AIDS at Work

The true story in this post is three pictures, seen sequentially. You actually don’t need the text but I’ll throw it in here to give you the context.

A few months back, I wrote about Tunyeswa, a (now-)18-year-old HIV-positive mother who has just had a disastrous life. She has walked out on her daughter more than a few times. When I saw her in February, I took this picture of her with her daughter.
Then in March I saw her again and took this picture.
She had tested positive for HIV in January and we had taken blood for the all-important CD4 count that would tell us how much the virus had affected her immune system. But she never came back with the results, no matter how many times we reminded her of it.

After that picture in March, we didn’t see her again until yesterday. When she walked in, she looked like this.
I’m not sure how clearly it comes through in the picture but it is a stunning and dramatic change. I actually didn’t recognize her at first. I thought perhaps it was a slimmer sister from the same family. Since March, she’s lost more than eight kilograms.

As she still hadn’t got her CD4 results, we drew the blood again and I drove her up to the clinic where the blood gets sent to the lab. I asked, out of curiosity, if the clinic had the results from the test in January. Surprisingly, they did. It was 216. That’s dramatically low, almost eligible for anti-retrovirals. It’s especially low for someone who is only 18. Either the virus has worked remarkably quickly on her or she contracted some time ago.

After nearly two years in Itipini, I actually have more hope about combatting the HIV epidemic than I ever have before. But people like Tunyeswa make me despair. She needs so much help and so much education to understand the significance of her diagnosis and all the work - like regular CD4 counts - she has to do as a result of that diagnosis. And there’s no indication that any of our efforts in that direction have taken root. There are other people in Itipini like this, people who are just - for whatever reason - totally clueless and uninvolved in their own health. I can do what I did today and hand-hold and escort her through the health-care system but that’s not sustainable and it’s not practical for the people in similar situations.

Thinking about Tunyeswa, I found myself thinking again about the line from Desmond Tutu I’ve thought a lot about in South Africa: “For true reconciliation is a deeply personal mater. It can happen only between persons who assert their own personhood and who acknowledge and respect that of others. You don’t get reconciled to your dog, do you?” There’s no indication to me that Tunyeswa is asserting her true, full, and complete God-given personhood in any meaningful way. And I have no idea how to help her do that.

Surprised by Gratitude

Many of you have asked after my recent monthly e-mail about the health of my cleaning lady, Hilda, who I recently found out is HIV-positive. She is doing much better, thanks to the drugs I was able to secure for her that took care of her oral thrush. Her CD4 count has dropped dramatically in the past few months but I sat with her and explained about ARVs and she is now busily engaged in the preparation process.
Hilda’s situation has prompted a number of thoughts for me.

It’s made me think about access to care again. Like the woman I mentioned in this recent post, Hilda lives in a relatively new housing development and so has to take a taxi to get to the clinic for her counseling. It’s fortunate that her health is still good and she can do this unaided. And it’s fortunate she has a job and only has to go to the clinic once a week and so can pay the taxi fare and combine it with her regular weekly shopping anyway.

It’s also made me give thanks for all the activism in the early part of this decade that brought down the price of drugs so much. The drug that alleviated her thrush is called Flucanazole. (I think I have the spelling correct.) She got it for free from the public health system. Five or seven years ago, that drug cost a whole lot more and the government didn’t provide it. It took unnecessary deaths and a whole lot of public pressure on drug companies and the South African government to make it available. I’ve just finished reading Edwin Cameron’s Witness to AIDS and he tells the story of Flucanazole in detail. Literally the day after I finished reading that, I found out Hilda was sick.

I’ve been thinking about just how much patients know. When I tried to talk to Hilda about ARVs, I was kind of stumped. How do you explain to someone that the thrush took hold because her immune system is weakened when she doesn’t know what an immune system is or does? If you can’t explain what the virus does to your body, how do you explain how to address it? I resorted mainly to saying that ARVs would give her strength (the all-purpose Xhosa word amandla, well-known from anti-apartheid activism), confident that the preparatory process for ARVs would teach her much more.

(Similarly, the other day I took a patient to admit him to tuberculosis treatment at the Ngangalizwe Health Centre. I explained on the way up where we were going and why. It looked like he understood so I left him alone. When I came back, the TB nurse told me the patient had said he was already taking TB treatment. It took me a while to figure out that the patient was taking a vitamin cocktail everyday that we give to HIV patients and he thought it was working on his TB. I had just assumed he realized all the different illness at work on him.)

Mostly, though, what I’ve been thinking about is gratitude. I don’t get a lot of it in Itipini. Basically, I think people there are so used to having white people help them, they come to take it for granted. Hilda is used to waiting on white people, not vice versa. As a result, her gratitude for my help has been overwhelming and overwhelmingly genuine. Last week I dropped her off for an ARV appointment and showed her where to go, the same thing I do for scores of other patients. She was effusive in her thanks. That same day I dropped a patient from Itipini off at the hospital. The only thing she could say as she got out of the car was to grumble that I wasn’t coming to pick her up later. The difference was striking.

