Girl Power

I had a meaningful conversation with these lovely 14 to 17 year olds a few weeks back. I was in Same, outside the HIV clinic, waiting for transport that never came. This gaggle of school girls approached me, sat down, introduced themselves, and began a memorable chat.

They had come to the outpatient clinic (not the HIV clinic) because one of them needed treatment for her acne, and all of her friends accompanied her (the importance of peers is global!). They were very interested in my work and why I was in Tanzania, how long I would stay, etc. Their English was impeccable, which told me that they had probably been educated in private schools, because English is not the language of instruction in government schools--kiswahili is. In fact, they attended a boarding school in Same, specifically for girls who want to study science. Four of the 6 girls wanted to be doctors. They were quite interested in why I didn't become a doctor instead of a nurse practitioner. I shared with them that although I love being a nurse practitioner, if I had been 10 years younger, I probably would have gone to medical school. I told them how at the time I was going to college, girls had a rough go of it just getting into medical school, and I didn't think it was possible. I told them that now more than half of medical students in the US are women--how times do change! And how lucky they were that their parents were sending them to a girls' school to study sciences. Anyway, they were quite interested in the medical work I am doing, and fascinated that I spend so much time here. 

Then came the zinger question that I was pretty sure was coming: "How do your children like it that you are in Tanzania so much of the time?" I am asked this question a lot, because it is a given here that if you are a woman, you will have children. And usually I am asked with the assumption that I do have children. They may say "How many children do you have?" or "Who takes care of your children while you are here?" When I tell them I don't have any children, they think there must be a communication barrier. They ask again, "No, I mean children--mtoto--how many?" When they finally realize that I am indeed saying "No, I don't have children." They say "Pole sana (I'm so sorry)". Sometimes, I choose to go further and tell them that it is a personal choice to not have children. That women in the US have a choice to have children or not. Other times, I just get a sad look on my face and look away, so they will drop it.

With these bright young women, however, I decided to have a conversation about it. And they were all ears. When they asked why I don't have children, I told them I made a mindful decision not to. That I have had a passion for my work my entire adult life, and I chose to put my energy into the life work I have chosen rather than raising children. Plus, I have many wonderful children in my life--nieces, nephews, friends' children. One asked "But don't you think it is natural to have children?" I said, "Of course, it is natural! I believe it is also natural for women to choose to not have children." Usually, when I share with people that I don't have children, there is a look of horror and/or sadness on their faces. These girls' faces, however, reflected wonderment and admiration. When I noticed that, I asked them, "Do all of you want to have children?" They looked at each other first, then at me. Three of them smiled and slowly shook their heads no. One of them said "I want only one!" and another said " I want many children!" What a delight to see these intelligent young women truly think about what they want in their lives, and then say it!

I consider myself very lucky to have grown up at a time in the US when women were beginning to take charge of their reproductive health and decisions. Tanzanian women are just now beginning to do this. It is so clear to me that if women can't be in charge of their reproductive and sexual lives, they really can't be truly in charge of the other realms of their lives. I have no idea what impact, if any, our conversation will have on these girls' life choices, but it sure felt hopeful to have it. 

BTW, these girls would love to have pen pals (or pen friends, as they say here). If you know of any teenage girls who would like to communicate with these delightful young women, let me know, and I can make the connection. Katie? Courtney? Finley? Claire? Maddy Fitzgerald? Maddy Barr?

Ooh! Aah! Jacarandas!

You know how it takes your breath away to see swaths of yellow of the Aspens changing color in the Rocky Mountains? Or how the vibrant reds and golds of the autumn leaves changing in the midwest or New England stimulates that same feeling? Or the cherry blossoms in the spring in DC? Well, I have had that very same feeling witnessing the beginning of Jacaranda tree blooming season. I was in Arusha region all week, doing some work in Monduli district, and wao. Jacarandas blooming EVERYWHERE. Hard to describe the flowers' color. Too dark to be lavender, too light to be purple. Its amazing what color in nature can do to the psyche. My photos here are all from Arusha town (I happened to be staying at the Jacaranda Hotel!), and as always, my photos don't fully capture the beauty. But at least you can get a glimpse. I'm told they will continue to bloom until Christmas! What a delight to have one's breath taken away for three months! 

Happy to be Alive!!!

Hello my blog readers! Today, for the first time in 3+ months, I did something recreational. I am in this stunning land, and I haven't gotten out into the beauty of it all until today. I hiked at the waterfalls at Marangu, which is the other place, aside from Moshi, from where one can climb Mt. Kilimanjaro. I really needed the recreation and the exercise for sure. Sharing photo of yours truly, loving life. My sweet and fun 20-something-year-old companions (Maurice on the far left is the taxi driver who so kindly and safely drives me around when EGPAF vehicle not available--the other 2 young men are his pals). And some gorgeous, dense greenness. BEAUTIFUL and just what the nurse practitioner ordered!

