Abram

It’s Monday now, and we have a full day planned. Ashley is leaving on Tuesday and there are errands to run, special order necklaces to pick up, and goodbyes to say. There are also three sick babies to visit. Julie tells me that Rachel, one of the Suubi women, has 10-month old triplets that have been at the local children’s hospital for weeks and that they’re not getting any better. She says she’s not convinced they’re getting the care they need, and wants to pass by later to see if she can get them transferred to a different clinic.

We run the first few errands, drop Ashley at home to pack, then head down the street to the hospital with Betty, whom we’ve asked to serve as our translator (Rachel speaks only limited English), in tow. When we get there, Rachel has one frail and listless baby boy in each of her arms. Her older daughter Beth is holding a third baby, a girl, whose fat cheeks and bright eyes only bring her brothers’ illness into sharper relief (Beth, by the way, is nine, and has been taken out of school to help her mother with the triplets). Rachel lays the boys in a crib so she can change Abram, the littlest and sickest of the three. John, the other one, begins whimpering feebly. I look at Betty.

“Can you ask her if it’s ok if I hold him while she changes the other one?” I ask. Betty translates and Rachel nods. I gently slide my hands under John’s little body and hold him close to my chest. I hum a lullaby, the only one I can remember (“Hush little baby, don’t say a word, Papa’s gonna buy you a mockingbird…”) and soon he is quiet, his small head tucked under my chin, his breathing shallow but steady.

Julie begins, through Betty, to explain to Rachel why we are here and how we want to help. All eyes are on us and soon a small crowd has formed. Two men (social workers, I learn) are there, asking questions about who we are and what organization we are with and where we will take the babies. Julie, who has since scooped up baby Abram, is trying to clarify our relationship with Rachel, when I suddenly realize that they think we want to take them from her.

“No, no,” I say. “We don’t want to take the babies from Rachel. We are just wanting to take them from here, to transfer them to another facility. We are concerned that, after being here so long, they are still so sick. We’d like to move them to another clinic, so they can see another doctor.”

The social workers nod their understanding, but by now the small crowd has grown. Now, there are nurses all around, and a large, sturdy woman descends upon us. I can tell right away that she’s pissed. She is the matron, I’m sure, the nurse-in-charge, and she is scowling with more than just her face – she is scowling with her entire dump-truck of a body. And I know that somehow, despite our best, most well-meaning intentions, we have managed to offend her and her entire staff.

Several people are talking at once: the social workers to the nurses; the nurses to Rachel; Rachel to the social workers; Betty to us; us to each other. We are told that we can’t remove the babies without the mother’s permission. In my meekest, most conciliatory tone, I assure everyone that we don’t intend to do anything without the mother’s permission, and that we are only here to help. We are then told that if we do remove them, it will be against medical advice.

I look at Julie, still holding Abram, with John in my own arms, and stammer something unintelligible. I feel helpless and completely in-over-my-head. We are causing a scene (just by virtue of being there and being white), angering the staff, and I’m concerned that Rachel is feeling pressured to do something she doesn’t really want to do. Julie says she doesn’t trust the medical advice or treatment they are being given here and she just wants to get the babies out, she doesn’t care who we offend in the process. The Mighty Mouse theme thrums a sardonic tune inside my head: “Here I come, to save the dayyy!!”

Suddenly, we are ushered out of the ward and into a small room across the hall, the matron insisting that the babies must be tested. “For what?” we ask. “HIV,” they tell us. We explain that the babies have already been tested and are negative, even show them where it says so in their books. We know that they know this, and that they are just stalling, but we don’t know why – other than to assert their authority. I do my best to smooth ruffled feathers, affecting a soothing, almost obsequious tone when I speak and engaging in lengthy greetings with each new nurse we meet, but it’s getting us nowhere. I want to call my brother; I am certain he’ll know what to do.

There’s more talking in languages I don’t understand and then someone else comes in (actually, I’m pretty sure it’s the matron again), asking us why we are wasting their time having the babies tested for HIV. Julie and I share an exasperated look. Finally, the matron dismisses us with a perfunctory wave.

We hustle out before she changes her mind and clamber up into the Mystery Machine, Rachel holding Abram, Beth holding Eva (who by the way has been sucking on the first two fingers of her right hand the entire time and it is the freaking most adorable thing I have ever seen) and me still holding John; Betty climbs in with Kymbi. Rachel’s husband, whose name I have forgotten (it’s something lyrical and multi-syllabic, like Sulongalonga), stays behind to wait for her mom. We pull out and head for Rippon Medical Center. It’s private, so it costs more money, but Julie’s mom has deposited money in her account to cover whatever medical expenses they incur.

At Rippon, we are seen almost immediately by the doctor. Dr. Christine is large, like Nurse Ratchet, but soft and round where the nurse was hard and square, and she is smiling a kind smile. I feel better already.

Julie leaves to check on her sister so I am left to explain how it is we’ve come to be here. Dr. Christine listens quietly, then examines each baby. She tells me malnutrition is the primary presenting condition, but orders a full blood work-up on all three to be safe.

The lab, however, is closed. And this is where I am reminded that, in Africa, time is not your own. Here, you are at the mercy of God or the Universe or that one lab tech who will take every second of his well-deserved afternoon break, by George, no matter how many desperately ill and hungry babies are waiting for him to stick them, again and again, rooting around for their tiny, atrophied veins in search of the blood that will tell the story of their sickness. And so we wait, on benches in the hot sun. It feels like forever before he returns. I want to scream.

He does return, though, and by then Julie is back with Ashley, so she takes Abram and follows the tech inside while I check messages on my cell. I hear Abram start to cry, and rush in after him. And there is Julie, seated into a corner, holding Abram while the techs (there is a second one now) hover over him and search fruitlessly for a vein. He is wailing – an agonizingly insistent, if faint, howl – and would flail his free arm in protest if he could but he is too weak to do much more than flap. He’s got a stent in his arm already, from the IV drip he was on at the other hospital, and we ask if it’s possible to draw from that one but the techs shake their heads. I watch, crying, my own fists clenched to keep from flailing, until I can’t stand it any longer. I run outside and cry some more.

