A week under my belt

Each day this past week I visited a clinic here in Lusaka and hung out with the midwives in the Labor Wards. It has been the best week so far - and it feels all warm and tingly to be doing that which I set out to do.

My initial sense? The midwives here are overworked and under paid. They are passionate like midwives around the world about what they do. They are skillful and are hungry for more techniques to save lives and reduce morbidity. They LOVE oxytocin and active management. The only reason they are not using it is if there is not oxytocin available. In some of my interviews, which I expected to be a careful unpacking of attitudes and barriers, I have been getting answers like "I love it" and "It works." The interviews that I expected to last an hour are barely 15 minutes. One midwife actually said "Why do you keep asking me about the same thing?" Hmmm...

But not all is well in the clinics. Mothers are separated from their babies almost immediately and are asked to get up, clean themselves off, and wash their own linens about 10 minutes after delivery. The babies stay stacked on an empty bed, wrapped in a HUGE bundle of blankets and towels, waiting for their mother to nap and rest before they come together. There is very little attention paid to the post partum period. Women are discharged 6 hours after delivery. When I explained that in the US they stay for 2 days post partum there were gasps. "What do you do with them for two days??" Ah, America.

I will spend a few more days observing in Lusaka this week - and then will take off for a series of trips to observe further out. Thursday I'm leaving for the Eastern Province, bordering Malawi... then will return Tuesday to head South to Choma and Mumbwa... then North to Ndola. I have expanded my sites because a) why not? and b) a few days in one place seems like enough time to become acquainted with the culture and the practices of a place.

So, 25 births later, I'm feeling like a researcher in Lusaka at last. Time is moving fast now and I just hope I can finish that which I set out to do.

More soon.

Back on track

Only a week later than promised - we have IRB approval, sanction from the Ministry of Health, and have officially begun data collection. Today I traveled to a health center in the middle of one of the largest compounds in Lusaka. THAT was the 'Africa' I was expecting, strangely. Kids with swollen bellies and no pants running around little concrete shacks. Smiling women behinds stalls of fruits and veggies - right next to the chickens and the goats. Women with precariously balanced watermelon slices on a platter on their heads - that somehow never falls amidst the bumpy roads.

I saw only two deliveries. Five delivered before our arrival (a research assistant and myself) and two were in active labor when our ride came. Tomorrow I will return and hopefully see many more. This week in Lusaka - and next week I'm (finally) on the road.

Initial impressions: 1. Although (or because) there were many less resources (no surgery, no pain meds, not even oxygen for the mom in case), the clinic is a much kinder environment in which to give birth than the big hospital. The windows were open. The midwives were kind and skilled. And women labored naturally, vocally, physically - without any yelling at all. Birth there felt as normal as grocery shopping. Something you do. Sometimes it's a pain. You get something yummy when you're done.

After delivering, one woman got up and WASHED her own chitenge in the sink (big piece of printed fabric... kanga, panya... etc) within 15 minutes.

God damn. Women are amazing.

Kindness

I had written a whole entry in my head after a long day of observing at the Hospital on Tuesday - but when I got to the office today - my Macintosh died. Now computerless, and feeling disoriented, I write at the end of the day from an internet cafe.

Tuesday I piloted my new and beautiful data-collection tools. I observed a hand full of births - and interviewed the midwives briefly. The births were mind-boggling in their routine-ness. The women delivering at the hospital were not treated at all as if this was a special day. On the contrary, they were treated as if they were doing something rather gross and animalistic. The woman deliver on flat beds (all on their backs - they are lucky to have a metal bar on which they can rest their head while they push. There are no sheets. women bring their own fabric - and if there is none, well, it's black-garbage-bag plastic to lay on.

But the surprise - or the noticeable component - was not the lack of resources. I expected that. It was the unkindness with which some of the midwives treated their patients. One, when seeing his patient grunting to push, scolded her and made her cross her legs until he had time to catch the baby. When he did come back, about 10 minutes later, he started waving his scissors about - near her perineum saying "If you do not push this baby out in 10 minutes I will CUT you (snip snip with the scissors) - or you baby will die...."

