thoughts about my visits to the clinics

The past two weeks have been filled with orientation, meaning we have been able to go around to various clinics in Lusaka and walk around the various parts of each, along with sitting in on doctor-patient visits. The first week I was here I remember all I wanted to do was to take pictures of everything. The streets are so natural looking and the people really are beautiful. The clinics inspired me because I was thinking it was such a wonderful thing that so many people were going and finding out their HIV status.

The past week and a half has been different for me. I go to the clinics everyday and everyday they are filled with people finding out their status, but also trying to hold onto their lives. I knew before that I was not just coming to see the different people in these clinics, but now, seeing these people all the time, and their families or lack there of, it's taxing and its heartbreaking. The people are not just sick and weak, they are dying from this horrific epidemic we call AIDS and they are fighting for life.

There are undoubtedly a number of obstacles in helping people in these clinics but the doctors have been amazing to see. They take these issues and just power through: they are kind to their patients, but also firm in getting things done. When I sit in on the visits, these issues go straight to my heart. Many people do not know their age, and the doctor will check multiple files and try to ask questions to the person to find out. For me, it's the reasoning behind the lack of information: many times the child grew up with different people than his parents and there were more important things to keep track of than age or the child never had anyone who looked after him. I think about how strange it must be to not know your age. .. and to not know your age because you did not know your parents. I take for granted that I know this information, that every year I have had people who have celebrated this knowledge with me, cards with the new number of years posted all over it. But right now in this clinic, this person is sitting right in front of me, and the many others just like this woman, they did not have this. There was no one for that child.

My days shadowing in pediatrics have shown me a lot about the stigma as well. This is what happens in the pediatric visits.
A twelve year old girl walks into the clinic with her caretaker (in this case her aunt) only she looks as if she is 6 because she is so small and thin. The doctor asks the girl how she is feeling and the girl will say her stomach is hurting from the pills she needs to take and her aunt will say she is having nightmares and she is not eating. The doctor then will ask the aunt how often she is taking her medication, and the aunt will smile sheepishly, a little bit embarrassed, because she is not sure. The doctor will ask who is at home with the child and the aunt says she is not at home with the child. Then the doctor will ask if the child knows why she is on the medication. And the aunt says no. The doctor then asks when the aunt is planning on telling the child and if she wants a counselor to be in the room to do it, and the aunt says she does not feel comfortable being there when it happens. And the doctor says, but the child will need you, and the aunt again has the smile, that she is embarrassed, she doesn't know what to do.
This whole time they are talking, the child is in the room. It's like this with all of the children, they sit right there as the doctor talks to their caretakers, and I notice that they all have the same eyes. Their eyes are wide open and they hang onto the doctor's every word; their eyes never leave the doctor's face. And when this happens, you want to be that person for the child, who will be home for the child, who will give the child the pills and who will talk to the child about anything the child wants to know. You want to just hug the child and you want to somehow implant the knowledge of the child's status so that it arrives gently and you want to be right there with the child so when his world is turned completely upside down, she will not be alone. You want to be that person for the child that keeps track of her age.
The doctor will turn to the child and ask if she understands what fighter cells are. The doctor says the more you have the better, because then they can fight off the bad things in the body. With this girl I remember the doctor asking if she wanted to have a little bit of good cells or not a lot of good cells. The girl nodded to "a lot of good cells". The doctor said, right now you have a little bit. The good cells are low, so that is why you need to take the medication. It kills me to hear the virus described in these terms, so simply and plainly. It kills me that this child does not fully understand why she feels the way she does.
I asked the doctor after the first time this happened, why they do not tell the children sooner. There are a lot of privacy policies and confidentiality surrounding the subject. It is forbidden for a doctor to tell the child any information unless having the caretaker's consent. Apparently it is very common for kids even 13 or 14 to not have been told their status. (some end up finding out themselves, but their parents don't know that they know) People are afriad at how they may react and they don't want to hurt the child. I think if I were 12 and no one told me that I have a life-threatening illness, I would feel not only horribly betrayed when I did find out, but also, feel empty like I did not know a big part of who I was. Also, I see this as prolonging the HIV stigma. I feel the child may grow up feeling he needs to hide this from others, since it was hidden from him this whole time.

More than ever now, I think it is so important to understand the individual and the culture in which the person lives. I see how the upbringing of a person can dramatically affect the chances of that person being HIV positive, affect when the person should or will find out his status, and how that person will take that new information. For example, talking to a child about HIV who is in an orphange and may not have solid parental units around is different than breaking the news with a family who can support the child. HIV stigma is a lot more powerful here than I could have imagined. I have seen how it prevents people from finding out their status and from seeking treatment- and how it is a double ended sword. We try to provide people with information about the virus, but at the same time we have all of these rules of confidentiality in telling people, especially children. We try to announce that there will be free HIV testing in the community, but in effort to make people comfortable and actually come to be tested, we have the line coming out the back of the building.

In protecting confidentiality, we prolong the stigma we are trying so desperately to mitigate. Prolonging the stigma prolongs the virus. Partners don't want to get tested or even be seen taking ARVs. It is common for men to have many sexual partners, but not be tied down to one of them. For this reason, it is easy for HIV to be spread, but less common to see men getting tested to know their status. A lot of women who are pregnant are found at the clinics because of the concern of the baby.

