Life is short, the cliffs are tall

This past weekend (and actually the one before as well), I visited Livingstone, where one can find Victoria Falls and a whole lot of tourists. It was a six and a half hour bus ride, much of which I spent crushed beneath the broad-shouldered woman nursing her already milk-drunk child next to me. At last we made it to Jollyboys Backpackers, one of those hippy traveler places with the familiar shared bunk rooms, colorful common areas, and youthful European clientele that characterize hostels everywhere on the planet. After settling in, I wandered around town a bit and found the immigration office, where a nice man gave me a stamp and permission to stay in Zambia another thirty days.

Julia and I started our first day there by taking a boat ride out to Livingstone Island, where a guide leads you barefoot through the mud to a certain spot and then says, “now look” and you realize with a bit of vertigo that you are about eighteen inches from the edge of the falls. It is the widest waterfall in the world, and so the water chooses its path at lowest points along its 1708 meter span, leaving gaps where it is dry. We were standing in one of those places, looking out along the line where the water suddly takes a ninety degree turn. There is a strange effect of sound that happens as you approach, because the roar of the water is not audible from above. It is only from places where you can see the water falling and feel the mist drenching you that you can also hear it. So there is this astonishing peacefulness at the top, and then you lean over and hear the crazy whoosh of a million gallons of water per second finding its way to the bottom of the gorge.

A plaque marks the place where Livingstone first “discovered” the falls, the fact that he was led to the spot by the local people who already called them “Mosi-o-Tunya” (the smoke that thunders) notwithstanding. Julia and I spent the remainder of the day exploring the rest of the area and mingling with the baboons and vervet monkeys who make their home there. Giraffes and zebra were also about, and we were appropriately impressed! The giraffes move the way I imagine dinosaurs did, with steps that look as though moving each limb is an effort that requires great forethought.

That night we went to the five-star Royal Livingstone Hotel for a sundowner on their porch. It was fun to pretend to be obscenely wealthy, sipping cocktails as the day ended with the mist from the falls rising in the distance. Inside the hotel, there was a parlour area lined with shelves stocked with old books. I pulled down a volume of the Encyclopedia of Health from around 1930 or so, in which there were many examples of Germans doing healthy things and an explanation of how health professions had finally discovered protoplasm, the elusive substance that forms the connection between mind and body. It seemed most promising.

We couldn’t resist the opportunity to raft the Zambezi, so the next day we were up at 6am to head off to that activity. Ours was the only raft that flipped over entirely, and after some near-drowning experiences in the class 4/5 rapids, we all took the river that much more seriously. It was a fantastic time though (I thought, though one member of our group reports that she never wants to go rafting again), and we finished the day with a sunset cruise, watching hippos bask in the shallows.

On Monday we crossed the Zambezi into Botswana at a point where you could see four countries at once – Zambia, Zimbabwe, Botswana, and Namibia. Naomi (the intern from our Kitwe site) and I convinced a woman at the border with a food cart emanating incredible aromas to accept our Zambian Kwacha for some of whatever she had when we learned that the “included” breakfast on our tour which we would not see until three hours in would consist of tea and a petite muffin. Botswanan food, whatever it was, certainly ranks high on my list.

We were in Botswana to visit Chobe Game Park, and our little safari did not disappoint. We saw a whole herd of bachelor impala, males who banded together when the dominant one cast them away from the ladies. Warthogs wandered about in little packs, and I cannot figure out how much influence Disney had on my impression of them as truly ugly but humerous nonetheless. We passed some giraffes as well, one of which had managed to lower itself into the ungainly-looking tripod position they use to get their mouths down near the water. A pod of twenty or so hippos looked like enormous stepping stones in the river, and I think I would have been happy with that, but moments later, we turned around to see a herd of elephants wandering across the path right in front of us, heading down to the water to drink. I am sure I could have watched them all day. Later we saw them from above as they crossed the plain in a long, thin line, a couple of stragglers pulling up the rear.

In the afternoon we saw more elephants who had forded the Chobe River for marsh grasses that they wound around their trunks like spaghetti before devouring. We were on an open flat boat, and it was a tranquil scene, looking down the river to see their silhouettes along with those of the storks and water buffalo. We watched a couple more of the great creatures make their way across, holding just the tips of their trunks above the surface of the water in order to breathe.