Luckily, she did. While she was pushing, however, he didn't like the effectiveness of each push and grabbed her lips and held them tight - in a mix of Nyanja (the local dialect here) and English- he said something all to easy to understand "Enough with the drama, drama, drama! Push with your mouth closed."

I used my new learned midwifery skill of biting my tongue and sitting on my hands or I think I would have jumped on him. She was also HIV positive - and on PMTCT. And I really hoped that he was not treating her badly because of that. Who knows. Stigma runs deeply.

They were not all so dramatic. However, it made me wish that my first idea for a project - looking at what happened to a mother-friendly-organization - had worked out. At the end of the day, I didn't care if they used active management - I just cared that they treated these women like the goddesses - or even the humans - that they are.

On another note- the 'expidited' IRB process still hasn't given birth to a letter of approval. Thus, full data collection is still on hold. We are INCHING closer by the day.

So, another day, another story. I'll keep you posted. On the flip side - Zambia is growing on me. It is the perfect weather to run - and the roads are long and dusty.

in conclusion?`

Many things have happened since my tearful post last week - and besides my sore throat today, I'm feeling much better.  

1. The organization paid the fee. I had nothing to do with the decision. They will meet today - so my fingers are crossed that it's a yes, and I will have to spend more time ruminating on the meaning of the on the un-ethical behavior of the Ethics committee.  

2.  I spent a night dancing to Congolese Rhumba at one of the few dance clubs here in Lusaka. One of the people who came dancing with us is a new friend Nathan - who happens to be  a Zambian wedding choreographer. He tried his best to teach me his moves (picture a slowed down and more controlled version of west-Africa dance).  It was a great evening - better still because of the un-sexuality of the dance floor. It was mostly young men - showing of their moves for each other - completely un-self-conscious and ready to bust a move at every song. Quite a refreshing change from the bop-your-head-to-the-beat style of may American men. 

3.  We conducted a training for our two fantastic research assistants. They are both experienced Zambian midwives who had great advice on the phrasing of questions.  We met outside, and ate insheema (a local maize mush) with a delicious vegetable called "rape" (not kidding) - which is like, if not exactly, Swiss Chard.  Once this project gets rolling, they will be a joy to work with.

4. I got a letter of permission from the Ministry of Health to pilot the data collection tools.  Yeah. One accomplishment. This morning I took the tool to the director of the hospital, who was at another meeting and will not be around until tomorrow. Argh. Stymied again.  "Don't worry," my friend Masuka said.  "You'll get used to the Zambian slowness. You people always do."

Hopefully tomorrow.....  

It's rare that I feel angry. But today I feel furious.

We have been promised almost daily since my arrival that "tomorrow" we will have word from the ethics committee here to get approval for this study to proceed.  I've gotten a lot of "don't call us, we'll call you" - when I keep bothering the poor secretary.  So today I called again, a bit more desperate, and asked to speak to the head of the committee. She explained that we wouldn't be reviewed until the end of the month? 

WHAT?? 

JUNE 30? 

That will add up to a month of waiting.

She has to be kidding.

There was one caveat. We could pay 2.5 million Kwatcha (about $800) to organize an expedited meeting that could be called in a day.  

Here, I have found out, officials are paid a "sitting fee" for each meeting that they attend. People in lots of health organizations  are impossible to get in touch with because they are always in meetings. And now I see why - what a supplemental income strategy.

So my project has been sucked into this fiasco.  It is possibly a combination of a miss-communication (the secretary hoping it would be passed, so she led me on in a way), the huge wall of bureaucracy with a hint of corruption peering through the silver walls...

I am trying to spin this in my head as a cross cultural experience (yes, thanks mom).  Perhaps it is a different sense of time,  a lack of a sense of urgency. I joke with people here that there is "Zambian time" and "America Time" when we call a meeting. A 9am meeting in Zambian time means between 10 and 10:30. In general, people here have been nothing but generous.  However, in this situation, I feel like I want to pull out my hair.