Obama Mania in Kenya

As most of you know, I was in Kisumu, Kenya last week. I was lucky enough to see an amazing HIV Clinic in action where my colleague Catherine is working. I got lots of ideas for my work here, and it helped me to know what is possible. This clinic is a definitely a model for HIV treatment in resource limited places. 

I must say, however, that my favorite part of the week in Kenya was seeing dear friends from the states at the end of the week. Darcie and Paul, who are working in rural Kenya for a year arrived on Thursday, and then Becky and Judi from Denver arrived on Friday. We all stayed at the same very nice hotel on Lake Victoria and had a grand time. Sitting and chatting with close friends, catching each other up on our lives, and exploring Kisumu together was just a delight. It was a quick and whirlwind visit, but rich and of high quality!

(I realize some of you reading my blog are not Obama fans. Believe me, I respect your political choices. And I hope you can appreciate the Obama phenomenon that is happening worldwide, especially in Africa, and that you can also appreciate this part of my blog! If not, feel free to skip this one! I love all of you, Obama supporters and not!) Now one of the things about Kenya, particularly this region, is how absolutely thrilled Kenyans are about Barak Obama's candidacy. See the fun poster above for a concert that is dedicated to him. I thought people in Tanzania were crazy for him. But, wao, nothing like Kenya. Because his father has roots in the Kisumu region, and he has relatives there, they truly see him as a son-cousin-brother. They are so proud of him. When Becky and Judi arrived, Becky was wearing an Obama shirt, and they brought us Obama campaign bracelets. My colleague, Catherine, had commissioned one of the local artists to make beaded Obama bracelets, so I had already been wearing one of those all week. Becky's t-shirt and our obvious support for Obama generated many comments from , and many conversations with, Kenyans. So many Kenyans were also wearing Obama shirts, and there were bumper stickers, posters, buttons galore. When we went back to the artist stalls where Catherine had commissioned the bracelets, we learned that these bracelets had taken off! At least 2 other artists had made their version of the bracelet. Some with American flags and Kenyan flags on them! 

My take on the Obama Mania here in Africa (besides the recent roots that he has here), is that Africans know that US politics and who is in power in the US affects the whole globe (PEPFAR and George W. is one example!). And they hope that having someone like Barak Obama in power will affect their lives in a positive way. I also have yet to meet a Tanzanian who supports how the US is managing things in Iraq and Afghanistan. The war almost always comes up when talking about Obama (and I'm not the one who brings it up). I am continually amazed at how knowledgeable many people here are about US politics. One thing that I hear repeatedly is that they would be really surprised if white people would vote for a black man, which makes me very sad. I tell them that many white people support, and will vote for, Mr. Obama. It is difficult for me to be so far away from such a big election season, but when I am here in Moshi, I do have TV that has CNN, BBC, and (gasp!) Al Jazeera, so I am catching a lot of the madness of it all (pigs and pit bulls wearing lipstick????). Go Obama Go!!!!!   

I could live in Same (sah-may) Part 2

Finally, I am posting "Same Part 2". . . Many of you know that one of the more challenging things for me about my new job is how frequently I move from one clinic and district to another. As soon as I get to a new place, I long to stay for longer than a week. Sometimes the desire to stay longer comes from the fact that there is so much work to do and there are fantastic nurses and clinicians with whom to do it. Other times I want to stay longer because it is such a beautiful place and I want to be surrounded by the beauty for awhile. Sometimes it is for both reasons, which was the case with Same.

Same is a tiny, quiet, friendly, easy-going town nestled at the base of the southern Pare (pah-ray) mountains. It is about 90 km southeast of Moshi. I arrived on Monday morning, and I was greeted like a long-lost relative by a woman named Habiba Mmaraba. Habiba is a nurse I had met in July at one of our mentoring trainings. Right before I arrived I learned that the coordinator of the CTC (HIV) Clinic, who was supposed to be my host for the week, left to go to a computer training without telling anyone. It was too late to re-schedule, and Habiba agreed to coordinate things, so I decided to stay and do the work. Habiba is an experienced nurse, who is so delightful and fun to work with. We laughed all week long. When she laughs, it is a full belly laugh, head flung back, nice and loud. There is a photo on the previous post of Habiba laughing.