We took the 6am bus the next day out of Livingstone, as we had projects to return to, and truth be told, I did not really need to stay in Tourist Land anymore. Lusaka is Zambia’s capital. As a sprawling, mostly unremarkable city, it does not attract many tourists except en route to elsewhere. But I have gotten pretty well used to it at this point, and there was a certain comfort as the bus rolled into town.

Models of care

When I am not busy in the office, I scoot off to the wards to try to see some clinical work. I have not really had as much opportunity to do this as I might have liked, but when I do, I get to see quite a bit. A few days ago I shadowed some interns who were working in CO3, the emergency gyn ward. UCSF is unusually focused on patient care along with excellent clinical skill development, and though that is the primary reason that I chose to go to medical school there, now that I have begun my training I find that it is easy to take it for granted that these attitudes are universal or at least persistent to some degree throughout the medical world. Being here has shocked me out of that particular delusion.

At school we invest a huge amount of time learning about how to interview a patient in a way that is respectful and thorough, practicing how to elicit the patient’s personal understanding of sickness and wellness (the “explanatory model of care”), and discussing the subtleties of culture, gender identity, past experience, and all manner of other influences that might come to bear upon the doctor-patient relationship. Here I watched the doctor answer his cell phone and chat for several minutes about his car midway through an interview with a woman in pain who already was being interviewed and then examined in a room with at least eight other people in it. A pregnant woman came in complaining of lower abdominal and upper thigh pain and was told basically, “You’re pregnant, and that’s how it is. Goodbye.” Women brought their own chitenges to use as drapes – they certainly cannot count on there being a clean cloth or paper or anything at all on the examining table. And in the background the whole time are the moans of the women undergoing manual vacuum aspiration abortions, a procedure normally done under general anesthesia, but because the women recovering from the anesthesia would take up too much time and too much space, it is done without anything at all. Abortion is legal here, but from what I gather, this is something of a technicality in this very Christian country. It had to be made legal in order to receive funding from some human rights organization, but most women do not know about this option, and many doctors will not perform the procedure. It is not unusual for them to misinform women that it is not legal. As a result a high proportion of the obstetrical hemorrhage cases that we see in the study are the result of botched home abortions.

I am interning at an interesting time in Lusaka, as the Project Coordinator mantle was officially passed this past week. For the past two weeks the old coordinator (Althea) has been training the new one (Kelly), and I have learned a great deal about the project by listening to their dialogue. The transition was a bit chaotic, and so it is an exciting time to be working here as Kelly gets her feet under her as well. We both have similarly compulsive tendencies with regard to the efficiency of procedures and project organization, so we have had long and multiple conversations about how to give the study a bit of a makeover. I have already started reorganizing the office, and if this is anything like what happened when I got my hands on the Scadden lab, soon there will be aqua blue signs everywhere telling people how not to mess it up again!

North to the Copperbelt

Julia’s birthday was fast approaching on the 15th of July. I wanted to see our other project site anyhow, so I got on a bus headed for Ndola to celebrate and explore. The bus system here is something of a mystery. One arrives at the station and is immediately set upon by crowds of young men yelling, “Madame, madame! Where are you going?!” In his desperation to get you to board his particular bus, a man will try to grab your luggage and stow it on his vehicle before you’ve agreed to anything or know exactly what has just happened. Ostensibly there are departure times for these busses, but the reality is that they will leave when they are full of passengers or when the driver is good and ready. Hence the touts’ fierce attempts to convince a potential passenger that his bus really is the one you would like to board this fine day – the sooner he gets it filled, the sooner he is done.

I had it on good authority that I should ignore these guys and take the Eurobus, which theoretically left “on time” with some level of reliability. As I waited for two hours on the stationary vehicle while it filled, I thought perhaps I had been misled, but it turns out that this is relatively standard, and was much better than the four to six hours I might have whiled away on another bus.

The trip was really lovely, and since I had been there so early, I had a seat right up front from which to watch the abundant activity along the side of the road. We passed villages of huts made from clay and grasses, most of which were the color of the earth around them. Occasionally, though, it seemed that someone got his hands on some sea foam green paint, and there you would have a sort of tropical island of color in the middle of nowhere. We went by Zambeef cattle ranches, rural health clinics, police stations with goats wandering in the yard, and fields brought to life in the dry season by irrigation machines with pterodactyl wings. The bright green crops ended abruptly where the watering stopped, colliding with the ubiquitous dust that could be a billion pulverized burnt sienna Crayolas. A woman in her bright chitenge wrap and a baby strapped to her back emerged from a field carrying an enormous bale of grasses on her head, her hips forward as she stepped deliberately, appearing entirely regal on the whole. Bored-looking people sold charcoal packaged in old mealy-meal sacks with woven nets of grasses sealing in the goods, and as we neared Kapiri Mposhi, bottles and bottles of honey were for sale on wooden tables. My sweet tooth would have had me buying some, but to my dismay, we did not stop to placate it.