In the end it leaves me feeling like I want to cry.  I am here. Now. I would love to get this thing off the ground.  We are trying to circumvent this by talking to people with power. At this point, my fingers can only be crossed  - that, or I (or the organization I'm working with) can cough up $800. Or, I could think of a fun plan to do for the next few weeks and take off for greener pastures.

Oy.

Cloudy day

Two unusual things happened yesterday.

1. It was cloudy here. 

Strange to say - but every other day has been cloudless and getting into the 70's. Yesterday it was windy, cloudy, and cool. It feels like fall here.  The clouds weren't ominous - or threatening of rain - just grey - and pervasive - and preventing sun.  Today is the same. I hope we see sun again soon.  

2. I finished two novels in the span of a week. 

I don't remember the last time I've done that.  After six here it's pitch black out - and there isn't much of a night life - so I've been staying in most evenings. I guess that's how one finishes two novels in a week.  I'm only on week 2 - and I am already half done with the books I brought. Hmmm... 

I'm anxious to get this project started. It's been a week and a half of prep work - paper work - office time. We still don't have local ethics committee approval - which means I can't even go into the hospital to pilot tools.  I've been talking to lots of people working in this field - and I am starting to get the impression that Active management - what I'm looking at - is being done pretty routinely in Lusaka.  Yesterday I went to a grand rounds at the hospital here - on the topic of a garment they are piloting to reduce death from hemorrhage - in their presentation they mentioned that they've seen lots of preventative measures being taken (ie: active management) and sort of brushed it off.  I have this fear that I won't find much of anything interesting at all.  I guess, stepping back, that 100% compliance is interesting - it means that the trainings worked. That there is a shift in culture.  

Oh well, hopefully with more prodding and nudging and bugging this IRB thing will go through and I will be able to get started. Data collection is scheduled to begin on Monday. We'll just see about that...

Population

Zambia is not a very densely populated country. Indeed, the whole population (roughly 11 million) is smaller that that of the city of Lahore in Pakistan (almost 15 million). There is not the hustle-bustle here of urban or rural life. In the rural areas, although I have not yet visited them, the towns are said to be miles away from each other, and each one sparsely populated with only 20-100 people living within the town walls.

Not only does this make for a non-hectic (almost suburban) experience when walking around the streets of Lusaka (indeed: after a week here I can count the number of times someone has asked me for money on one hand: 2), but it poses interesting challenges when developing health care interventions for the rural areas.  

On Friday I sat in on a professional meeting for people working on pediatric health in Zambia. New research was presented and discussions were had regarding how to decrease the extremely high neonatal mortality rate.  One pediatrician shared her research regarding the intervention of barefoot neonatologists - that is, lay people trained in basic neonatal health and newborn resuscitation to accompany traditional birth attendants or to visit new moms shortly after birth.  This intervention has been rolled out in India, and in some areas, has reduced neonatal mortality by 30-40%.  However, an interesting concern was brought up: with such a small population, and such sparsely populated rural areas, would a trained lay-person have too little to do to maintain upkeep of their skills? If they only had three or four babies per year in a small town of 20 - would that be enough?  Until you are REALLY comfortable - clinical skills certainly fall under the category of 'use it or lose it' - and they are afraid it is a 'lose it' scenario.  But, with such a small population - it is not worth putting one of the rare doctors in these towns. So that is the challenge of Zambia (ok, one of the many). One solution is to have a system set up where doctors literally fly into rural towns when there is an emergency - but this, too, poses challenges.

