Lessons in Zambia

30 May 2014

There is a culture shock that occurs when one travels from the developed to the developing rule.  Uncomfortable, worried, sad, lonely, isolated, irritated describe many of the feelings I experienced when I first arrived in Zambia two-weeks ago.  It was busy, dirty, and foreign.  I stood out as one of the only white faces in a sea of black.  People stared; there were catcalls.  I felt a million miles away from home; I was a million miles away in every sense imaginable.  As the last two-weeks unfolded, and I traveled around the country, my sentiments gradually changed as I really had time to understand Zambia and Africa in general.

After arriving, we had two-days of rest and recuperation in what is arguable the nicest hotel in Zambia before we were thrust out into the heart of the country.  Our first excursion was to the city of Ndola, in the heart of Zambia, the Copperbelt Region.  Our Zambian colleagues boasted that Ndola was the cleanest city in Zambia as we drove into it.  There was nothing aesthetically appealing about Ndola.  It was an industrial town full of copper and steel mills, dilapidated cinderblock buildings, heavy traffic, roads torn apart with construction, red dusty earth, tractor-trailers overfilled with metalwork supplies.  Numerous billboards lined the streets however  90% of the billboards carried only advertisements for G. Rutherford Outdoor Advertising, the company that owned them and sold advertising space.  G. Rutherford tries to entice you to buy ad space by posting photos of people in cheesy poses with encouraging slogans like, “You are never too small to advertise!” “Your advert will look very good here,” “It’s party time, let’s advertise!”

We arrived at what we thought would be our hotel, only to find out the rooms had been booked for the wrong nights and were full now.  The driving tour of Ndola continued until we found a place called Fatmols Lodge, Conference Center, and Casino across the street from a large sports stadium that looked straight out of the Soviet Era.  The rooms we toured were awkwardly designed, some excessively large with old gaudy pleather furniture sitting in oversized areas.  The TV in the reception was tuned to a telenovelo (Spanish soap opera) dubbed in English; a few people watched the laughable acting in rapture.  I realized the casino was not yet operational when I found three dusty, antique slot machines sitting in a room with old two-by-fours and no electricity.  Dinner was served in a dingy, dim area with a Coca-Cola refrigerator that had a built in alarm that sounded incessantly as I gnawed on an over-cooked pork chop.  The bedside lamps in my rooms had no light bulbs. 

We visited three different clinics in Ndola that were simple but overall well functioning.  All were located in a gated area in the midst of slum accessible only by an unpaved, dirt, pothole-ridden road.  I ate more fast food in the Ndola region over the course of three days that I had in the past three years.  First there was Hungry Lion, also known as Zambian KFC, then there was Nandos Chicken, and finally Debonair’s Pizza, which will go down in history as the world’s worst pizza making even Dominos seem gourmet; I ordered the Hawaiian pizza for irony’s sake.  The meat was mysterious to say the least.  That was Ndola.

The next region we paid a visit to was the Southern Province known for its sugar-cane industry, with the provincial capital of Mazabuku.  The drive to this region was much prettier than the one to Ndola.  We drove through rural scenes containing rolling hills, plateaus, open dry plains, and even a few baobab trees.  We learned some of the common names people had in the Southern Province such as, Progress, Loveness, Weather Expert, Liveness, Patience, Gifty.  We visited a very rural clinic where women had to travel up to 15-km on foot or bicycle to receive care for themselves or their children.  A large group of them formed a line in front of a large tree where a hanging scale was suspended to weigh their children.  They talked about us in their local dialect when we arrived, saying something to the effect of, “Children! Stop crying! The white ladies are here!”  They don’t get a lot of foreign visitors out in these parts.

Our only eastbound journey outside of the capital city was to a region called Refunsa, to visit an extremely rural outreach clinic.  There was no running water and the electricity was out.  One of the patients was wearing Toms shoes; I guess they really do donate them in Africa.  The eastern area seemed even drier and for the first time, I saw the mud huts with thatched roofs that one imagines seeing in Africa. 

We made a few stops during our 3-hour drive.  One was at tsetse fly checkpoint where a man walked around our vehicle with a net, ready to catch any of these nasty flies that carry the always-fatal-if-untreated African Sleeping Sickness.  The other stops were at produce stands.  Inevitably, every time we stopped at one, women with bowls full of various produce swarmed our car.  We tried baobab fruit, which came in a large fuzzy shell and had chalky citrus flavored meat, and also had something like jicama.  Our driver bought bananas and sweet potatoes and commented on the fact that the price for the produce went up as soon as they saw “muzukus” (white people) in the car.  A drunk, mentally ill appearing man threw his upper body on the hood of our car when we didn’t give him money.  His hand looked like it had been run over my something heavy.  Our guides were very excited to stop and show us a hot springs on the way home.  Not far off the main road, we got out to see the hot springs water bubbling out of a short fat metal pipe.  The steam smelled like sulfur.  Cattle roamed around.  Our driver, Chris, told us that people come here to baptize themselves in the water, to attempt to obtain improved fertility.  He said people had tried to channel the water into a pipe, but the pipes continued to break.  Salome bought some rape greens (like kale) from a farm just beyond the springs.