My goal was for Hilda to be on ARVs before I leave but health care moves slowly here and it doesn’t look like that will be possible anymore. I’ll just try to get her as far along in the system as I can.

Memorable Encounters at Ngangalizwe

It seems that I spend at least a bit of each day at the Ngangalizwe Health Centre, the government-run clinic about a fifteen-minute walk up a hill from Itipini. It is our “mother ship,” so to speak. We get some medicines from there and refer people there for preparation for anti-retrovirals or ante-natal care. I am often up there to get pills, because I’ve given a sick patient a ride, or to check results from the lab, among many other reasons.

Here’s one of the clinic buildings, though the whole complex is currently undergoing a dramatic face-lift.
I frequently bump into people I know, whether it be the (formerly) fearsome nurses who run the place, the pharmacist I have to sweet-talk every time I want something, or people from Itipini we’ve sent up for something. I am the only white person I have EVER seen in that clinic so I attract a lot of attention even from patients who don’t know me, who often think I am a doctor.

The other day I bumped into Noncedo, formerly a student in my after-school English class. She was in grade 12 last year and failed the high-stakes test at the end of the year that determines if the student gets a diploma or not. But she didn’t fail by much and in January I strongly encouraged her to go to the supplementary education to prepare to re-write the test. She initially seemed interested but then disappeared and I hadn’t seen or heard from her since about mid-February.
So I was happy to see her on Thursday and asked how she was and commented that I hadn’t seen her in a while. As I was asking why she was at the clinic I glanced down from her face and noticed a tell-tale bump in her abdomen. I switched to my standard set of questions for women when I learn they are pregnant - are you going to the ante-natal clinic? have you had an HIV test? when are you due?

It’s not unusual for me to learn about a new pregnant teenager but as I walked away I couldn’t help but remember a sentence Noncedo had written in a letter to our pen pals in South Carolina last year. I don’t remember it word for word but it was something like, “Some girls think it is OK to sleep with men but that is not our culture and I don’t do that.” (How that worked its way into a letter that was supposed to be about what her favourite subject is is beyond me.)

The pregnancy explains why she lost interest in school and disappeared. There’s this belief around here that pregnant women can’t go to school, which is dumb. Noncedo isn’t due for another month or two. She could have gone to the extra education and already re-written the test by this point.

On another trip on Thursday to Ngangalizwe, I stopped in the Infectious Diseases (read: HIV) part of the clinic. There were five women from Itipini, all getting the results of their most recent CD4 count. They all wanted a ride back, which I was happy to provide. As I watched the women standing by the truck, staring at their results, it reminded me of what it was like to get a test back in middle school. Everyone looked at their results and then started peeking over at their neighbour to see what he or she got. The same thing unfolded in the parking lot. I didn’t catch the whole conversation but it went something like, “What’d you get?” “753” “Oh, that’s good.” “No, not really. Last time it was 943. What’d you get?” “504” and so on. It was heartening to me that they would all be talking so openly about their CD4 counts.

When we returned to Itipini, I marched them all into the clinic so I could record their results. Nothemba, in the middle, didn’t want to have her picture taken.
And so that’s Ngangalizwe. Maybe someday I’ll convince some of the nurses there to let me take their pictures and can write a bit about them.

Waiting in the clinic for mom to be seen

Long Walk to TB Treatment

I’ve noted before that transportation is a crucial - and often neglected - part of health-care infrastructure. Good quality care might exist but if a person can’t get to it, they’re out of luck. That’s one reason why I spend a good chunk of my day behind the wheel, driving people places.

Here’s a picture of a neighbourhood called Mayden Farm. It consists entirely of low-income housing built by the government and distributed free to poor people. Several people who used to live in Itipini have now been moved here.
Mayden Farm is one of the biggest such communities in Mthatha (there are three or four). There are thousands of people living here. And in the entire community there is not a single clinic.

I’ve been thinking about this because there’s an older woman who lives in Mayden Farm with her daughter - an Itipini employee - and family. The older woman defaulted on TB treatment a few years back and is now re-starting. That’s good. She was getting pretty sick. But as a re-treatment patient she needs 56 doses of a drug called streptomycin that can only be given as an intra-muscular injection. If she only had to take pills, we might bend the rules a bit and give the pills to the daughter to give to her mother. But since she needs an injection, the mother has to go to a clinic every day for nearly three months.

We’ve all sat around and thought about this and concluded we are the closest clinic to their home. And we are about two miles away. On Tuesday, this mother left home at 8am and didn’t make it to the clinic until 10am. (I thought that was pretty fast.) She’s old and weak and has TB. She can’t go any faster. She shows up, gets her shot, and turns around and starts home again. That is basically her entire day.