The sparse population has affected me as well. The entire time I've been here - I have kept waiting to feel like I am in "Africa." This has begged lots of reflection on my part around the questions of my biases, my expectations, my sterotypes of "Africa." What was I looking for? What was I expecting? Why, when Zambia is almost smack-dab in the middle of this continent, can it not feel like Africa? And I think it comes down to that feeling of being overwhelmed that I am used to - or that I experienced in Mali and Kenya long ago.  I am not really overwhelmed at all. Perhaps this is due to my cush-living situation in ex-pat ville, and perhaps it is due to Zambian culture. It is not a pushy culture. People so far that I have meet have been nothing but lovely, and rarely pushy at all. Even at the markets. Perhaps it is because English is used widely here - so I have been able to communicate rather freely. Perhaps it is in part simply due to my incorrect expectations and assumptions about what this country would feel like on the outside.

Saturday,  in a quest for hustle-bustle, my new friend and I ventured into the down-town area on Cairo-road. I had been warned to 'not get excited' - that it is little more than a row of Banks.

It was more than banks, and my friend and I found a big (ish) Zambian market with local food (ensheema - sp?) which is corn paste - similar to ugali - and fried fish, chicken, and dark greens.  We found pirated DVDs, lots of car parts, sink parts, and the nuts and bolts (literally) of life. Hair salons teeming with women getting new-do's, extensions, un-extensions, braids... and some tailors with black singer sewing machines and foot-pedals.  

I brought my camera - but was too nervous to take lots of photos for some reason.  A few people said 'NO' with their hands when I lifted it out of my bag, and one woman asked for money.

The photos aren't great - and I tried over and over to upload them - but the connection must not like it.... I'll try again later. 

Today I'm going to visit a midwifery class to get a 'feel' for education here.  It will be my second observation, the first of which led to many insights indeed.

Drastic Drop

The preliminary report of the Demographic Health Survey (DHS) for Zambia came out this week.  This report gives statistics from the last 6 years on all of the key health and education indicators: neonatal mortality, infant mortality, under 5yo mortality, and maternal mortality are the statistics that affect the organization with whom I’m working.

The maternal mortality rate for Zambia in 2002 was estimated to be 729 for 100,000 births. That’s huge. 1 in 19 – and compares to places like Sierra Leone and Afghanistan (who have the highest, I think - close to 2000/100,000).  Lots of money has been poured into Zambia - lots of programs – lots of trainings – and guess what? This Monday – preliminary findings say it is now 442 per 100,000. That’s almost a 300 point drop! Huge! Huge mongus. Amazing if it’s true. The question it begs – if it’s true – is what happened here? And how can it be replicated?

There is disbelief amongst the NGO community from what I gather. “That can’t be!” One well known (un-named) organization has already heard threats that they will lose major funding because of the less dire straights of Zambia.  “They need to check those numbers before they release the report. That’s CRAZY!”

So, is it true? It’s statistics only. But has something changed? I asked a Zambian doctor who works with the organization and she gave me a long and thoughtful answer in her lilting and lovely Zambian accent (A fairly geographical accent, I think – sort of a East Africa meets South Africa mix). I would have killed to have gotten her explanation on tape.

“I think it is” – she said.  I don’t know about numbers – but something drastic has changed here in the past five years. She told me that five years ago, after graduating from medical school and working in the crappy Zambian facilities for a few years – she and her husband up and moved to Botswana – where they have more resources and better facilities. “It was awful here.” She said. “The hospitals were terrible – the clinics were terrible. When you went into the field – all of the kids looked malnourished – with swollen bellies and light hair. But now? Only a few. We used to have admissions all the time for malnourishment – but now it’s rare. Things are a lot better.”

She paused.

“I think it has to do – in a strange way - with AIDS.  When the AIDS epidemic came here many people rushed here with lots of money, lots of programs, and lots of help for our Ministry.  In order to get out ARVs and do health education programs, they made the clinics better and taught the people that they needed a basic level of care.  The people now think that they deserve better – there is more of a demand.  People now think about ‘good health’ in  way that they didn’t used to talk about before.  And with ARVs, the people are stronger. Women are stronger and can give birth when they are not so weak.”

“When I returned last year from Botswana – it felt different.  It is getting better.  But sometimes I wonder – if South East Asia – and Latin America – and South Asia  - who are all in a similar economic position as Africa can get their mortality rates so low (Indeed – they hover around 50-100/100,000 women – about an eighth of Zambia) – why can’t Africa? Why can’t we?”