When I come back, Julie is standing with Abram; the techs have given up. She looks at me. “Do you want to hold – ”

“Yes,” I say, and scoop his tiny, birdlike body into my arms, rocking him gently and cooing in his ear. At ten months, he weighs even less than my niece, herself a preemie, did at five. He has no hair on his head, but his long lashes are tinged with orange, the tell-tale sign of malnutrition. His head fits neatly in the palm of my hand and I can feel each of his vertebrae through his thin onesie, like a row of skittles beneath his skin. I hold him close and hum a lullaby, then a hymn.

I wait in the office with Abram while the techs repeat their torture on John and Eva. Julie sticks her head in and asks if I mind staying. She still has a long list of things to help Ashley with before she leaves and they are running out of time. “Of course,” I assure her.

When they finish with Eva, I stand to leave, but now another doctor is there, and he is saying they must try again with Abram. “We didn’t get enough,” they say. They need more blood to conduct their tests. I sit back down and hold Abram tightly while the doctor ties a rubber glove around his pencil-thin arm; this seems to pain him even more than the needle. I close my eyes and press my lips to his forehead. I don’t think I can watch him endure this again.

The doctor leans over and spies my own veins, swollen from the heat of the sun and pulsing with my anxious heartbeat. “Ah, but yours,” he says, pointing at my arm. I smile wryly. “Yes,” I say, and wish I could offer my own veins instead, a vial of my own blood.

The doctor sticks Abram again and he keens. I pull him closer, and begin humming again. I look at the doctor. “Do you think maybe he could rest?” I ask. “Do you think maybe we could try again tomorrow? He is just so dehydrated and – ”

“Yes,” the doctor says, straightening. “His veins are very tired. I think maybe we will try again tomorrow.”

“But … he can stay here tonight, yes?” I ask, but he is not listening. He is looking outside, at Dr. Christine. They consult through the window and agree that Abram can stay the night. I hurry outside and confirm with Dr. Christine. She tells me that they will keep him overnight so they can re-hydrate him and start him on treatment, then try again to draw blood tomorrow.

“And the others,” I say. “They can stay, too?”

“Yes,” she says. “I think we can manage.” I thank her profusely and ask her if she will explain to Rachel and her husband what is happening. She does, and promises to also explain to her how to prepare a rice porridge that will be better for the babies than milk (milk, it turns out, only exacerbates the diarrhea). Then we follow the other doctor to a private room where a nurse is putting clean sheets on the bed and another is readying the IV drip.

I stay with the family until they are settled. I notice John and Eva’s wet bottoms, and gesture to Rachel. She shakes her head – she has no more diapers. I tell her I am going and ask if there’s anything I can bring her. She asks for milk. I promise to be back soon.

I walk home and pack a bag with new cloth diapers that someone had donated a while back, then set off for the market in town. Back at Rippon, I present Rachel with the milk and clean diapers, then collect the pile of soiled ones she’s wadded in a ball and stuff them in my bag. I will wash them myself. I kiss each of the babies, and Beth, shake Rachel’s hand and head home. I am drained, but I feel lighter. I know that everything will be ok.

At the house, I boil water so I can soak the soiled diapers, only two of which are actual diapers, by the way. The rest: a faded onesie, an old toddler’s t-shirt, a piece of a bed sheet, a threadbare dishtowel that Rachel ties around her children’s tiny middles. They reek of vomit and diarrhea, a sickly sweet, almost yeasty smell. I scrub until my fingers are red, boil more water, and scrub them again.

On Tuesday morning, Julie and I share a piki (a scooter) to Rippon – I straddle the seat behind the driver and Julie perches, sidesaddle in her skirt, behind me. The diapers I’ve washed aren’t dry yet – we’ll have to bring them by later – but we want to get over there first thing. We are anxious to see how the babies are improving.

When we get there, we are met by the two doctors from yesterday, Dr. Christine and Dr. Needle Stick; they inform us that the family is no longer there. They were transported, we are told, back to the children’s hospital from whence we removed them, in the middle of the night. Abram’s treatment was failing, we are told, and the night duty staff thought it best to send him to a facility that had more experience dealing exclusively with children.

“But … they weren’t giving him the right treatment there!” Julie splutters in protest. “We took him out of that place, and brought him here so he could get the treatment he needs!” She shakes her head, exasperated. “I am afraid that if he stays there, he will die,” she says. The doctors have nothing to say to that. Then, after an awkward silence, Christine says she will make a call and inquire after Abram for us.

Julie and I thank her, but we are seething. And though I can’t speak for Julie on this, I am also scared. I know how much we angered the matron and her nurses yesterday and I am worried that Abram will be punished for it. We stand on the corner and debate our next move. She wants to go over and remove him, to transfer him Al Shafa, the last best clinic in Jinja. I am certain that removing him will only make things worse. “For whom?” she asks, and says again she’s not worried about who we might offend. “If he stays there, he’ll die,” she repeats. I know she’s probably right, but I can’t help but think that swooping in again will have other larger and less immediate, but more lasting consequences – for Rachel and her other children, for any other woman we might want to help at that hospital – even if I can’t seem to articulate why I believe that.

I feel, if it’s possible, even more helpless than I did yesterday. In a fit of desperation, I text my brother and ask him to call me. Scarcely a minute has passed when a matatu pulls up to the curb and Rachel and her husband spill out. I am relieved, and greet her warmly, but her face is impassive.

“Where is Abram?” Julie asks.

“He is dead,” she says, and flicks her hand, a vague, faraway gesture, her eyes squinting into the morning sun. I am speechless, and feel very suddenly and very violently ill.

“We are so sorry, Rachel,” we both finally say. “So very, very sorry.”

*****

I walk home from Rippon in stunned silence, weeping. I am irrationally angry – at Rippon, for failing him; at the matron, for being such a bitch; at Rachel, even, for not understanding that milk was only making him worse; at myself for knowing it and being stupid enough to buy her more; at Julie, for thinking we had any right; at myself, again, for not agreeing with her.

And then I am ashamed – ashamed that I could have wasted a millisecond worrying about how I might spare someone offense when a life hung in the balance. Not that it would have made a difference – he was dead already when we had that argument.

