched some monkeys dart between the trees.

After our banana stroll, we walked by the fish farm. At that point, I was rather hot and thirsty, and decided to return to camp rather than explore. That decision ended up costing me an intereting experience. My friends who did decide to go ended up meeting the old British couple who runs the fish farm, and they turned out to be the parents in the memoir I mentioned above. Indeed, if you turn to the last page of the book, Alexandra Fuller describes how here parents are living on a fish farm in Chirundu, on the Zambezi river, down the road from some Italian nuns. How neat is that? Talk about bringing a book to life. I could not have feigned the ignorance my friends did when they were speaking to the couple, the parents in the books, “Oh yeah? We’ve never heard of the book, we’ll have to check it out.”

I was sad when it was time to head out. Relaxing is addictive. Yet much like I feel when returning to Boston, coming to Lusaka this time felt like coming home, in a way.

The weekend ended with a nice surprise. Our friend Rodney, the plains camp manager, came to visit (we thought he was coming next weekend). The occasion called for dinner at this lovely Italian restaurant called Portico. One of those places you can go and forget you’re in Zambia. Hidden among the green trees, we all dined on caprese salad, homemade pasta and crème brulee, and sipped red wine by the polo grounds (yes, there are polo grounds), surrounded by actual Italians speaking Italian. It’s nice to discover all the other foreigners who are in Zambia too.

I didn’t want all the relaxation to end. I have many busy weeks ahead. But actually, that feels good too.

Some morning harmony

I was sitting in the ART (antiretroviral) clinic registry at Bauleni this morning, getting started on our pre-implementation wait time survey, when I heard this heavenly, harmonious singing, which sounded rather close. Where in the world was that coming from?

“Oh, that’s from the MCH (maternal child health) building, right next door,” they informed me. “Here, I’ll take you over.” With that, I followed one of the clerks out the door to a neighboring building. As I would have expected, I walked into a crowded waiting room of patients waiting to be seen. But instead of sitting packed in, on every available chair and bench, they were all standing, facing a nurse at the front with a proud look on her face, who seemed to be conducting in a way. They were all singing, in perfect harmony. I just wanted to stand there and listen. When’s the last time you saw a waiting room full of patients sing, let alone as if they were in a choir together. The clerk told me that they were singing a gospel song in Bemba, one of the most spoken languages of Zambia. I’m not entirely sure if there was a meaning or a purpore, or perhaps just an insprirational way to start the day, with a long wait ahead and not much to do, fueled by that glow of pregnancy. At the very least, they lent some inspiration to my day. I definitely walked out of the room feeling uplifted.

It’s actually not uncommon to hear Zambians singing. Especially on the way to funerals, when they pile onto those trucks. It’s as if they are born with perfect pitch and ready to harmonize. I think we could all do with a bit more Zambian gospel singing in our lives. Bet you never even realized you were missing it.

Garbage

After living in Lusaka for almost two months, I’ve become quite familiar with the smell of burning garbage. Take a drive at night, and you’re bound to see groupings of small fires set in fields, along the side of the road, dry brush burning, fueling the attempted disposal of cardboard containers, plastic bottles and bags. Sometimes we’ll pass small fires early in the morning, while we’re out running, and I curse it for the oxygen it deprives of my hardworking lungs.
Occasionally the fire will grace us a flurry of ashen snowflakes. Even in our living room at night, if the wind blows just right, we’ll get a whiff of that tangy, almost suffocating, thick smoke.
Part of the problem is the lack of municipal garbage collection. Garbage pickup is handled by private companies. If you can’t afford it, then another option is to burn it. Or dump it. Empty pieces of land, and by empty I mean land that doesn’t have a house sitting on top of it, tend to accumulate vast carpets of wrappers and bottles. From the office to the Arcades Shopping Center, there is a dirt pathway cut perfectly through a field of the last vestiges of long ago enjoyed Orange Fantas and Eet-Sum-Mores biscuits. It’s hard to tell if the garbage, or the path, came first.
Today at lunchtime, I took an uneventful walk over to Arcades along that very path. When I returned, I saw thick smoke from across the main road. In the short time I was gone, somebody had set the largest garbage fire I’ve seen so far in the field across from CIDRZ. Under the heat and haze of the midday sun, the smoke burned especially thick and black, and the dark red flames jumped up what seemed to be several feet in the air.
I cringe every time I am not able to recycle a glass jar, a plastic bottle, a tin can. I want to yell every time an old minibus goes by coughing massive amounts of black exhaust into the air, but I’m too busy choking. On a regular basis, we open our front door, and even early in the morning, the smog and haze have already descended. It’s sort of like those pictures of LA at the height of its air pollution, only worse.
Lusaka has been growing by leaps and bounds. I’ve heard that even in the past year, the number of vehicles has exploded and traffic has visibly worsened. Roads are being paved. Intersections will back up for blocks, especially during rush hour. Buildings, houses and shopping centers are under construction in every corner of the city. But all that growth and development come at a price. It seems that it’s growing too fast for its own good. The battles that have already begun to be fought at home have not yet begun here.
I’m reminded of that Shel Silverstein poem “Sarah Synthia Sylvia Stout, Would Not Take the Garbage Out,” which he wrote way back in 1974…

Sarah Cynthia Sylvia Stout
Would not take the garbage out!
She'd scour the pots and scrape the pans,
Candy the yams and spice the hams,
And though her daddy would scream and shout,
She simply would not take the garbage out.
And so it piled up to the ceilings:
Coffee grounds, potato peelings,
Brown bananas, rotten peas,
Chunks of sour cottage cheese.
It filled the can, it covered the floor,
It cracked the window and blocked the door
With bacon rinds and chicken bones,
Drippy ends of ice cream cones,
Prune pits, peach pits, orange peel,
Gloppy glumps of cold oatmeal,
Pizza crusts and withered greens,
Soggy beans and tangerines,
Crusts of black burned buttered toast,
Gristly bits of beefy roasts. . .
The garbage rolled on down the hall,
It raised the roof, it broke the wall. . .
Greasy napkins, cookie crumbs,
Globs of gooey bubble gum,
Cellophane from green baloney,
Rubbery blubbery macaroni,
Peanut butter, caked and dry,
Curdled milk and crusts of pie,
Moldy melons, dried-up mustard,
Eggshells mixed with lemon custard,
Cold french fried and rancid meat,
Yellow lumps of Cream of Wheat.
At last the garbage reached so high
That it finally touched the sky.
And all the neighbors moved away,
And none of her friends would come to play.
And finally Sarah Cynthia Stout said,
"OK, I'll take the garbage out!"
But then, of course, it was too late. . .
The garbage reached across the state,
From New York to the Golden Gate.
And there, in the garbage she did hate,
Poor Sarah met an awful fate,
That I cannot now relate
Because the hour is much too late.
But children, remember Sarah Stout
And always take the garbage out!

There are murmurs of conservation efforts here, but only if you go looking for them. They’re directed more towards preservation and the national parks. I wonder if that type of thinking is somewhat bewildering to people here. After all, there are villages bordering on, in the middle of, national parks. So what really is the difference between one person’s little piece of land, and the land across the road, which, though it looks exactly the same, is actually a piece of land to be preserved and protected.
I wonder how long the garbage will have to pile up before they decide to really do something about it. With all the other issues the government has to worry about right now, sanitation does not seem to be priority.