There is another clinic about two miles in the other direction and the advantage is that taxis ply that route. But the taxi costs about five rand in each direction or a little more than a dollar for the round trip. That doesn’t sound like much but when you live on a dollar a day, well… This family earns more than a dollar a day but not by much and they need to stretch it pretty far. (She initially defaulted on her TB treatment when she was living in the rural areas because she couldn’t afford the daily taxi ride to the closest clinic for the pills.)

The reality is that Mthatha has experienced rapid growth in the past decade or so and the government hasn’t been able to keep up with infrastructure. (But churches and privately-run schools have. They dot communities like Mayden Farm.) This older woman’s condition should not be life-threatening. It’s serious, yes, but I’ve seen other people with similar symptoms make full recoveries. But because of a set of factors outside our control, this is a very serious situation.

The situation raises all kinds of questions for me. Should I just pick her up every day and drive her to the clinic? (It’s way out of the way on my daily commute.) Is that fair or right? Should we just pay for the taxi? One factor that distinguishes this situation from others is that this is an ongoing and consistent need for transportation whereas I usually provide emergency or one-time lifts places.

We did some more thinking and appear to have reached an acceptable solution that is too complex to explain here but won’t require her to do that walk every day. Still, there must be many other people like her in Mayden Farm and around Mthatha that we don’t know about. What will happen to them?

The title for this post is a corruption of the title of Nelson Mandela’s autobiography. He is famous for saying, “There is no easy walk to freedom anywhere.” Which is true. Fifteen years after he was elected, neither is there an easy walk to treatment.

Juba, the breakfast of champions

I’ve only ever mentioned it in passing before but it is impossible to get a full understanding of life in Itipini without mentioning the prevalence of alcohol. It is everywhere and affects everything.

It comes in many forms - all cheap - but one of the most common is Juba, a beer(-ish) type substance that comes in a one-liter milk-carton-like container and sells for less than 50-cents U.S. Itipini is littered with empty containers like this one.
Note the warning on the container - “don’t drink and walk on the road, you may be killed” - an appropriate public-safety campaign in a place where most consumers of Juba don’t know how to drive or own cars but still have to get places.

The empties are put to creative use by people of all ages. This shack has walls made of Juba containers.
There’s also Xhosa homebrew, called mqombote (I’m a bit unsure of the spelling), that is basically fermented corn meal cooked over an open fire and then stored in someone’s house.
I’ve learned over time that the different drinks are favoured by different groups of people. Juba, for instance, is for older women and men. If you see a young man drinking Juba, you know he’s desperate. Younger men traditionally drink brand-name beers that come in bottles and is more expensive.

All this alcohol is served out of local shebeens, or unlicensed liquor establishments. The people who are the best off financially in Itipini are, I believe, the ones who own a shebeen. And there are plenty of shebeens around, including one just up the hill behind the clinic. Some people go into town and hang out in front of a bottle store all day.

Naturally, alcohol has the same affect on people in Itipini that it does on people all over the world - it makes them do stupid things, like get in fights and hurt each other, neglect their families, or spend money on alcohol they should be spending on necessities. Lots of those people end up seeking help from the clinic, occasionally when they are still drunk.

Where does the money for all this come from? Addicted people have an income-inelastic demand for alcohol so they’ll find it wherever of course but a major source, I believe, is the government grants that go to older people. In my experience, a lot of those old-age pensions are going right into the shebeens around Itipini.

Alcohol is brought into Itipini in massive quantities. I often see women walking down the dirt road to Itipini carrying a crate of Juba on their head. Or you see men like this one wheeling in a few crates. (I don’t know why he’s crouching over for the picture.)
I saw these two young boys (not in school) pushing this wheelbarrow down Mthatha’s main street a few months back. They both live in Itipini and were taking their load to re-stock a shebeen someplace.
Occasionally, a shebeen orders enough to warrant a truck delivery, like this one I saw a few days ago.Mthatha consumes Juba by the truckload. I frequently see 18-wheeler trucks stacked high and long with crates and crates and crates of Juba. I wonder how many of those trucks Mthatha consumes in a day, a week, a year?

In his book about Rwanda, We wish to inform you that tomorrow we will be killed with our families, Philip Gourevitch mentions off-handedly that some huge percentage of Rwandans were likely alcoholic. (I don’t have the book in front of me and can’t check the exact number.) It would be impossible to calculate that figure precisely but I imagine it’s huge in Itipini as well.

People know that they shouldn’t be drinking, or at least they’re embarrassed to be seen drinking. As I drive down the road to Itipini or walk around the community, I frequently see people trying to hide a container of Juba so I won’t see it. But as soon as I leave it’s brought back out again. I think my main objection to alcohol consumption is that resources are so limited here that any money spent on alcohol could have been and should have been spent someplace more productive.

One of the beer brands, Castle, has a large ad campaign showing a strapping steelworker almost single-handedly lifting an I-beam into place. The caption says something like, “You deserve a Castle.” The trouble is that so few people here have jobs that allow them to have alcohol, which should be a luxury, or have jobs at all. So they miss out on the hard work part of it and skip right to the drinking stage. And when they spend most of the day drunk, they further reduce their chances of finding the kind of work that might make them “deserve” beer.