I am ashamed, too, for thinking we could fix it in the first place and then ashamed that we didn’t, that we failed. And I wonder if Rachel is angry, if she blames us.

And I think, still, of that fucking nurse.

And then I am just sad, wishing I could have held him one more time, hummed him one more hymn, felt the tiny weight of him.

And then I am gripped, suddenly, with a terrible fear, wondering crazily if the last time I held him, I held him too tight; if in holding him still for that last, fruitless needle prick, I squeezed an indispensable breath from him, a breath that might have made the difference.

And then I am home, and the day must begin. There are Suubi women to visit, and flights to catch, and diapers to press and deliver, and two other babies that still need us.

We pile into the Mystery Machine and head out.

Suubi (or, Hope)

You have got to be kidding me, I think, when I awake Sunday morning at 4am. The muezzin isn’t even up yet! I take half an Ambien and crawl back to bed. Four more blessed hours of sleep and I am feeling much better. I even manage some dry toast for breakfast, and two more slices for lunch.

I am glad to be feeling better, not only because I am a big fat giant baby when I’m sick, but because it’s Sunday and Sundays are Suubi days, when all of the women come together. Today we will be buying the necklaces that they have made with the clasps they were given last week (the women buy their own paper for rolling the beads, and their own varnish, and the plastic thread they string with, but Suubi provides the clasps).

We head out around 2pm, the lumbering Mystery Machine bouncing along the pockmarked roads on the way to Walukuba. We pull up in front of Santa’s house, and a handful of women pile in, wrapped in brightly colored fabrics and mismatched skirts and t-shirts, laughing and chattering excitedly in their native tongue (or tongues, as the case may be – with over 40 tribal languages spoken in Uganda, it is not unusual for one to be multilingual). Most of the Suubi women are Acholi, from the north, refugees of a lengthy civil war. The documentary, Invisible Children, helped to bring international attention to that war’s most innocent victims: children kidnapped and forced into marriage or service as child soldiers.

At the meeting place, I sit beside Gertrude, who teaches me some basic Luo (the language of the Acholi): ningo (hello), kop ango (how are you), kop pe (I am fine), apwoyo (thank you) … Gertrude has five children, aged twelve (er, I think…) to twenty-two; she lost her husband in 1999 and has not remarried. “It is difficult,” she says. To find someone who will help care for children that are not his own, that is. We form a small assembly line: Julie takes the necklaces and pays the women, Ashley inspects them for length and tension, and Gertrude and I re-fasten the clasps.

When business is finished, I help Santa serve water to the women who want it, narrowly avoid giving a speech (although Daisy warns me I should have one prepared for next Sunday), and load the Mystery Machine with the bags of completed necklaces. We pick up a couple more women for the ride home, squeezing fourteen into a vehicle built for seven. There is more laughter and more chattering, and I am struck, for the millionth time, at how these people who have so little seem so much happier than most people I know who have so much.

I think of Gertrude, raising her five children on her own after her husband’s death; and Betty, whose baby’s father took off when he learned of her pregnancy; and Agnes and Mary and Scovia and Margaret and Joyce and Sumini and Pross. I think of their wide smiles, and the light in their eyes, and their laughter like wind chimes.

I think of all these things and hope only that their smiles get bigger, the light in their eyes brighter, and their laughter never ceases.

The First Few Days

Uganda is a predominantly Christian nation, but (especially in towns) there is a sizable Muslim population, and I wake early Thursday morning to the muezzin’s call to prayer, echoing solemnly in the darkness. I think of Zanzibar, and the TAZARA train, and fall back to sleep. When I rise, I shower, straighten my room, and forage through my bag for breakfast – I’ve got an emergency stash of Clif bars that should tide me over until I have a chance to go to market.

I join Ashley and Julie, who are sipping coffee and reading, in the living room. Betty is bustling about, boiling water for drinking, sweeping floors, washing dishes and tidying rooms. I am mid-sentence when I hear her behind me.

“Auntie!” she tsks. “You didn’t have to do that!” I turn to her, confused. She is shaking her head. I turn back to Julie.

“Oh,” Julie says, nodding knowingly. “You made your bed.”

“You don’t have to do that,” Betty admonishes again.

“But…I like to,” I offer feebly. She shakes her head and sighs, then disappears behind the door.

Soon after, Ashley, Julie and I pile into the Mystery Machine (seriously, this thing is straight out of Scooby Doo) and head out to run errands. We get me money and a cell phone charger (I’ve got a phone that I used in Zambia, but it’s dead), and then drive to Walukaba, a nearby village where several of the Suubi women live. We meet Nora, ancient and stooped, her tiny eyes filmy and nearly sightless, and place a special order of necklaces for Ashley. Then it’s to Santa’s, and Scovia’s; after that, Emily’s.

We bounce along a rutted dirt road lined with maize and matooke trees, and pantless children (I don’t know why it’s shirts they wear, and not shorts) chase us, waving dirty hands, their dimpled bottoms caked with mud. “Howahyooou! Howahyooou! Howahyooou!” they shout, gleeful. I wave and smile back.

Santa and Scovia live in what I’ll loosely term an apartment, or tenement, building. It is long and low, and made of cinderblock; maybe four units each, with one or two tiny rooms per unit only. We crowd into one of Santa’s rooms, Scovia joining us, and learn how to roll beads. I can untwine fishing wire for hours, so the fine motor skills and focus required appeal to me. Still, though, my bead is loose, and lopsided. Julie’s is worse.

“Santa,” she says. “Mine is all uneven.”

“Just make it straight!” Santa says, as if saying it will make it so. We laugh and roll our eyes.

Emily’s house is in a different part of the village, but pretty much the same as Santa’s and Scovia’s. She emerges from the tall grass dressed to the nines, in a long red sheath dress, with white-beaded jewelry hanging from her lobes and around her neck; the toes of her bare feet are painted a shimmery pink. We visit for a minute in her small, dark room, place Ashley’s order, then head for the markets: the Indian-run supermarket (which is really more like a corner convenience store) for things like cereal and peanut butter and pasta, and the outdoor market, for tomatoes and onions and carrots and garlic.