The first thing I always have to do when I arrive to a new district is to meet with the District Medical Officer (DMO). The DMO controls the entire budget for the district hospital as well as any health-related activities that happen in the district. It is a highly political position. This person is usually a man, in fact usually a "big man", as Tanzanians say. A "big man" or a "benzi" (a newer slang term I recently heard that alludes to a Mercedes Benz) is wealthier man, who either works high up in the government or is a super-successful businessman. The terms conjure an image of a well-dressed man with a big belly (and 9 times out of 10 he does have a big belly). Meeting with the DMO is one of my least favorite things to do. He sits behind a massive desk in a throne-like chair, with us peons lined up in chairs on the other side of the desk. The DMO can make or break a mentoring week. In fact, The DMO can make or break a district's HIV treatment program. For our program's purposes, he has the power to allow or not allow a district vehicle to take us to the village clinics to mentor the staff (which is the reason I am in TZ). Even though EGPAF (our funder) awards each district funds to provide transport, some DMOs don't release the funds when we need them to. Most DMOs are supportive, but some are most definitely not. I've worked with both. So these meetings are about sucking up and explaining in a polite, graveling manner why it is important to have transport. Sometimes I have to do a mini-teaching session on what clinical mentoring is. While I was in Same, the DMO (who I hear is supportive) was away, so our meeting was with the acting DMO. He did promise transport for two days (that is what we ask for), but in the end, he canceled the second trip TWICE. Transport is the source for one of the biggest frustrations of doing this work.

The hotel I stayed in was about a km from the hospital, so I walked to and from every day. Habiba's house was along the way, so the first day going home, she showed me her shortcut on winding dirt paths, through people's homes and compounds, past the well where everyone fetched their water, across the town football (soccer) field. Every morning, I took this route on my own, soaking in the tremendous beauty of the sky, the mountains, the people. The dirt is red, the mountains are green and lush and giant. I have become accustomed to people in Moshi and Arusha following me, asking me to buy things or hire them as a guide or to marry them, that it was such a relief for people to be simply curious, and kind and genuinely interested in what the heck I was doing in Same, where they rarely see a white person. Since my last UCSF colleague left a few weeks ago, I find myself immersing myself more in the Tanzanian way of life, practicing my Kiswahili more, just taking it all in more. I do miss having my colleagues to talk things through with, but I love being on my own, too. It reminds me of my Peace Corps experience, which was very positive.

One of my most rewarding things with a patient happened during my week in Same. It is rare for me to be able to follow a patient over time, and to see them get better. There was a 32 yr old woman who came in on Monday, yet another case of TB-HIV co-infection. She had wasting syndrome (weighed about 70 lbs), so weak she couldn't speak above a whisper, dehydrated, coughing, carried in by a family member. She was admitted to the ward and started on TB treatment and also got IV fluids. I visitied with her each day with the clinician I was mentoring on the ward. It was amazing how much she improved in five days. Certainly not 100%, but well on her way to recovery. Amazing what a little TB medicine can do! By the end of the week, she was sitting up on her own, eating and talking. She will start antiretrovirals in another 2-ish weeks, and it is likely to be a happy ending for her and her family.

On Tuesday of my week in Same, Habiba and I took a road trip up into the mountains to a village clinic called Ndungu. We rode in a rattling pick up truck for almost 2 hours on a red dirt and pot-holed road. But wao, was it beautiful! Surrounded on all sides by green mountains, palm trees, banana trees, sisal fields, purple-flowering jacaranda trees, mud homes. The CTC Clinic was in one tiny room, the size of a walk in closet. The clinician saw patients there and the nurses set up outside the door, right next to all the other waiting patients, to do adherence counseling and uncomplicated follow up visits (so much for confidentiality--a different concept here than in the states). Nurses are the lifeblood of these clinics. There are so many patients, there is no way they can all be seen without the nurses seeing a large number of them. Unfortunately, though, they aren't supported institutionally to do this, they are just told to do it out of necessity. They don't get any formal training. So I do spend a lot of my time working to build capacity among the nurses to conduct these visits in a quality way. We saw 44 patients in 4 hours (too many). LOTS of children. Whew. It was a great, but exhausting, day! The rest of the week I spent in the hospital clinic, working with different nurses and clinicians. Such a great week, despite my host bailing at the last minute, and despite the DMO sabotaging our trip to the second village. We ended the week with a case-based teaching session that I had put together based on the knowledge gaps I had noted during the week. It was well attended, very interactive, and lots of fun.

Habiba. . .such a generous soul she is. She is Muslim, so she was fasting until sundown all week long for Ramadan. That did not stop her, though, from inviting me to her home twice during the week, introducing me to her family, and feeding me delicious food (beans with coconut and homemade chapatis--yum!). Such a lovely person she is. When we said good by at the end of the week, we did this kind of hug they do here. Kind of like they do in France, a hug and a kiss in the air on one side of the body and then the other. But she didn't want to stop the hug, she kept doing it over and over, pulling me close and kissing the air on each side of my face, until she finally stopped by giving me a quick kiss on the mouth! It was very sweet and felt so sincere.

Haven't quite figured out how to make photo captions, so here are some explanations of the photos above:

#1 On my way to work. That is Same Town nestled at the base of the mountains.