Playing with Live Ammo

I don’t kid myself: for most people in Itipini, my impending departure won’t matter all that much. They’ll still get the same kind of services from the clinic, more or less, regardless of my presence or absence.

The people I’ve found myself spending the most time thinking about lately are the people of all ages and both sexes I’ve come to be closest to. If they feel my absence half as much as I know I’ll feel theirs then I have some sort of obligation to help both of us achieve some sort of satisfactory “end.”

One person is Simnikiwe, a child I’ve written about before. I think I’ve played a big role in his life these past few years, especially since his father died unexpectedly last October. Indeed, as you can see from this picture at the funeral, I was standing next to Simnikiwe as we watched his father be buried.
Knowing that I’d be leaving, I’ve intentionally tried to distance myself from him these past few months with modest success. He spends much more time in pre-school and has lots of friends his own age he chooses to play with. Still, on Friday I sat down with his mother and him and made sure he understand that I was leaving and not coming back. He said he understood but how do you communicate such a final concept to a four-year old?

Another person I knew I needed to speak with was Vuyelwa, a young woman I started helping a long time ago. She was the centrepiece of the sermon I preached last September when I was raising money. I had given her some money to start a business selling second-hand clothes and for a while it seemed to be going alright.

I haven’t ever written a follow-up post about her because soon after I returned in October, the business rapidly crumbled for numerous reasons I won’t take the time to explain here. I responded poorly to the situation and basically didn’t see her after October. I let myself be wracked by guilt about the whole matter and tried not to think about it.

I had heard she had moved to a village outside of Mthatha. On several occasions this year, I had thought I should go see her but I had awful thoughts about how she was living and what she was doing and I couldn’t bring myself to face what I believed to be my failure.

But I happened to be driving in that direction on Saturday and felt clearly I needed to see her. I tried calling her on her cell phone, not expecting the number to still work or that she would want to see me. Shockingly, she answered on about the second ring and said I should definitely stop by. A few phone calls later, I managed to find her and we sat down to catch up.

It was a good conversation and she took the news that I was leaving relatively well. It also put me at peace about a number of things. She doesn’t have a great life - she has no job and there are no prospects in the little village - but she is living in a good home, is teaching Sunday School at her church, can support two of her three children (the third is with the grandmother), and is more or less eking out a living. She’s late for a CD4 count and recently went to the doctor for another reason and didn’t tell him she had HIV so she might have to work on coming to terms with that.
Here she is with her Sunday School class. The child in the red shirt is her son, Bongamusa. I’ve written about him before but hadn’t seen him in months. So I was shocked when he came running out of the house, shouting my name, and tackled me around the knees. He’s a talkative little guy, unlike a number of the children around her who are pretty shy about speaking Xhosa with a white guy.

I was relieved when I drove away from Vuyelwa’s and relieved that I had been able to talk with Simnikiwe. These are just two examples of the kind of conversations I am trying to have before I leave. They are difficult. And they remind me that as a missionary I am playing with live ammo, as it were. These are real people with real feelings and my departure is not some sort of abstract resume line - I worked two years in a shantytown in South Africa - but in some cases is a difficult and hard-to-accept blow to the lives of real human beings who are my friends. It might be different if they had had a sense all along, as I did, that this was always going to be a temporary thing for me or if they had a sense how far away North America is and how hard it is to get to South Africa to visit. But they don’t. And they are not nearly as mobile as I am. They are stuck here while I get to fly freely away. It is one last reminder of the vast power differential between us.

Grace vs. Law vs. Infant Formula

I once described one of the core jobs of a missionary to be “sharing grace gracefully.” (That’s not my phrase.) And I think that’s still accurate. But lately I’ve been wondering where law comes in.

We distribute infant formula at our baby clinic on Tuesday. I’ve written about how frustrating this can be. One aspect of the frustration is the mothers who claim they “can’t” breast-feed when more often they don’t want to. They don’t want to for any number of reasons I won’t explain here but none of them are very legitimate (in my not-so-humble opinion).

What does grace demand in this situation? Grace is often closely associated with love. I remember during a Bible study on the Great Commission during my mission training, one missionary saying, “I just think we are called to love everyone” over and over again. And she was right, of course. But is that it? And what does love look like in this situation?

If I give the mother who doesn’t want to breast-feed infant formula is that an act of grace? I don’t think so. It’s doing long-term damage to the baby’s health and well-being and wasting resources when they could be used someplace else. The mother in this case needs to learn from law. In this case, that’s the idea that - as it says on all the infant formula - “breast-feeding is best for your baby.”

Love is not handing stuff out. It is not charity in the non-King-James sense of that word. But that’s the easiest kind of mission and one so many of us are so quickly drawn to because it makes us feel like we are having an impact with a minimal amount of effort. And the people getting the stuff often appreciate it and that makes for great pictures and a lovely moment. But what happens when that moment is passed? And where do you find the resources to keep creating those moments?