After shopping, we head to Bukaya, another village just outside town. There is a sort of girls’ group home there, where Julie had been living until she moved into the LGH house five days ago, and where she still goes twice a week to visit and play with the girls. Seven live there, all under age twelve: Agnes, Mary, Scovia, Margaret, Joyce, Sumini and Pross (said like “rose”, but with a soft “s”). Betty’s sister Christine lives with them, a kind of house mother. The girls are not orphaned, but their families are either unable or unwilling to care for them.

They came to live in the house when a young American volunteer first met three of the girls (sisters Agnes, Mary and Scovia) on a visit last year. Dirty, hungry, and abandoned, one of them injured from the collapse of the hut where they were living, she took them in, got them food and medical attention, then set about finding them a place to stay.

She’d come to volunteer for an education project, but quickly decided to start her own nonprofit. Since Ugandan law requires that all nonprofits have a Ugandan address, she decided to kill two birds with one stone: she rented the house, made it her nonprofit base, and moved them all in. Margaret, Joyce, Sumini and Pross soon followed.

We go there this Thursday bearing supplies for an art project, spend an hour watching them giggle and create, then head home to make dinner. I boil pasta and sauté garlic, onions, tomatoes and carrots for a marinara sauce. It is, I’m afraid to say, a resounding disappointment. Ah, well.

By 8pm, I’m doing the jello-necked head bob. I fight to stay awake until 10pm and then give up.

*****

On Friday, I am up again at 4.30am, the adhan rousing me and the neighborhood dogs, who howl in protest. I feel like howling, too, when George (the night guard who is seated right outside my door) turns on Ugandan talk radio at a volume I am certain you all can hear in America. I toss and turn until 6.30am, then huff out of bed and go for a run.

It’s a dismal, gray day, and there are no Suubi activities scheduled, so we spend much of it curled on the sofa and in arm chairs, talking and reading our books. We plan a little 4th of July celebration and head to the market for burgers and balloons. I bake fresh rolls (like the marinara, kind of a disaster. boo.) and Ashley makes sugary sweet layer bars and Betty fries the potatoes and Julie cuts the pineapple.

We find one of those “Happy Birthday” streamers in the bookcase (except ours says “Happy rthday”), the kind with the shiny red and blue and yellow and green letters hinged together with grommets, and Ashley hangs it on nearby hooks. We were going to add “...America” to it, but we get lazy and forget.

We drink wine and tell stories and laugh about the random text messages I have suddenly started receiving from strangers in foreign languages. By 10pm, we are plumb tuckered, and so call it a day.

*****

It is Saturday, and I am awake early again – only this time I have aches and chills and knifelike cramps in my muscles. By midmorning, I’m battling waves of nausea and I’m starting to worry. I text my brother: How early can malaria present? He tells me it’s unlikely that I would have contracted it while on prophylaxis, but says I should get tested. We call the American doctor in town to schedule the test, but she is in Kampala. She confirms that malaria is unlikely, especially this early, prescribes a course of ciproflaxin (which I happen to have from my last trip, thank you Denver Health Travel Clinic), and tells us to call her in twelve hours.

Several hours and two naps later, I am no better. In addition to the aches and chills, I am now vomiting and – well, anyway. You can figure it out. Julie and Ashley go for dinner at a local Indian restaurant, and bring me back a ginger ale. I sip it slowly, swallow another cipro, and go to bed, praying that I will be better in the morning.

Kulika Yo (Or, Welcome to Uganda)

I arrive in Entebbe at just after 7am on Wednesday, bleary-eyed with exhaustion, move easily through customs and claim my bags. Outside, a stout, square-faced man is holding a brightly-colored sign bearing my name. I smile broadly and wave. “Hi! That’s me! I am Kate!” I say, pointing at the sign, and then at myself. The man smiles back, shakes my hand, and takes one of my bags. We load the car and set off.

Lake Victoria looms before us, flat and sparkling, a giant silver dollar glinting in the hazy morning light. We drive east, through a lush, hilly countryside, a palette of rich, earthy colors – deep terra cottas and dark reds and muddy browns set against velvety greens – shimmering vibrantly beneath an expansive blue sky. We zoom past acres of maize and banana trees and palms and hundreds of other plants and trees for which I have no names. The road is paved, but riddled with potholes, and scored on either side by the familiar, constantly-moving lines of heavy-laden Africans on their ways to and fro.

Abdullah (that’s the driver who met me) is a kind, quiet man, with three children. I’d like to learn more about him, and about this new place, and I try (at first), asking lots of questions, but now I’m fighting to stay awake. “I think you are very tired,” he says, after several minutes of silence. I smile. “A bit,” I tell him.

Just outside Kampala, Abdullah hands me off to William, who will take me the rest of the way to Jinja. We arrive at the LGH volunteer house at just after 10.30am local time. A tall, lithe, bushy-haired African woman opens the heavy blue security gate for us. Her dark skin is stretched over exquisitely high cheekbones, her waist and hips narrow, her limbs impossibly, elegantly long. She pokes her head into the car. “She is the one?” she asks William. He nods.

Julie, the in-country director for LGH, comes out to meet me and introduces me officially to the African woman (her name is Betty and she’s the housekeeper; she is also, I quickly learn, a total freakin’ riot). Inside, I meet Julie’s sister Ashley, who has been visiting for three weeks, and Betty’s seven-month-old son, Kymbi, bouncing happily in a swing.

The house (brick exterior, with a long cement porch) is wide and airy, with spare but comfortable furnishings, brown-tiled floors, and dark woodwork set against white walls. My room is in the back. I deposit my bags and join Julie and Ashley in the living room for a little meet and greet and howdy-do before I (glory hallelujah!) disappear to the bathroom for a shower.

Kneeling in the tub, rinsing soap with a faint trickle of warm-ish water from the handheld showerhead, I don’t notice my swollen legs. Yeah, so … ‘member that one episode of Friends? The One Where Ross Tells Rachel She Has Cankles? It isn’t until I’ve patted myself dry and am smoothing on lotion that I notice I have … thankles. Seriously. My calves and ankles have swollen to – I swear – the same circumference as my thighs, the left one sporting what looks like a giant, slug-like welt on the outside of my shin. I panic. Oh my God, I think. I have a blood clot! From sitting too long on the plane! I am totally gonna DIE! I dress quickly. If I’m going to collapse at any moment, I don’t want to be found sprawled naked. I’ve only just met these people.