She concluded – “If we keep going at this pace, we will do it I think. We have far still to go – but I think we will make it.”

Wow-ee. What an exciting time to arrive. What a way to start a project in reducing maternal health. How positive. What a sense of promise.  The facilities really are changing here – there is a sense of possibility in the air – and it makes me excited to be here – and take this leap…

*Please note - the statistics on this page are a rough estimate. Exact numbers differ between sites. Luckily for me, I'm not writing a publishable paper right now - so I can be duly liberal with my numbers. Also, the theories posted in this are only that. Theories. Thoughts. Some interesting ideas.

Lion on the bed

I am sitting on my big bed with a Lion print blanket (it does get cool here at night) – not a lion print as in leopard print – but an enormous picture of the head of a lion printed onto the blanket. Yeah, a bit scary. But then again, it’s Africa, right? Even in ex-pat style. will post this tomorrow morning from the office.

The electricity has just come back on. It was out during the dinner hour – about 6pm to 8:30pm – “rashioning” it’s called.  Fairly smart if you ask me.  Apparently there is a schedule, although the electric company doesn’t keep it, so every few nights or days – or both – the power goes off in different neighborhoods for a few prime hours just to save.  It was fairly incredible – within seconds, literally, of the electricity suddenly shutting off – the surrounding houses looked like they started turning on lights. Folks around here have the flash-light-mixed-with-candles lighting down to a science.

I am feeling less resistant to the expatriate style. I even wore heels to work today – ha! I never once wore them to my clinical site this year- but today we had a meeting with the ministry of health so, what better a time? 

It was refreshing in some way to visit the ministry.  A rather drab building – about 7 stories in the middle of nowhere in Lusaka – jutting upwards like a big box built with legos in the middle of a living room floor.  It had decent landscaping dozens of white 4x4s in the parking lot, and a fountain with dolphins (hmmmm? It’s land locked country. Not exactly their mascot). The building was rather dark inside – and the offices had little to no decoration – a small fridge jammed up against a standing fan- jammed next to a built in shelf made of peeling and old formica with big binders labeled “Action Plan” and “WHO recommendations” and “Child Mortality.”  Some of the ceiling tiles were falling out, I noticed, as I waited for the meeting.  One of the few decorations in the Hall was a World Breastfeeding Week poster (shout out to WABA – my old job). But the minister we met with was really sharp – really smart – gave great feedback and supportive advice for the study. 

That was the Zambia I was expecting. And in some really selfish way – I was glad to see it.  Some how the peeling formica and pictures hung-too-high on the walls made me feel at home.

Thursday and Friday I’m scheduled to visit some midwifery school clinical rotations – that should be another big step towards opening my eyes to what this country is – and how it functions.  I don’t think I’ll wear heels for that day. 

Africa-light

We'll, I've arrived in Lusaka after 27 hrs of flying - but oddly feel like my trip has yet to start. While the flying is behind me, I still feel swept up in American ex-pat life - and have not experienced the challenges that I had expected. I am staying with my professional contact, Donna, who lives in a beautiful house in the Kabolunga neighborhood in Lusaka- which might as well be called ex-patriot-ville. The houses are all surrounded by walls - and the only way to recognize one house from another is to recognize the gate that the gate-boy opens.

Tomorrow the project officially begins - I have meetings with a member of the ministry of health and will start my project arrangements. For now, I am left to wonder about this place -to wonder what it is like beyond protected walls.

Yesterday I ventured out to a tame market with everything from knit plastic tote bags made from recycled plastic, to traditional African print fabrics, to gem-stone rings worth hundreds of dollars. Very few people hassled me. Only one street kid followed me to ask for money. What an interesting place...

My challenge will certainly be to strike a balance between who I am (American, student, midwife) and where I am. I am excited nonetheless to be here, and look forward to what the next 10 weeks has to offer.