The western province of Zambia would be our final journey.  To get to the provincial capital of Mongu, we had to make a 7-hour car drive; two hours of which were through a large national park/game preserve.  This portion of the drive was beautiful in a desolate way; the park consisted mostly of tall dry grasses, brush, and short trees.  We saw brush fires and even a few animals including impalas, small monkeys, baboons, large waterfowl with organ plumes, and even two hippos in the water.  The western province was extremely primitive.  We saw countless villages on the side of the road that were comprised of small mud huts with roofs thatched with dried river reeds.  These villages were extremely cut-off from all modern amenities and reminiscent of how we humans would have lived thousands of years ago.  Cotton and river reeds seemed to be the only industry in this area.

The town of Mongu was perched just above a large flood plain with views as far as the eye could see.  There was an unfinished bridge to nowhere and a stagnant harbor with small fishing boats.  During the rainy season, many parts of the western province become accessible only by boat.  During these times, there are real concerns for tragedies like crocodile attacks while boating to work.  There wasn’t much water left at this time of year, in fact Mongu was almost desert like and full of sand.  Walking around one of the remote clinics was like trekking down a beach with black sand and no water; four-wheel drive is necessary to navigate the area.  Among the sand and grunge also grew tropical flowering vegetation, like bougainvillea and plumeria.  We ventured into the heart of the slums in Mongu during our clinic visits and even visited a small market place where we observed the community health workers as they did a call and response song with the women about Family Planning.  There was dancing and clapping; it was moving. 

Finally back in Lusaka, which felt like a modern metropolis compared to Mongu, we spent our final days.  For our last clinic day, we ventured into an area called Kanyama, which is one of the most densely populated areas of Lusaka containing at least 160,000 people.  Our driver, Chris, had to navigate through a sea of humanity to get there.  He mentioned he would avoid one short cut due to the fact that “thieves” congregated there and another due to the high volume of drug raids.  The streets were packed with cars and buses that did not appear to following any sort of traffic laws.  Thousands of people walked in and around the traffic.  Women carried heavy loads on their heads and babies on their backs so their hands were free to carry more.  I saw one man who had three cases of Gatorade balanced on his head as he walked through the masses, trying to sell the bottles.  Some men even waded through the traffic, standing between the lanes, holding up a random solitary windbreaker jacket, stuffed animal, or even an Ab-Flex contraption in a box with a blond 80’s aerobic instructor on it. 

Kanyama clinic was an experience in and of itself.  One of the nurse midwives gas a tour of the facilities, which also serve the 160,000 plus people in this poor area. There was the TB treatment area, the HIV testing and antiretroviral dispensing area, the children’s clinic and weighing station, inpatient wards, clinics that performed male circumcision, cervical cancer screening, and family planning, and finally, labor and delivery.   There were long lines out the doors of virtually every clinical area.  At one point, a car pulled up, the door opened, and a stiff elderly woman was dragged out of the back seat and thrown on her granddaughter’s back and carried in piggyback style. 

The labor ward was incredibly busy for a tiny facility.  The delivery area consisted of 6 cots separated by curtains.  Women were naked and screaming as they labored and pushed out their babies.  I saw one young woman deliver her baby on the cold hard floor with nothing but a trash bag under her to contain the amniotic fluid.  Another woman was pushing and grunting.  The nurse stood next to her and smacked her legs, yelling at her to push harder, not even trying to really help guide out the head that already stuck out of her vagina.  Flys landed on her newborn baby as it sat on her abdomen.  Next door to the labor room, was the postnatal recovery area, which also doubled as a laboring space.  It was a fairly small, open room, packed with cots.  There were 3 to 4 women per single cot.  Some were nursing their babies, others were moving around, grimacing with labor pains.  The screams of the laboring women were very audible through the wall.  The whole process seemed terrifying, and to think this is considered a safe birth in Africa.