We consult Julie’s medical book and determine that my death is not, in fact, imminent, and that some ibuprofen and elevation should restore me to normalcy. Betty has made matooke (a thick porridge made from what looks like bananas but what tastes like potatoes, and a staple of the Ugandan diet) with peanut sauce. It’s not my favorite, but it kicks the crap out of nshima.

Showered and sated, I pop a couple ibuprofen and stretch out on my bed “just for a minute.” Three hours later, I wake to an empty house. Julie and Ashley have gone to meet some of the Suubi women who will be adding t-shirt bags to their creative repertoire, and then to teach the weekly English class. I am bummed to have missed it, but grateful for the rest. When they return, we go to dinner at a local Chinese restaurant and chat until it’s time for bed.

London

So I left Denver at 8.15pm on Monday, June 30. My itinerary, which ends with my arrival in Entebbe, Uganda on Wednesday morning, includes a lengthy layover in London – nine hours, to be exact. I’ve heard conflicting reports about whether nine hours is enough time to scoot out and see a bit of the city, but I’d rather eat glass than be stuck in Heathrow all bleedin’ day, so I decide to chance it.

I follow a motley crew of rock-climbing teenagers (they’re headed to France to climb – how cool is that!) and their fearless leaders – one of whom looks astonishingly like my new boyfriend, Michael Stipe – to customs, get my stamp, ask a few directions, and head for the Tube.

I’m without a guidebook, but all I really want is some good Indian food which, for all its rap about bad domestic cuisine, London has in spades. I hop the Piccadilly line towards Leicester Square and Covent Garden (the theatre district! wee!) – a good 50-60 minute ride from Heathrow – and notice a slight, withered woman to my left, talking to herself. I think that whatever the subject is, it must be grave, for she is sagging under some great, invisible weight. Her thin, papery skin hangs in loose jowls; her long aquiline nose slopes downward and her hunched shoulders curve around her breasts, which hang from her bony frame like two small but heavy sandbags. I hope she works it out before she sinks into the floor beneath her.

Dappled sunlight dances across the faces of the other passengers and warms my skin. The wind and the wheels roar in my ears. I close my eyes and smell the sweet, spicy scent of men’s aftershave. Two young Polish guys have boarded and sit across from me, one bony and angular, the other sporting an oxford whose buttons stretch optimistically across what I am certain is his recently-amassed, still-unacknowledged new girth. I think perhaps the shirt fit at the start of the school year, but that the end has brought with it the proverbial Freshman Fifteen and he’s just not ready to admit it, despite the evidence. They are earnest in conversation, sharing a laugh at something in the magazine they read together. Each shift in position, each full-body chortle, sends a cloud of their clean, masculine scent my way. Neither is particularly handsome, but they sure do smell good. I bite the inside of my cheek; I think I feel a tingle.

At Leicester Square, I hoist my backpack on my shoulder and head out to enjoy the few hours of my London nano-vacation. I spy Maharaja Restaurant and know immediately where I’ll have lunch. It’s too early yet, so I poke my head in and inquire about the hours. Alom tells me they will be serving until 11pm. I thank him and say I’ll be back at 4pm.

I wander to Trafalgar Square, where hundreds bedecked in red and white mill about celebrating Canada Day, and park my tired ass on the lawn in front of the National Portrait Gallery. I try to nap, but the sun is too hot; I try to read, but I’m too tired. I decide instead that I will just sit and simply enjoy the fact that I’m lucky enough to be lounging on the grass in front of the National Portrait Gallery in London on a glorious Tuesday afternoon. With nothing else to do but catch a flight to Africa (Africa! where I’ll be for five weeks!) in six hours. Awww yeah!

It’s nearing 4pm, so I make my way back to Covent Garden and duck into a gourmet Italian cheese shop. I reminisce for a moment about my week in Bore last summer before I stumble into a narrow alleyway lined with tiny used and rare book shops. I see a bright yellow, circus-like sign: David Drummond – Theatrical Bookseller & Ephemerist. Are you kidding me? It’s a square, stuffy, musty-smelling old shop lined floor to ceiling with books about magic, opera, dance, and the theatre, and old playbills and marquee one-sheets (and post-card-sized replicas of said one-sheets) from long-since-shuttered West End Theatres. It’s fabulous. Mr. Drummond obliges my questions politely but grudgingly. He’s doing his books, see. By hand. As he has for the last 41 years (that’s how long he’s been open), I’m sure. He needs to concentrate.

I leave Mr. Drummond to his bookkeeping and head for Maharaja. Alom grins sheepishly, surprised to see me. He didn’t think I meant it when I said I’d be back and, well, the chef has gone on break. But after a brief conversation (with the manager? the owner? the maitre d’?) in what I later learn is Bangli, I am ushered to a seat and handed a menu. “It’s ok,” Alom says, so I order chicken curry and pilau rice (with saffron and butter and cardamom, oh my!) and chat with Abdul while I wait. I savor each bite when it comes. It’s not quite Muskaan (my most favorite Indian restaurant in the world, where I’m hoping we’ll go at least once when I get to Lusaka, Chris and Amy, hint hint), but it hits the spot.

The customs official told me to be back two hours before my scheduled flight departure, so I pay my bill and start off for the Tube. I get back to Heathrow with more than enough time to spare. In fact, I’m so early, they haven’t even posted my gate information yet. I find a corner table in a Food Court and read, fatigue buzzing in slow-moving waves through my body. Soon, I think. Soon I will sleep.

At my gate, I strike a few yoga poses to loosen my stiffening limbs … and spot a pigeon waddling under the seats.

Yep. I’m on my way to Africa.

Here I Go Again

Of all the people I have ever met who have been to Africa – who have spent any significant amount of time there, anyway – I have never met one who hasn’t wanted to go back. Maybe it’s because Africa is a mysterious, almost mythical, place; the stuff of legends. It is, after all, the Dark Continent, The Dark Star, The Place Where Time Began (or, at least, Man). Or maybe it’s because the whole place is such a surprising and unsettling paradox, like some exotic, black-eyed beauty that bears the jagged, angry scars of a scorned lover’s knife – you see her glory and her heartbreak both.