#2  HIV clinician Mmari and nurse Bulili.

#3 Habiba (on right) and her best friend Mary (also a nurse)

#4 Children having fun at the well, on my way to work

I could live in Same (sah-may)!

Okay, friends. I am a Blogger Novice and having some technical problems. Some doesn't have to do with my inexperience, but my intermittent internet connection in Kenya, where I am at the moment. Here, I will tell you about these photos that I took in Same, and then when I get back to Moshi, I will post the narrative that goes with the photos. I had a fantastic time in Same despite some logistical blips (what would this work be without blips?). Also, I changed some settings for leaving comments on my blog. It should be easier now for those of you who tried without success to leave a comment.

 I have been in Kisumu Kenya this week, helping a UCSF colleague do some training and mentoring (although she doesn't really need me, I have learned). The most exciting news, however, is that tomorrow, my dear friends Darcie and Paul, who have been volunteering at a clinic in rural Kenya for the last 6 months (and will be there for 6 months more), are coming to Kisumu! So I will get to see them and hear their stories and just enjoy one another's company. AND THEN on Friday! My pal Becky Howard and her gal Judi will be arriving to Kisumu! They are spending 2 wks in the bush with Darcie and Paul, and so I get to spend time with them too! It will be so lovely to see the familiar faces of dear friends. Plus Becky and Judi are bringing me a new bra- - -mine seem to have disintegrated (hopefully that's not TMI). BTW for an awesome narrative and some of the most amazing photos you have ever seen in your life, check out Darcie and Paul's blog. They posted a comment on Marabou Stork's Revenge, so you can connect to their blog there. For those of you who were at our commitment ceremony 3 yrs ago, Darcie was our stellar photographer. 

Okay, now for the photos: Top Left: my walk home from the district hospital to the Elephant Motel (the sign is for the motel). It was such a gloriously beautiful walk to and from work.

Top Right: The amazing nurse mentor I worked with all week in Same: Habiba Mmaraba and her famous laugh. More about this woman when I get back to Moshi

Just below Left: Palm trees and green everything on the way up to village clinic Ndungu.

Just below Right: Patient Josefina and her baby. Josefina just learned that her baby's HIV viral load test is negative. Although it is preliminary, it is likely that baby is uninfected. Aren't they both beautiful?

Far bottom: Habiba's granddaughter Majuma finishing her chores after school.

Marabou Stork's Revenge

Well, it's about time, isn't it? I've been here in Tanzania for 2 1/2 months helping with capacity building in the arena of HIV treatment. And I am finally getting around to creating a blog so that my people can share in the experience. I am starting with the following story because I shared this story by email but the pics wouldn't send and MANY of you have asked for the photos.  This story has absolutely nothing to do with HIV. . .this took place in Shinyanga town (fondly known by locals as Shy Town) which is the center of a huge region (also called Shinyanga) in western Tanzania. It is a vast rural region that contains gold and diamond mines. The town is dusty, friendly, bustling yet laid back. My colleague Sophy wanted her photo taken with a Marabou stork. Shinyanga region is FULL of these gigantic birds. They amble around town, just like people do. You can also see 20 or 30 of them at a time hanging out in the trees. They are pretty ugly (I know that is mean, but I think you would agree). They look like curmudgeonly old men with seborrheic keratosis on their scalps, thinning hair and some of them have this long irritated-looking red appendage hanging below their beaks. A doctor I was working with in Bukombe (a town in Shy region) joked that they are Bukombe's "health officers" because they are scavengers--they hang around picking up garbage, and keep the place clean. I used to see them in Kampala eating out of dumpsters. They've always given me the creeps. Anyway, as I said, Sophy wanted a picture WITH a stork. She is only 5 feet tall and I think she wanted to see how tall she looked next to a Marabou. So we found one hanging out on a corner in the middle of town. Sophy's husband and I got our cameras ready while Sophy approached the stork slowly and quietly. In the first photo, you can see Sophy sneaking in on the right. Then, it was clear the Marabou did NOT want his photo taken with Sophy. He started looking around, and then. . . he spread his HUGE black wings, lifted off the ground, and flew right AT ME! I saw his very sharp beak pointed right at my face. In the second photo you can see me bolting as fast as I could from the giant bird. Of course, it wasn't aiming for ME, it just flew right over my head to escape the whole crazy human scene. In this photo, you can easily see the bird's shadow on my heels, but if you look closely, you can see the actual bird flying well above my head. We made quite the spectacle. We and the women cooking outside at the Garden Pub were laughing soooo hard. It created a lasting (somewhat traumatic) memory, and now I feel somehow bonded for life to the Marabou stork. Sophy even made me a beautiful origami Marabou so that I could de-sensitise myself from the trauma of it all!!