I’ve come to see the grace we need in mission as an active concept and one that doesn’t necessarily make situations comfortable. In fact, it should make them difficult. Being graceful and loving can’t be divorced from the fact that the law exists and exists for a positive and salutary reason. Somehow the two are tied together.

In the lectionary reading for this Sunday (John 15:9-17), Jesus closely follows his commandment to love one another with a comment on the sharing of knowledge. “I do not call you servants any longer because the servant does do not know what the master is doing; but I have called you friends because I have made known to you everything I have heard from my father.” Somehow the missionary is called to - gracefully - share knowledge of the law so that we can all move more closely to right relationships. In a cross-cultural context, that requires building meaningful relationships and finding a common vocabulary. It’s a lot harder than handing out tins of baby formula but it’s so much more right.

In lieu of actually writing anything...

Snapshots

I mentioned in a previous post that things have seemed very busy in the clinic lately. There are lots of stories of people I’d like to tell in detail but I keep putting them off and realize now I’m never going to be able to get to them with the justice they deserve. So here are some quick synopses of some of the patient care we’ve been involved in lately.

Zanthemba has AIDS and tuberculosis. I took this picture in March, shortly before I left for Djibouti and Ethiopia, when he had just started TB treatment. I wasn’t sure he’d be alive when I returned. But he was and he still is. I recently sent him up to begin preparation for anti-retrovirals. Given how many difficulties I’ve had with the ARV prep process in the past, it was remarkable how easy it was this time. I chalk that up to my increased expertise, relationships with the right nurses, and the fact that Zanethemba knows me and trusts me and does whatever I tell him to.

Lindiswa just gave birth to her second child. She’s 17. This is notable for a few reasons. Both children are by the same father and they have been traditionally married. I’m not sure how I feel about that but there it is. She stood out from the crowd of other young pregnant women because she was transparently honest and open about how difficult it is to be pregnant and she was absolutely hilarious about it.

Ntombizine is about my age and just gave birth to this baby. She came into the clinic kind of nonchalantly one morning and tried to tell me something. I was having trouble understanding so I asked Dorothy what was going on. “She just had her baby,” Dorothy told me. Oh. The baby had been born a few hours before in her shack and now Ntombizine wanted a ride to the government clinic to formally register the birth. I was happy to oblige, though I must confess that being around newborns always makes me nervous. They seem so fragile. Ntombizine also has AIDS but - through a process that was much more complicated and involved than it should have been - got nevarapine almost at the last possible minute to prevent transmission of HIV during birth. Then the nurses at the clinic told her not to breast feed, which infuriates me, but that’s a story for another time.

Jackson is very sick. In fact, I haven’t seen him in a few weeks and I wonder if he is still alive. He used to be a pretty energetic and kind of funny older man but his condition has deteriorated so rapidly and I was shocked when he came in looking like this. It’s kind of unclear just what is wrong with him. I think it has something to do with excessive alcohol intake and a swollen abdomen but there are some eye problems and possibly TB at work as well.

Nomantombi used to be an energetic and kind of confrontational young woman. I respected her energy, even if I didn’t always appreciate being on the receiving end of it. She’s HIV positive but was seemingly asymptomatic for all the time I knew her. But rapidly in the last few months she has markedly deteriorated and now labours just to make it to the clinic. I have been giving her lots of rides to appointments so she can ultimately get on ARVs but it has been a frustrating process that is taking too long to bear fruit.

Her medical records make fascinating - and tragic - reading. She’s 21 now and the records start when she was 8, documenting when she first starting taking family planning (age 12), when she had her first baby (age 14), when she tested positive for HIV (age 15), how she was brought in after a bout of glue-sniffing, all the times she had been assaulted, and much else. Perhaps if - when - she gets ARVs, it will mark a new start to what has been a difficult and obstacle-ridden life.

To close on an upbeat note - and not one primarily medical-related - here’s a picture of Ziyanda holding her first quarter report card. You might remember Ziyanda and all the obstacles she has endured in her education from an earlier post. She did remarkably well in the first quarter, including an 80-percent in English. I can’t communicate how astounding that is, when you consider what I’ve already written about what “doing well” means around here. (She also got a 13-percent in science. “Bad teacher,” she told me.) When she showed me the report card she also wanted to talk about going to college and has already begun doing the research into scholarships and application deadlines. I wish I was going to be around to help her see that process through.

(On another education note, Mbuyiselo, the young man who also has a complicated history that I once wrote about, has apparently been kicked out of school. I just found this out and haven’t been able to track him down yet. If it’s true, given all the work I put into getting him into school, I’m going to want to punch that guy in the teeth when I find him.)

And these are only the people I have pictures of. Numerous other cases like these walk through the doors every day.

Shedding a Burden

I have felt very busy lately in Itipini. Not to the point of being overwhelmed but such that every minute of the day seems to be occupied, moving from one situation to the next. It is such a contrast to what it was like when I first arrived and it has made me feel very competent, which is an unusual feeling.