I imagine the reasons are as varied and as numerous as the visitors. For me, Africa is, quite simply, a place where I lived for seven months in 2007; a place to which I ran when my oft-broken heart, broken once more, could not (I believed) mend itself again.

I am asked frequently what the impetus was for my trip last year. And my answer, which some of you have heard me give a time or two, is roughly this: I needed Africa. I had struggled for some years with an often paralyzing depression and the attendant self-loathing that came when I couldn’t “snap out of it.” When I looked at my life objectively (er, as objectively as one can look at one’s own life), I felt that a person with a life as richly blessed as mine had no business feeling as sorry for herself as I did. Yet I couldn’t dispel the sorrow that had tamped its way into my chest; I couldn’t seem to move beyond my own self-indulgent misery – or maybe I just didn’t know how to. I don’t know. I just knew that I was stuck and I didn’t want to be anymore. So I ran. I thought that maybe if I went someplace where there was real need and real heartbreak, I wouldn’t focus so much on my own. I had grand expectations for how Africa would fix me, heal me, change me – and a very narrow idea of the ways in which I wanted it to.

For those of you that have kept up with this blog, you know that my trip last year was pretty much nothing like I expected it would be but that – in the end – it was exactly what it was supposed to be. And it did change me. I couldn’t say how different I was when I first came back, if at all, but I know that I am different now. But maybe that’s how change happens. Maybe the most significant and enduring shifts happen at the cellular level, unseen to the naked eye, and measured only by comparing the point at which you began to the point at which you are now. Whatever the case, I believe I am seeing the world with new eyes now and that I have Africa, at least in part, to thank (and Europe a little bit, too). So I want to go back. And, thanks to a fortuitous confluence of events, I am.

I’m going to Uganda first, to volunteer with an organization called Light Gives Heat (www.lightgivesheat.org). They run a project in Jinja, Uganda (about two and a half hours east of Kampala, the capital city) called Suubi. Suubi is a beading project, one of several in Uganda (you may have heard of Bead for Life or Thread of Life). Suubi women roll beads from long, thin slices of paper (posters, magazines, brochures), which they then varnish and string into necklaces. The LGH folks buy the necklaces from the women, sell them in the West, then use the proceeds to buy more necklaces. I’ll be doing, well, I don’t know, exactly. For sure I will help with the buying. But I’m told I should also expect to do anything from assisting with the weekly English and literacy classes LGH holds to boiling water for the women to playing with the children while the women roll the beads – in other words, whatever the need is. I’ll be in Uganda for just over two weeks. Then it’s off to Zambia to visit the fam.

I’ve been asked if I’m nervous this time. If I think about that bungee jump I plan on repeating when I get to Zambia, the answer is, um, YES (since, y’know, I actually know what there is to fear now). But mostly, I’m just excited. To see my niece, of course. And my brother and my sister-in-law. And to work with the Suubi and LGH folks. But to go, too, without the burden of my own need, without the weight of my impossibly narrow expectations, and just see what happens.

I’m not bringing my computer this time, so I don’t know how much I’ll get to blog. But if I do, it’ll be posted here. I hope you’ll check it out. And leave a comment, if you like. Those are nice. :-)

The Last Word

It's happening again.

This time, I am at Logan Airport in Boston, about to embark on the penultimate leg of my journey home. I'm going to Vegas to hang out with my Auntie Beth for a couple of days and to pick up my car for the road-trip back to Denver. I've purchased a snack and a bottle of water and have settled in to a chair with my book, since – as it turns out – I actually have lots of time to kill (we were worried for a while, Lisa and me, that I wouldn't make it; we'd lost track of time, as we often do, when a cursory glance at my mother's kitchen clock had us scurrying to her car, hurling all 60 kilos of my stuff into the back seat, and white-knuckling it down the Mass Pike all the way to the airport shuttle drop-off). Soon enough, though, the gate attendant's voice is crackling over the PA and it's my turn to board, so I hoist my backpack onto my shoulder, tuck my bottle of water under my arm, and fall in with the other weary travelers shuffling towards the gate.

I am rifling through the pages of my book (it's called Gilead, incidentally – and it's fabulous; you should all read it) for my bookmark-slash-boarding pass when I feel it – a faint but urgent ache, swelling and pressing against my throat like a small but steadily growing tumor. My eyes sting, and the pretty, artificially cheerful gate attendant – her blond hair a golden helmet framing her bright face - blurs in front of me. I blink furiously – I can't believe I'm crying again, and I'm not even sure yet why I am – and I swallow. And then text Lisa. "I'm crying," I type. "I'm getting on the plane and I'm crying. This is it. It's all over now. I'm finally going home."

I take a breath and clutch my backpack closer. I am suddenly tempted to turn around, to hop back onto the shuttle, and retrace the steps I've taken – to go back to New York, back to London, back to Venice and Bore and Paris and London again; back to Joburg and Lusaka, then Saint Francis and Mwandi; back to Zanzibar, Vic Falls, Mukinge, and Chilonga. I could go back, I think, just for a little while, and live it all over again – just so I don't forget.

*****

Except that that's been the point of this blog, I guess. To write it all down so I don't forget. To chart the course of my grand adventure and leave you, now, with a final thought. But where to begin? I mean, the truth is, nothing about the last eight months went as I expected it would – or, frankly, as I thought it should. And I spent a lot of time while I was over there – indeed, too much time – lamenting this fact. I was embarrassed, even, that I didn't have better stories to tell, or more tales from the trenches. But now that it's over, none of that seems to matter very much.

There were challenges, to be sure, and frustrations and disappointments. And there were times, I will tell you, when I felt more lost and more alone than I have ever felt in my entire life. But when I think back on these last eight months, it is not feeling frustrated that I remember; it is not feeling embarrassed or lost or alone.