For this reason and others, a huge goal of HIV treatment is to spread public awareness about HIV and dispell rumors. Every day there are false ideas being spread, such as newspapers with articles about the "cure" for HIV. One day we walked past a stand that was selling these herbal remedies that supposedly not only cured TB and HIV, but also sexually transmitted diseases. It's also common for very religious people to refrain from accepting HIV treatment and information because they believe so strongly that God will save them and they do not have to practice safe ways of avoiding HIV transmission. Without taking into account religious, moral, family values of a person, I think it is impossible to reach that person and to connect to that person when counseling about HIV. I think apart from everything else, it is just so important to respect other people's beliefs.
The last story that I will share was about a woman at a support group who was praising her husband for helping her to find out her HIV status and for helping her to go to her support groups. Her husband was there and kept looking down and had a somewhat strange look on his face, especially because his wife was telling everyone how he had the "heart of a lion." Later, she stepped down and into the light and only then did we see one of her eyes was very very bruised. The community leader walked up to the woman's husband after the group meeting and told him he "also had the fist of a lion" and that if he hit her again, she was going to report him.

I see female empowerment, within the context of the culture, to be a crucial part of support and counseling for women. I say this because it is part of the culture for women to be submissive to men in certain ways, such as not being able to refrain from having sex with their partners if asked. If men are seeing other women on the side and not using protection(highly common), this is a prime way to spread HIV around. It was tempting to me at first to believe the answer to this is to empower women to be able to say "no" to their husbands, especially when they know they are sleeping around. However, in thinking about it, I can't see it going well if we think someone can go into a support group and tell women to withold from their husbands from sex or any other things for that matter. For many people, this goes against their cultural and religious beliefs, and I think it would do a lot more harm than good to try to get around this. I think talking to women about issues they are dealing with and thinking of alternatives to keep them safer is a much more logical idea. I think knowledge about safe sex and having groups where women can talk to eachother about things and/or report violence is empowering women and keeping them safer.

In the end, the goal is to help people to help themselves - it's to show people that they DO have a chance at living a positive sucessful life, even if they find they are HIV positive. People tell me that before anti-retroviral meds came along, people were just dying in the streets, and being carted away in wheel barrels. Now with the medicine and counseling, people are finding they can live again. There are always going to obstacles in finding people who need treatment, and then when they do find the people, in effectively treating them with the medication that will work best for their body, for their situation. But with those obstacles, it is so glaringly obvious how strong these people are. In church they praise God for thier lives and for their family's lives, those who are still with them. At work they pray to God for that day that they are living. In the clinics, they sing and they dance that they are alive.

As for me, I feel great. Some days are sad because it is hard seeing people go through what they must go through but every day is a new and incredible challenge in living in this new place. My great aunt passed away about a week ago, and it was definitely a different experience being far away from home and not being able to see my family during this time. She was a wonderful and strong Greek woman, who always had a smile on her face and had the most beautiful gardens in her back yard. I will always be grateful that I had the chance to know her and I will always remember eating eggs at her house each summer in traveling to East Hampton :) I got a chance to see how supportive my roomates were during this time and i did a lot of baking and running. Also, I had the wonderful opportunity to play the piano and I wrote a short song in the few words of Nyange that I know, about my great aunt.

Although I am getting more used to this new place, I am still getting very intense dreams each night. Also, another adjustment is walking everywhere! We walk hours out of each day and the days we go shopping we carry our gorceries miles home. I think it's really neat and I've started thinking about the places I will be walking when I get back home to md!
My housemates are really wonderful. I love that there is a great range of age (i'm the youngest) and range of fields people are interested in and places where they come from. We have started to cook lots of meals all together, which is so fun. Anddddd I made spanikopita last night! The two intern houses are about 3 miles away from eachother, so that means more walking! Here is an updated list of the housemates!
Katie - 26 - Public health major - she lives right next to me and is very sarcastic and funny. She has been such a good friend to me this whole time - she was the first person I met in coming on the trip!
Kim- 30 - She has been to sooo many different places and worked in the Peacecorps. She makes awesome food out of nothing and is very independent! She is applying to medical school right now.
Laura - also 30 - She has been in grad school and also has been to a lot of places, including living in a jungle for a few months to look at water conservation! She is such a sweet person and is always very calm, even in problematic circumstances.
Alanna - 23 - She is planning on going to medical school and has spent time in Lusaka previous to this trip. She was a diver in college and she is really small and cute! She is someone that is very relatable and good to talk to.
Steph - 28 - She has gotten two different master's degrees already and is from Australia. She is an amazing cook and is one of those people you can always count on to get good advice from. She is also really fun and up for adventure
Nicole - 26 - She just finished med school and is really cheery and a super fun person to talk and laugh with. She is a really warm person and wants to go into pediatrics.
Connor - 28 - He has finished his 3rd year in med school and is working in Obgyn. He's very nice, laid back, and from the south and likes to call people "gunners" when they overachieve. (for example, i said something in nyanga one day and he was like "ohh she's firing from both barrels" haha)
Nathan - 28 - He has worked in Peace Corps before and is planning on taking the mcats and going to med school. he is really really funny and enjoys quoting from movies like anchorman.
Eric - 32 - Really nice, finished med school and a masters in engineering. (yea, really smart) He will be working in the lab with me.
Gina - i think upper 20s - really sweet, she is working on a different project so I don't know her that well yet.

That's it for now! Hope everyone is doing well! I miss you all!