What I hadn’t realized until today, however, is that I’ve been carrying a tremendous burden around these last few weeks while also being so busy. Up until today, virtually no one in Itipini knew I am leaving in the not-too-distant future. The burden I was carrying was the obligation of sharing difficult news in a tender and honest way. As I’m in denial about the fact of my departure, I’ve been putting off sharing that news for several weeks.

But I booked my plane tickets this week and that was sort of what told me I needed to go public with the news. Because there are so many people in Itipini who will be affected by my departure and I wanted to do them the favour of telling them all individually or in as small groups as possible, that meant numerous similar - painful - conversations.

I began before the clinic day began when I told Dorothy and Mkuseli in the clinic. Dorothy gave the sudden shake of her head I’ve seen her give when she learns someone has died. Mkuseli looked like I was telling him I’d killed his mother. “Bad news for Itipini,” he muttered darkly under his breath.

After the clinic day was over, I gathered the rest of the staff together and told them. My pulse was racing and I was as nervous about this as I ever have been about addressing a group of people. This conversation was almost entirely in Xhosa; I’ve been laying awake late at night lately figuring out the right vocabulary. I talked about wanting to be in two places at once. I talked about how there is a season for everything. I stressed the finality of it all and that this was not a temporary break but a pretty permanent termination of my work in Itipini. Remarkably, by the time I go around to my future plans they were smiling a little bit.

I next headed downtown to see Vuyelwa, the young woman I’ve invested a lot of energy in helping her get started in the hair-styling business. Her mother is on the staff so I knew she’d find out when she got home and I wanted to tell her in person. As the words were coming out of my mouth - actually before I even said anything - she could tell where the conversation was going. “No, no, no!” she cut me off and clearly wanted to end the conversation. I plowed ahead. She was kind of smiling by the time I left.

Later, after we had finished reading “The BFG” for the day, I told my English class. I have never had their attention fixed on me as carefully as it was at that moment. I tried to meet each one of their gazes individually as I spoke. The ones who’ve been with me from the beginning were the most disappointed, I could tell. A few wanted to know what was in it for them. “Don’t forget to buy us blazers before you go!”

It was a draining series of conversations and I still need to announce it publicly tomorrow morning after our Friday morning education session. But I realized as soon as I told Dorothy and Mkuseli that a huge burden had lifted from my shoulders. No longer did I have to worry about this piece of news. For better or worse, that burden is now on the shoulders of all the people I told today. I’ll help them bear that load - I spent some time in the middle of the day privately talking with Mkuseli about the news - but it is no longer mine to bear. I feel guilty about dumping this on them but it’s a relief.

Parting may be such sweet sorrow but preparing to part is just sorrowful.

Accountability

I often toss off the phrase “cultural and language barriers” like you should know what it means. The language barrier part is pretty obvious. And I’ve written about the culture barrier before in many different ways but the idea encompasses a wide swath of life. Here’s an example.

I live on the grounds of one of Mthatha’s hospitals and frequently visit another. Here’s the entrance to Umtata General Hospital.

As you can see, at the entrance are private security guards. Their job is to make each visitor sign in and check the trunk of each car as it leaves to ensure no one is stealing anything.

Here’s what I often see when I leave.

The guard simply removes the cone - the automatic bar has long since broken and not been fixed - and allows me to pass without checking a thing.

There could be eight gazillion reasons for this. Maybe he recognizes me and knows I’m a trustworthy type. Maybe because of the racial history of South Africa he’d never actually press me to search the trunk.

But the fact remains that he hasn’t done his job. And this isn’t a one-off sort of thing. It happens all the time. A job that the government is paying a private security company to do is simply not done.

The larger point is this: who holds these guards accountable? As far as I can tell, no one. And that is one aspect of the culture in Mthatha that I have had to adjust to. The usual standards of accountability to which I am accustomed simply do not pertain. And I shouldn’t pick on the guards. I see this lack of accountability in scores of situations all over town, including Itipini. People don’t do their jobs or do them late or do them half-heartedly and nothing seems to happen. There are no apparent consequences for inaction.

(A related cultural trait here is people who follow the letter of the law but not the spirit. One time I was leaving the hospital with some donated medical supplies, exactly the kind of thing the guards are supposed to prevent being taken from the hospital grounds. The boxes - clearly labeled “medical supplies” - were so big they didn’t fit in the trunk so I had them in the back seat. The guard dutifully checked the trunk, saw it was empty, and waved me through, not noticing or caring about what I had in the back seat. He had completely missed the larger purpose of what he was supposed to be doing.)

There was a brief gasp of accountability in February. Before then, the guards were government employees who worked about as hard as the private security guards do now. But then on February 1, all the government guards were fired and replaced by the private ones. For about a week and a half, the new guards were very diligent in checking trunks and making people sign in. It gradually began to lapse and now we are back where we were before.

I also should be careful what I wish for. The fact that I don’t have to sign in each time I enter the hospital is a tremendous time-saver and I’m glad they don’t make me open the trunk every time I leave.