When I think back on these last eight months, I think of Victoria Falls, and of soaring – weightless and free – for four gloriously insane seconds; or of the Tanzanian countryside, the dappled sunlight reflecting off acres of sunflowers and shining black faces smiling up at me as the train blurs past; or of Maggie, and her Irish husband who-loves-her-so-much, and the 40,000 kwacha she collected to buy two tired and hungry muzungu strangers lunch. I think of Robb and Sanjiv and the rest of the IHV team; the missionaries at Mwandi; and the med students at St Francis.

I think of Dorica, clapping and screeching with joy when comprehension dawns on her face; and of Jonathan bowing his head and saying thank you; and of Thomas and Temba and Jakob and Stan; and the way dawn and dusk always came on so quickly it was like God just flipped a switch.

And then I think of Kondwani and her perfect pink lips, her mocha skin, and her tiny fingers clutching at the neckline of my shirt; and of the way my brother – who has always been my rock, the one on whom I've counted to carry me and help me find my way – finally allowed himself to need me, and dared to trust me, for even a little while, with the care of his most treasured gift.

I think of all these things – and so many, many more – and I know that I am blessed. And I am deeply, profoundly grateful – and I haven't even started talking about Europe yet. :-)

"Do you even realize what you've gotten to experience these last eight months?" my father asked me last week, shaking his head and squinting at my computer monitor. We were looking at some of the pictures I'd taken while I'd been gone. Do I realize what I've gotten to experience?? I'm almost offended that he's even asked. Does he really think I don't?

I bungee-jumped off the second highest bungee-jump in the world. I saw more of Zambia than most Zambians do; stared a lion straight in his limpid, amber eyes (from the safety of a Jeep, of course, with a trained game driver at the wheel); and lived for two weeks in Tanzania and Zanzibar on less than $15 US a day.

I watched the changing of the guard at Buckingham Palace; stood where Anne Boleyn was beheaded; took a train through the French Alps; and stumbled into Sacre Coeur – completely and totally by accident, I should point out (I'd gotten lost on my way to dinner) – and was so overcome by the beauty of it, I literally sat down and wept. I saw Notre Dame, Doge's Palace, the Musée D'Orsay, and the Tate Modern. I watched a show at the Old Vic and a concert in the Palazzo di San Marco. I saw the Paris Opera, London Bridge, the Eiffel Tower and Saint Chappelle.

I drank homemade wine with every meal in Bore; kissed a Frenchman on the streets of Montmartre; danced with an Italian under a starlit sky at San Rocco; and got drunk with a bunch of Aussies, a couple Germans, two Canadians, and a Dane in London.

I had the time of my friggin' life.

But now it's over. And I'm boarding the plane for Vegas, where I'll pick up my car and head home. And just as it did when I left Lusaka, London, Bore and Paris, the ache presses against my throat and I falter. I look behind me. I could go back, I think, just for a little while, and live it all over again – just so I don't forget…

*****

To all of you who sent emails or comments while I was away, or who simply stood beside me and labored through the reading of this blog as I labored through the writing of it – from the bottom of my full-to-bursting heart, I thank you.

Uishi salama.

Picture: Me and Stan

Dear Diary, Part 3

Day 15 – Monday

Ugh. So I was leaving the hospital late last night and saw a man, dead as a doornail, lying in a pool of his own blood in the back of a truck. Just lying there, with about a half a dozen people milling about like he was no more than a sack of potatoes. Gave me the willies.

I found out today he’d been one of two casualties from a horrific traffic accident. There were four guys involved: one was killed instantly (the guy in the back of the truck); two others were rushed to the hospital and saved by the doctors on call; the fourth was left to die in his car because they couldn’t get him out. Can you imagine? They literally had to look this guy in the eye and be like “Sorry, mate. You’re just gonna have to lie there all twisted and trapped and bleed to death while we take these other two to the hospital.” Ugh. Ugh ugh ugh. Seems so senseless to me. But then they don’t exactly have the jaws of life here. Ugh.


Day 16 – Tuesday

It was another long day today. Spent most of it with Thomas in the main store room trying to make headway on an actual physical count of the entire store room inventory. Somebody had the grand idea that we needed to import the entire formulary with stock counts, which frankly doesn’t make sense to me since those counts are going to change (several times) before anybody knows how to modify the data in the system. But this is what I’ve been asked to do so I’m doing it. At the rate we’re going, though, we’ll be counting well into next week. Only I’m meant to leave on Friday and I’ve got a good three days worth of stuff to do after we’ve finished the physical count. On the plus side, I did get to hang with Thomas (he’s a close second to my other favorite, Stan), which was cool. He’s a totally sharp guy (confounding devotion to Benny Hinn notwithstanding) and a blast to be around. In addition to pursuing scholarship opportunities for further study in Canada, he’s going to school right now for psychosocial counseling so that he can be more effective when dispensing ARVs to HIV patients (pharmacy folks spend a really long time with each patient explaining the oft-mentioned complicated regimens that require strict adherence and he thought taking a course in counseling would help him). He also shows real enthusiasm for this new system I’m trying to implement and seems to be grasping the big picture business process concepts better than any of the other guys. I think I’m going to recommend that he gets added as one of the project leaders.

Oh, and just because this made me giggle: I was leaving the hospital last night after checking email for word from mSupply and there was the hospital guard, bundled within an inch of his life (Zambians hate to be cold and will wear turtlenecks in 80-degree weather) in a giant poofy ski parka, a scarf, two pairs of gloves…and a Santa hat. :-P And me without my camera.


Day 17 – Wednesday

It’s hard to express the gratitude I’m feeling today. I mean, we lost power again and two days before I’m meant to leave I’ve had to throw out the whole plan for the next phase of the implementation and start on a new one which is going to accelerate the timetable and the things I’ve got to do before I go, but – I don’t know…I’ve just – I’ve got that Wes-Bentley-and-the-plastic-bag-from-American-Beauty thing going on right now.

Maybe it’s as simple as feeling like I’ve got a purpose here; or the fact that I was recently the beneficiary of the proverbial “kindness of strangers”. Maybe it’s because I managed to squeeze in a run before dinner tonight or because I’m figuring out this mSupply thing and I’m enjoying the satisfaction that comes with learning something new. Or maybe it’s just because the weather has been really nice. I don’t know. But it’s there, and it’s kind of overwhelming, which means I haven’t the first clue how to write about it.


Day 18 – Thursday

Lost power again today. Water, too.