In Ndola we celebrated Julia’s birthday with delicious Indian food and Castle beers from South Africa. The city is much smaller, more quiet, and prettier than Lusaka, as is the Central Hospital. Julia works there, and another intern, Naomi, works in the neighboring city of Kitwe. (That’s the two of them posing in the Ndola Hospital hallway.) I had a chance to tour the maternity section of the hospital and to meet some of the nurses who worked with our study. We saw twins just as the second cord was being cut, and though I probably should have been watching what was going on with the mom, I couldn’t take my eyes off those tiny, perfect, still-wrinkled people in their bassinet. It may be that pediatrics is more my calling than obstetrics.

Elusive hippos

On the 3rd of July I moved in with Adelina, a researcher working on a neuro-AIDS project also at University Teaching Hospital. Up until this point, I had been staying at Althea’s place while she was away in Zimbabwe. This after Julia and I were first placed with some nuns who tried to extort unreasonable sums of money from us for a rather unpleasant living situation. Shira fortunately connected me with Adelina, and from that point on, I have been a happy resident of Roan Road.

A long holiday weekend was upon us, so Adelina and I decided to pack up and head for Siavonga, a town along Lake Kariba. Our friend Naser joined us the next day. The lake was created in 1958 when the course of the Zambezi River was altered with the construction of the Kariba Dam. Many people were forced to leave their homes for higher ground, and the communities that they formed around the resulting body of water became local tourist destinations. Supposedly there are hippos and crocodiles in these waters, but sadly they did not see fit to visit with us that particular weekend, even when we went out on a boat ride to try to find them. Alas. The sunset we saw over the lake from the boat was spectacular anyway, with wide open skies and perfectly placed clouds lit up from beneath.

On the drive back, we gawked at Baobab trees and stopped at several roadside stands to buy baskets and other items made from a type of ubiquitous stiff grass. Naser owns a candy factory, and at every stop we would look back to see him handing out sweets to the delight of kids and adults alike. He became very popular that day along the road to Siavonga.

Muli bwanji

Muli bwanji is “How are you?” in Nyanja, the language most spoken in Lusaka. Though English is the official language of Zambia, everyone speaks one or two and often as many as five or six local languages as their first tongue. Nearly everyone seems to learn English in schools, and it is spoken with a distinctly Zambian accent that is a cross of British English (thanks, colonialism) and these languages indigenous to this part of the world. So though everyone does speak English, a traveller receives a much warmer welcome if she at least uses the local greetings. The shocked expression on people’s faces on hearing a mizungu (white person) say anything at all in Nyanja (not that I know much), is generally replaced with a giant smile and some level of appreciation that I gave it a shot. Or they just laugh at me. Fair enough.

Before I left UCSF, I learned from my professor Dana Rohde that her sister Shira would be here in Zambia this summer also. Shira is taking a year off from her job at Pfizer to finish setting up the Flip Flop Foundation, an organization that supports locally-run childrens’ programs with food and hygiene supplies. For more information see: http://www.flipflopfoundation.com/.

During my first couple of weeks here, I went on several distributions with Shira and FFF’s local staff, Elijah and Mwanza. (These guys were especially good language teachers! That's Mwanza in the photo with me.) I was excited to see some of Zambia, and I couldn’t really bear the idea of spending each and every day in a small office. So I packed up work to do in the evenings at home, and many afternoons I ran off with the Flip Flop crew.

During visits to schools, hospices, childrens’ programs, and an orphanage, it was clear how much need there is here. Schools had virtually no supplies and were heavily overcrowded. Classrooms were often closet-sized and dark (as in the photo to the right, where the teacher also has an infant tied onto her back), and several times we saw an arrangement in which two separate classes were taught side by side in the same small room, with each class facing its respective teacher in opposite directions. The principal at one school explained to us how much it helped to be able to feed the students one meal per day so that they would come to school and be able to pay attention to their studies.

The site that I struggled with the most was one which provided shelter to girls who had been victims of rape, often by a close relative, and were left pregnant. Though abortion is legal here, these girls are encouraged by this particular organization to keep their pregnancies, despite the fact that they will be completely ostracized and have absolutely no social or financial support for raising them. In addition, many of them contract HIV from their rapists, so now they have a baby, HIV, and nothing else. I left feeling terribly angry and torn between ideals of cultural respect and what my gut said about justice.