On the other hand, this lack of accountability hit home this past weekend. I haven’t driven my red car in a few weeks because Jenny is out of town. It has been parked at the hospital, where I thought it would be safe behind a fence on guarded hospital premises. But when I happened to see it the other day, I noticed someone had tried to steal the front windscreen by cutting loose the rubber caulking. As you can see from this picture, I can stick my hand between the windscreen and the car frame.
The guards at my hospital are supposed to make frequent rounds of the grounds to prevent exactly this sort of thing from happening. But as the nights have gotten colder these past few weeks, I’ve seen them out less and less frequently and more frequently huddled in their hut at the gate. No one apparently held them accountable to do their job and my windscreen is the result.

This post kind of makes it sound like I’m complaining about the car. I’m really not. I’m just trying to point to some of the larger cultural trends that routinely frustrate me here.

“Give me formula, feed me for a week; encourage me to breast-feed, feed me for…”

Tuesday is the baby clinic day in Itipini. That means mothers (almost exclusively) bring their newborns into the clinic for immunizations and check-ups. As an enticement, we distribute baby food and infant formula. That way the mothers keep coming back every week and we can check on not only the health of their babies but also of the mothers themselves and their other children who might tag along. It should be pretty straightforward, if always verging on completely chaotic. Why then have I found myself dreading Tuesdays?

The main problem is the infant formula. The idea is to give formula only to children of HIV-positive mothers. Those mothers shouldn’t be breast-feeding because of the risk of transmitting the virus to their children. (And even then the South African health guidelines recommend exclusive breast-feeding for the first six months even for HIV-positive mothers for a variety of reasons I won’t discuss here.) That makes sense to me.

But there seems to be this view among a number of the young mothers that infant formula is better than breast-feeding, that somehow some powder concocted in some lab someplace could do better than what thousands of generations have survived on. Even if formula is equivalent to breast milk, there is still a tremendous cost associated with formula feeding in a place like Itipini. The water is more or less clean but the bottles aren’t always sterilized, for instance. What’s the point of preventing babies from getting HIV if they’re just going to die of diarrhoea?

But these young women are insistent on formula. I don’t quite know why. Perhaps they worry about how breast-feeding will make them look. Maybe they think that things you have to pay for (and formula is expensive!) are automatically better than things your body produces for free. And so they concoct some story - I have a wound on my breast, I’m not producing, etc., etc. - to explain why they’re not breast-feeding. It is particularly galling when I see them breast-feed as they are waiting in line to be seen and then sit down in front of me and begin to spin me a tale.

Today, for instance, a woman who gave birth less than a month ago, came in complaining she wasn’t producing any milk. She’s been breast-feeding and we’ve been giving her vitamins and a nutritional supplement. I checked to see that she had those. She did. I made to send her on her way but she protested, quite vigorously, in front of the entire clinic. “Nothing’s coming out! The baby is hungry!” and on and on and on. As she has a history of this sort of behaviour, I told her to wait outside a few minutes to calm down. Not thirty seconds later, I looked out the door and this is what I saw.
(Note that she's smiling!)

The question all this raises for me is the difference between the short term and the long term. Sure, I could have given that woman today formula to shut her up and get her out of my hair. It was a tempting thought. But breast milk works on a supply and demand model. If the baby needed more milk, the mother would eventually produce more. If I filled that demand gap with formula, the mother would not produce more and the child would end up in some mixed feeding purgatory. My seeming “help” in the short-term would actually exact a long-term cost on the health of the baby.

The difficulty is convincing the mothers that breast-feeding now will pay dividends in the future. Most people come into the clinic with an attitude of “I want my problems fixed right now.” Telling them that what they can do for themselves over time is better than what I can do for them now is a difficult message. Anyway, people here work on a different timeline than I’m used to. They’re thinking about getting through the next day or week not, primarily, the long-term health of their baby.

The obvious answer is education, teaching mothers about the importance of breast-feeding and its benefits. But that takes time and can be difficult to do in a meaningful way. Plus, how do you have an extended chat about the importance of breast-feeding with a young mother when there are scores of babies and mothers waiting in line behind her? The end result is that we end up giving more formula out than I believe we should and that always frustrates me.

The larger question of short-term versus long-term assistance continues to bedevil me. Everyone knows the “give me a fish, feed me for a day; teach me to fish, feed me for a lifetime” saying. The trouble is what to do before they’ve learned to fish on their own. Doesn’t on some level giving people fish reduce the will to learn to fish on their own?

When gaining weight is a good thing

I first showed this picture about 11 months ago.
At the time, I was wondering why some people who are sick with HIV wait so long before seeking treatment, often dying before the anti-retrovirals can take effect. But this woman, named Nomanesi, had been very active in her own care and, on the day I took that previous picture, had just received her first ARVs.