As I sit in the hotel lobby, waiting for my shuttle to take me to the airport.  I feel sadness at leaving Zambia.  When I first arrived, I yearned for home, for the “western” world.  Now I felt surprised at my melancholy in leaving this place.  I had begun to feel more comfortable here, fascinated by the sights and sounds, charmed by the friendly people.  Life is hard here, but the people make the most of it.  They aren’t tied to social media and the many petty concerns that we have.  They appreciated life, health, family, and their country; the simple but important things.  We could learn a thing or two from Zambia.

It aint easy being a woman, especially in Africa...

25 March 2014

The concept of being “born” is a crazy one; one moment you don’t exist, the next moment, boom, there you are.  The clock starts, experiences happen, memories form.  We have no control over by whom or how we are born, it just happens to us.  I didn’t choose to be born into a family with kind parents in a developed country, but I sure feel fortunate I was.  As we travel around Africa and I interact with my peers here, I can’t stop thinking how lucky I am.  At the same time, I feel kindred to these women; I could be her, she could be me. 

Life is harder for women; some may argue that, but I believe that is a fact.  As women, the world over, we subject our bodies to the risks of pregnancy and childbirth, we are more likely to be the victims of sexual and domestic violence, we are sexually objectified, we earn less money than our male counterparts, and even in developed countries, we must endure sexual oppression.  All of us women of the developed world can share stories of our experiences with gender-based harassment, abuse, discrimination and oppression, but our sufferings most likely pale in comparison to the sufferings of our “sisters” in the developing world.

Let me enlighten you with the facts about life as a woman in Zambia.  She starts off with fewer days on her clock than we do, with the projected life expectancy for a Zambian woman being 58 years (compared to 81 in the US).  She might consider herself lucky to even make it past the age of 5, since 89 out of 1,000 Zambian babies won’t make it that long (compared to 7 of 1000 US ones).  She will probably start bearing children at a young age since 125 of 100,000 live births are to women aged 15 to 24 (compared to 31/100,000 in the US).  She will have a lot of babies, on average, nearly six.  Not all of those babies will make it through pregnancy, as Zambian infant mortality is 56 of 1000 live births (versus 6 of 1000 in the US).  There are also fairly good odds that she may not survive pregnancy or childbirth either since 8% of women of reproductive age will die during childbirth (compared to 0.8% in Canada and 1.5% in the US).  Sometime during her life, she very well may be contract HIV, with prevalence in Zambia of 14%.

Zambian women might actually feel fortunate when they compare themselves to some of their neighbors, though.  The situation seems to be particularly poor in Chad and Sierra Leone.  Chad has the highest adolescent fertility rate at 152 of 100,00 births and the second worst maternal mortality at 980 per 100,000 childbirths, which translates into this staggering fact:  29% of women of reproductive age will die during childbirth. One out of three!  Sierra Leone has the highest maternal and infant mortality rates in the world at 1100 per 100,000 births and 117 per 1000, respectively.  A few other countries in Africa had some shocking statistics as well, like the 20% prevalence of HIV in women aged 15 to 24 in Swaziland.  Then there is the 39% female literacy rate in Mali (compared to 56% in their male counterparts).  Finally, there is also the fact that 44% of girls aged 7 to 14 are employed and working in Burkina Faso and Guinea. 

 

The many reasons I listed are essentially why I am here in Zambia right now.  Providing contraception and educating women about family planning saves lives of women and children.  That is a fact.  With an unmet need for family planning quoted at 27% in Zambia (compared to 7% in the US), there is still room for improvement.  That is why groups like PSI, the NGO with whom I am working, have helped to establish Family Planning programs in Zambia and similar countries.  It is not as simple as merely teaching the local providers about contraception and providing the birth control methods though.  There are many barriers to overcome here that we simply do not deal with in the developed world and many of these barriers are just inherent to being a woman in Africa.

 

The first barrier is education and socioeconomics.  The women that I have seen in the clinics here are not a privileged and educated bunch.  In 1998, it was estimated that 63% of Zambians were living below the poverty line, making less than ONE DOLLAR a day.  This number has surely improved since then, but I hope it illustrates the kind of poverty I am talking about here.  Many of the women that I have seen interviewed seem to have made it about halfway through school, maybe to grade 7.  One woman said she never went at all.

There are a whole slew of contraceptive myths we have encountered during our trip which, to me, also highlight the lack of education these women have:  “the implant can move from the arm to the heart and pierce it,” “IUDs cause cancer,” “if the man’s penis is very long, can it move the IUD out of the womb.”  Half of the work that I have been involved with here is focused on educating women, dispelling myths, increasing awareness, and even identifying women in the community that spread rumors against contraception. 