On a brighter note, one of my favorite partner organizations was a program called Tiyanjane that conveyed public health messages through theatre, dance, and music. They also seemed to have a sports program and various other activities. The kids were ridiculously excited to have “snaps” taken of them, so I have about a bazillion photos of beautiful Zambian children. (There is an unusual number of shockingly gorgeous people here; somehow they have cornered the genetic market on bone structure.) Tiyanjane will be performing in a couple of weeks, and I look forward to seeing their show.

Wait, remind me what I’m doing here?

The project coordinator, Althea, met us at the airport. Neglecting the extraordinary lack of sleep that I had enjoyed over the previous 48 to 72 hours, I stupidly told her that I’d be fine to go to the office to learn about what I would be doing over the next week while she went away to Zimbabwe. When I showed up to the office on Monday, I had little clue as to what I was supposed to be doing, and I had to try to decipher the cryptic notes that evidently I had written but had no recollection of whatsoever. I had largely snoozed through the makeshift orientation, though my eyes had indeed been open for at least part of it.

The project’s office is in the maternity department at Lusaka’s University Teaching Hospital. As the country’s primary referral hospital, it is quite a large place. Medical and nursing schools are also based here.

While great strides in maternal mortality have been made in rich countries, pregnancy and childbirth in the developing world remains a dangerous undertaking. A woman’s lifetime risk of death in pregnancy or childbirth in developed regions (as defined by the UN) is 1 in 7300. In sub-saharan Africa, this figure is 1 in 22.

Our research is looking at the efficacy of a Non-pneumatic Anti-Shock Garment in treating obstetrical hemorrhage and the resulting shock, the leading cause of maternal mortality. The NASG is basically a simple compression device applied to the lower half of the body that shunts blood to the heart and brain and brings up the patient’s blood pressure. For more on the NASG, see http://www.lifewraps.org/.

As an intern, I am mainly helping out right now with data organization for the project. Though not the most exciting task, a database that I spent a couple of weeks creating is already helping to increase efficiency and reduce the considerable confusion that existed previously. Julia and I will also be collaborating on a baseline analysis of patient demographics and outcomes from two of the project sites.

Here are a couple of sites so you all can become experts on maternal health & safety:

WHO maternal health site
http://www.who.int/topics/maternal_health/en/

White Ribbon Alliance for Safe Motherhood
http://www.whiteribbonalliance.org/

Ukaipa dwiza kuvina

I found this figure of speech in the Nyanja section of my Zambian languages phrase book. Ukaipa dziwa kuvina. If you are ugly, know how to dance.

Showing up in a new place, I am always at a bit of a loss. That really is the excitement of travelling. You get off of a plane and find yourself at the edge of a certain kind of wilderness, not totally sure what you've signed up for or gotten yourself into, or what the next few days or weeks have in store. A sort of ancient fear of the unknown kicks in, and you realize that you are alive and a small thing in big old world. I think that that Ukaipa dwiza kuvina says something about gathering your resources, figuring out what you've got and what you haven't, and moving forward with a bit of chutzpah into the next adventure.

When I first arrived here in Lusaka, Zambia on June 27th, that was just how I felt. I had signed up to be an intern for a project investigating the efficacy of a device that would be used as an intervention in resource-poor settings for obstetrical hemorrhage. A friend and classmate, Julia Bruckner, had done the same, though she was assigned to work in the Copperbelt region, about four hours to the north. After disembarking from a 15 hour flight in Johannesburg, South Africa (this after getting to Atlanta from San Francisco), we were not thrilled to learn that we had missed our connection to Lusaka. We staked out benches in the check-in area, wishing we had thought to abscond with blankets and pillows from the plane. Through the night we contemplated the necessity of the ever-so-brilliant florescent lighting and eclectic music of altering volume provided by the good people of the Johannesburg airport. Our quasi-sleep was punctuated by our own laughter at our pathetic situation, because that was really all we could do. I should mention that we had also been told that we were going to have to pay three hundred dollars in the morning to change our ticket, which added to the misery somewhat. However, a miracle occurred around 5:30am when a lovely woman who may have had a halo over her head handed us our boarding passes without relieving us of our money. A further miracle allowed us to locate our luggage which, via a tour-guided odyssey through the airport, we found languishing in the Doomed Baggage Department. And then we were off.