I saw her in the clinic again today, a routine visit in which she came to get some vitamins we distribute to HIV-positive patients and a nutritional supplement. She had also just returned from the ARV clinic so I made her repeat last year’s picture.
I also checked her medical records. In the 11 months since she’s started ARVs, she’s gained 12-kilograms. That’s a substantial amount of weight and an undeniably good thing. She looks healthy, feels stronger, and generally has a better quality of life.

Also today this gentleman came into the clinic.
He tested positive for HIV about a year ago but hasn’t been in the clinic in more than six months. He’s long since run out of vitamins and the nutritional supplement. More importantly, he’s never had a CD4 count that would track the progression of the virus and determine when he can start ARV preparation. Today he was weak, gaunt, barely able to walk on his own, and had all the symptoms of tuberculosis. We drew blood for a CD4 count and gave him sputum pots to test for TB. I hope this time he doesn’t wait six months before returning to the clinic.

There's been too much text on this blog lately

"Swine flu"

Seems folks in the Western media have been consumed of late talking about this swine flu thing. I'd like to second everything my friend Heidi preached this morning.

Now, maybe later you can blame me for disregarding the first signs of a serious global pandemic. But I’m sorry, I think the media storm that is thundering all around us is ridiculous. Not only that, I think this is self-centered richer nations making a big deal out of something that pales in comparison to what poorer nations deal with on a DAILY basis.

Let’s talk about… sex!

When I was a teaching assistant for an introduction to political science course in college and leading a discussion section on some of the challenges confronting Africa, I asked, “Why is HIV epidemic in parts of Africa but not Canada?” One student slouched in the back of the classroom raised his hand. “Because Africans have more sex?” (What he said was somewhat cruder actually.)

The inescapable fact about the HIV/AIDS epidemic in sub-Saharan Africa is that the primary means of transmission is heterosexual intercourse. That means any conversation about HIV is necessarily also a conversation about sex. Of course, it makes many people - including me, with my years of safe church training - uncomfortable to discuss sex and that impedes conversations about HIV.

I don’t know if I have special insight into the matter but I’ve been reading Edwin Cameron’s Witness to AIDS recently and he keeps discussing the complicated relationship between HIV, race, sex, and stigma in Africa and that sparked a few thoughts. Plus, people ask me about this quite often, it seems, so surely someone is interested somewhere.

One major question in explaining why HIV is epidemic in sub-Saharan Africa is whether or how it is related to different sexual practices or mores among Africans. This is what my erstwhile student was getting at and it is a very contentious issue. Helen Epstein’s book The Invisible Cure says Africans have sex differently than, say, Westerners and that explains the epidemic. Eileen Stillwaggon’s book AIDS and Ecology of Poverty says it is not a factor.

The people I have met in Itipini are not, I think, any more promiscuous than anyone else their age I’ve met in other places I’ve lived. I haven’t done an exhaustive survey of the sexual habits of everyone I’ve ever met everywhere I’ve ever lived but I think - based on what I see and hear and understand - that people in Itipini largely have one sexual partner at a time and that they are faithful to that person for an extended period of time.

What makes sex different in Itipini - and many parts of Africa - is that there is less privacy attached to it. This is for a very obvious reason. When a family of six, say, lives in a 10 foot by 10 foot shack with one or two beds jammed together, the older siblings are going to know exactly when and how their younger siblings were conceived.

I’ve asked some of my cultural interpreters in Itipini about this and they say this is just taken for granted. One told me that when she was growing up and living with her aunt temporarily, her aunt brought her boyfriend home and they started having sex in a bed just a foot or two away from where my friend - then 8 or 10 years old - was sleeping. My friend says she lit a match, looked over at the bed, and asked her aunt why she was crying and moaning. “As you can imagine,” my friend told me with a grin. “They were not very impressed with me.”

What I don’t have a good grasp on is how that firsthand knowledge of sex affects children as they grow up. I have seen young children striking sexually suggestive poses at times in Itipini, as if in imitation of their parents or older siblings, but I wonder if that’s a universal thing now, given the hyper-sexualization of western/global culture. I usually try to put a stop to it. But I wonder how many parents in Itipini do that. Children in Itipini are allowed to run freely from a shockingly young age. There are reasons that can be a good thing but it also means that there aren’t often parents around to put a stop to behaviour I would deem inappropriate. I saw two young boys, both three, the other day with their pants off peeing by the side of the road the other day. They both had conspiratorial grins on their faces that said they knew they were up to no good and were enjoying getting away with it. I told them to put their pants on but that was about all I had the vocabulary for.

And that’s a major problem. If I want to be relevant to the challenges facing people here, sex is obviously something I need to be able to talk about. But talking about sex in one’s own language is hard enough; in another language, it is enough to be paralyzing. For one thing, how do you figure out the right vocabulary, words that are neither distantly medical nor vulgar or rude? Then add in the gender overlay, that I am a young man talking primarily with young women about this, and then the power overlay, that I am educationally and economically more powerful than everyone I talk with, and it’s enough to make me just want to give up, which is what I mostly do.

Just one of those ongoing challenges in Itipini.