Transportation, or lack thereof, is another huge barrier.  Driving down the roads, we see hundreds of women on foot with babies strapped to their backs or fronts, maybe even simultaneously breastfeeding.  If they are lucky, they may have a bicycle for transportation, but it seems mostly men get the bikes.  Some rural areas may not have a clinic or hospital any closer than 15-km.  Although the majority of Zambians have mobile phones, the reception in these rural areas is unreliable.  All of these realities explain why only 42% of Zambian births are attended by skilled professionals.  This circles back to the maternal mortality again…

The women here do not have a lot of control over their lives.  The men largely dictate when and how many children they have.   I have heard a number of women say they don’t want any more children, but they must defer to their husbands.  The men get to have the final say about contraception and whether they can use it.  Many of the contraceptive counselors here sell the IUD to the patients by reminding them that it is a “secret method” that their husbands will not be able to tell they are using.  She can’t use the female condom for pregnancy and HIV prevention, because the man will think she is promiscuous and diseased instead of empowered.  In some groups, the women don’t even get to decide when they can wash or shave their genitals, as the husband must perform it.  If she were to wash or shave herself, it would lead him to believe she was unfaithful.  Many of the husbands even send the women to do the manual labor like farming or selling of produce, while they do the beer drinking.  They do it all while tending to a couple small children at the same time.

Domestic violence is clearly another major problem here based on the number of billboards and posters around the country making public service announcements.  Nearly every other woman who is interested in the contraceptive implant (in the arm) has asked, “If the man beats you and hurts your arm, can the implant move to the heart?”  Domestic violence is clearly all too common a worry on these women’s minds. 

During one of our clinic visits last week, the nurse asked the patient if she would mind letting us observe the insertion of her IUD.  She giggled a little at first, looking shy, but they said, “Yes, why not, they are my fellow sisters after all.”  When you have a rough day and feel like life can’t get worse, remember your sisters in Africa. 

(Statistics I listed came mainly from the World Health Organization but also the World Bank, most stats were from 2013)

Tales from the road in Zambia

23 May 2014

I cannot imagine living in Zambia.  The most redeeming aspect I can find is the people; they are warm, friendly and quick to smile – at least the ones we meet in the medical field.  Driving through the run-down towns, I noticed a lot of hardened faces walking down dusty roads; it’s not all smiles here.  I like the people, but I find Zambia in general to be one of the most depressing developing countries I have visited. 

Unfortunately, the Zambia I have seen so far is lacking in natural beauty.  The terrain is mostly flat with some occasional rolling hills.  Then there are the dusty roads, open plains with tall grasses, interspersed with large trees, and once in awhile, a slow-moving river or marsh area.  The winter weather we are experiencing here now is lovely though; it’s cool in the evenings and warm, sunny, and dry in the daytime.  I have only seen one mosquito all week.

The highways we’ve been driving are pretty decent by third world standards.  They are overall well paved with occasional dirt portions.  They like to throw in a series of speed bumps and police checkpoints at random locations, which creates a lot of traffic.   The highway only consists of two lanes, which means there is a lot of high speed passing going on, even with large tractor-trailers which is proving to be more unnerving than normal due to the fact that they drive on the opposite side of the road here.  So as the driver (which fortunately I am not), you are not only darting past tractor-trailers, but you are also trying to avoid the man teetering past on his bicycle in the shoulder, the teenage boy who sprints out into the street, the brush fires on the side of the road, and the many broken down cars, trucks and buses who take up one of the two lanes.  Our driver, Chris, has been doing a great job getting us safely around Zambia.  Without him, we’d be screwed.

Spending three to six hours a day in the car has given me a lot of time to observe Zambian life from the roadside:  at certain times of day, there are groups of uniformed school children walking along, most young women have a baby strapped to their back and sometimes a heavy item on their head, sometimes there are two men on a bicycle in their factory uniforms.  Also on the side of the road, you will find any number of items for sale:  bright red tomatoes stacked into a pyramid, dozens of watermelon, freshly made cinderblocks, butternut squash, plates of honeycomb, couches, packages of charcoal the size of a man.  One town was selling nothing but calabash gourds.  According to our Zambian travel partner, these gourds are dried out and then used to hold and drink the local moonshine.

 

From driving around, it is clear that the Zambians are very religious people.  It seems that half the buildings we pass by are churches, everything from the United Church of Zambia, to the Church of Latter Day Saints, and even the Jehovah’s Witnesses have made it out there.  The tiny cramped buses that pass by have giant stickers on the front and side with slogans like, “God’s time is the best time,” “Only Prayers,” “Favour from God,” and “Missing Identity.”  Although I am not sure the religious significance of the last slogan, but it was on the side of the “God’s time is the best time” bus.

It is obvious that Zambia is an industrial nation.  During our travels, we have passed by steel and copper mills, oil refineries, cement factories, and large agricultural corporations like Zambeef and Zamseed.  The hand-painted billboards on the side of the road advertise for borehole drilling and flushing or construction supplies like Harvey Roof Tiles, “A house with out Harvey Tiles is like a zoo without animals, there is no entertainment!”  Many of the towns that have sprouted up, are located around major transit points.  We always see a steady line of tractor trailers at the major highway junctions, some are coming to and from the capital city of Lusaka, others are on their way to adjacent countries like Zimbabwe, Malawi, Tanzania, or the Democratic Republic of the Congo. 

 

Zambia is not all industry though; in fact most of it is rural with some farmland.  We have visited a number of cities already, but between those cities, is nothing but dusty earth, bush, trees, and anthills that seems to stretch as far as the eye can see across the flat terrain.  

Polygamists and Sinful IUDs: Family Planning in Zambia

19 May 2014

“Every morning she used to shampoo my locks…first we were dating, now we are mating, penetrating…” went the lyrics to the African rap/reggae song that so appropriately welcomed me to Zambia where I would be working in family planning.   After over 35-hours of travel time, I had finally made it to Zambia and was on the way to my hotel at last.  I had literally traveled to the opposite side of the globe from the middle of the Pacific Ocean to southern Africa.  When the chauffeur to the hotel asked where I was from, and I answered, “Hawaii,” she was actually surprised to hear that that was an island.  She asked if we had a Mediterranean climate there.  Clearly she knew about as much about the geography of my continent as I knew about hers.

I had about 24-hours to try to recover from serious jetlag before we had to report to work Monday morning.  I was to be working with another OBGYN from Seattle and a physician from Madagascar to perform a quality assurance audit of the Society of Family Health program in Zambia.  Together, we would spend the next two-weeks traveling to different regions of Zambia on behalf of a global NGO called Population Services International (PSI).  We would observe the local practices related to intrauterine devices and contraceptive implants to be sure they were performing these services up to code. 

A driver picked us up on Monday morning.  Leaving the hotel, we literally made two left turns and a right before we arrived at the Society of Family Health (SFH) headquarters.  When we got out of the car, we realized that SFH was literally across the street from the back of the hotel.  “We did not want to make you walk on your first day!” they explained.

A bowl of both female and male condoms caught my eye as I walked in the front door.  This was the first time I had ever seen a female condom since they model they showed in high school sex ed class; let’s just say, its not a popular birth control method in the US. 

We received a very warm, friendly greeting from the staff at SFH in an office building that was as nice as any I had been to in the US.  We spent the morning being debriefed by the leaders of the reproductive health program, which consisted primarily of four Zambian women, two of whom used to be practicing pediatricians, another who was a midwife, and the fourth who had more of a public health background.  I was happy to see this group of smart, progressive women running such a worthwhile program.  They were all exceedingly professional, polite, energetic, and articulate.

During the morning presentation, we learned that the organization, in place since 1992, focuses on HIV care, male circumcision, malaria net distribution, chlorine tablets for water purification, and reproductive health and family planning.  The organization worked to train retired midwives who work out of government-funded clinics to place implants and IUDs free of charge.

Zambia is healthier than a lot of African countries, but still not anywhere near the status of a developed country; about 14% of people have HIV, 591 out of 100,000 women die during or after childbirth, and the average woman has at least 6-children.  They said it was not uncommon to see a woman in her late 20’s who had already had 8 or 9 children.  Clearly this highlights the need for family planning options and sadly, les than 1% of women were option for long-term contraceptives like intrauterine devices or implants.  This group is working to change this by training more nurses and midwives to place them and have what they call “mobilizers” go out into the community and talk about birth control.  The group here feels that the tide is turning with funds coming in from the Gates Foundation and political support from the first lady of Zambia who happens to be an OBGYN.

I have heard many a myth and misconception about the contraceptive devices in the US, but they were even more interesting and outlandish in Zambia.  The reasons women said they avoided IUDs and implants included, “it causes cancer,” “it could move and travel to my heart,” “it’s a sin to have a foreign object in your body when you die, who will take it out of I die,” and then some men said, “we want our women to have their monthly periods to clean them out.”  Many women also want to have a lot of children.   Having many children is seen as a sign of wealth.  Polygamy is quite common in Zambia so women contest to be the wife with the most children; they say it offers them polygamist marriage security. 

After our debriefing, we spent the remainder of the day sorting through the documents that the SFH headquarters uses to train, audit and oversee its many sites all over the country.  It was as a good overview to get an idea of what we would be seeing and experiencing as we traveled to four different provinces in Zambia to observe and audit the contraceptive practices over the coming two weeks.