Watched a toddler splash happily (and obliviously) in a puddle of her own pee while she waited to be seen by the doctor.

Ate lunch with blood-splattered mid-wives who looked (and sounded, frankly) as though they were fresh from battle.

And I found out that someone in the pharmacy’s been pilfering drugs. I don’t know who, but I have a sinking feeling I might.


Day 19 – Friday

So it was my last official day at Saint Francis today. I was supposed to have left this morning but I ended up staying an extra day to wrap up a few things, so I’ll leave tomorrow – bright and early on the 5.45am bus.

I feel good, I guess – I accomplished what I came to do and then some: I turned in a project plan; I left the guys with detailed next steps; I even managed to get the formulary imported and got the guys trained and starting to do a few of the more basic tasks in the system, which was more than I ever dreamed – but I feel sad, too.

I dug it here. For all of its frustrations and for all of the setbacks, I totally dug it. I dug the people, I dug the work, I even dug taking a bath with a bucket (although I’ll be thrilled to finally shave my legs…). I don’t know. I’m a sentimental mush, so it should surprise no one that my leaving feels so bittersweet.

Oh, and I found out who’s been pilfering the drugs from the store room. It was not, as I had suspected, Stanislas. I’m both relieved that it’s not and embarrassed that I jumped so quickly to that conclusion.

He was sweet today, Stanislas. It was the end of the day and everyone was knocking off but Thomas and me. Stan came in to the office where we were working. “So I’ll see you on Monday,” he said, grinning and extending his hand.

“Monday!” I said, taking it and giving him the traditional three-part handshake. “But I will not be here. I am leaving tomorrow, Stanislas. You know that.”

“Ok,” he said and nodded, his hand still firmly grasping mine. “So I will just see you on Monday then.”

“Stanislas! What do you mean, ‘See you on Monday,’” Jeremiah laughs. “But she cannot be here on Monday if she is leaving tomorrow!”

“I am just saying she can’t go,” Stan says.

“Ah, but I must,” I tell him.

“Ok, then you will just have to come back,” he says. Then, “You will come back?”

“I hope so,” I say.

“When,” he asks.

“I don’t know,” I tell him truthfully. “Soon, I hope. But we will see.”


Anyway, so that’s that. I’ve got one week left in Lusaka to pack and ship stuff home and write thank you notes and get ready for my Europe trip, and then my little adventure will come to an end. I feel in some ways like I’ve been here for years, in others like I just got here yesterday. Either way, though, I can’t believe it’s over.

…

Yeah, I’m kinda really sad. :-(

Dear Diary, Part 2

Day 9 – Tuesday

I cannot believe I’ve been here a week already – more than a week, actually! Man, time is fuh-lyin’ here. Or at least it seems that way, I’m so stinkin’ busy. But, better busy than bored, I always say.

I spent most of today holed up in my house on the computer, further fleshing out the project plan and analyzing the mSupply system in the context of the pharmacy’s business processes. Although I did pop by the dispensary for a couple hours in the morning to help pack pills and whatnot. Stan was missing again (he went to Chipata yesterday) and I found out he’s been admitted to the hospital. Apparently, he was on quite a bender over the weekend and got himself into a fight at a bar; split his face open pretty good.

“In Chipata?” I asked Temba.

“No, in Katete stores,” he told me, spreading the latest batch of scrips on the counter. Katete is the boma, or main town, closest to Saint Francis; it’s maybe 8 – 10 kilometers from the hospital, but there is a modest “shopping district” just about 2 or 3 kilometers away called Katete stores. There are some small groceries carrying only non-perishables, a couple bars, a few small take-away restaurants serving mainly nshima and chicken, a petrol station, and other “general dealers” carrying basic household items.

“But I thought he was in Chipata yesterday,” I say. “Was this last night then?”

“Yes,” nods Temba, counting pills.

“But he will be ok?” I ask.

“He will be fine,” Temba says.

“Poor Stanislas,” I say, shaking my head. “That is not good.”

Temba laughs. “Ah, but don’t worry. Stanislas – he will be fine. He just sometimes likes too much to enjoy – to, to have a drink. And then he gets very…talkative.”

“Talkative?”

“Yes, talkative.”

“Ah, gotcha,” I nod. “But…he will be ok?” I ask.

“He will be fine,” Temba says.

I wonder to myself if I should go visit him and ultimately decide against it – I tell myself it’s because I’m afraid my showing up might embarrass him, but I think the truth is I’m still slightly uncomfortable about our encounter on Saturday. Maybe I will go tomorrow.


Day 10 – Wednesday

So…kind of a weird day today. I spent part of the morning at pharmacy (where I learned that Stan is on the mend and will be discharged soon), and then a few hours back at my house modifying the ARV dispensing tool that I built back in February (I’ve managed to convince the guys that they should start using it again - at least until mSupply is fully implemented - but there’s a drug regimen that needs to be added to it and, consequently, the formulas for all of the related cells across all 72 worksheets need to be updated). Anyhoo, so I was back at my house working on that but, for some reason, I couldn’t focus. So I did this really silly thing where I started reading through old (I mean really old – years old) journal entries and suddenly found myself wrestling some old ghosts – ones I thought I’d long since vanquished – and it kinda threw me. Funny how that stuff can just come up out of nowhere and bite you in the ass.

Anyway, so I wrestled. And, of course, prayed – which for me, most of the time, is just another form of wrestling. But, as a pastor once told me, that is pretty much the way it should be. “Do you know,” he asked, “that Israel, the name God gave his people, literally means struggles with God?” I looked at him. “Yeah, y’know – Jacob and the angel and the hip socket?” I nodded. “‘You shall no longer be called Jacob but Israel, because you have struggled with God,’” he quoted. “So go on and struggle, Katie. As a Christian, it’s kind of your job – your birthright, even. And anyway, God’s big enough.”

So I struggled with God today. Quite a bit, I might add. Even did a little fist-shaking. And I cried, too – big snotty, wailing tears. But it was good.

Except that now I’m behind on my work.


Day 11 – Thursday

Stan was discharged today. He popped by pharmacy for a bit and seemed in good spirits. He’ll be back on the clock tomorrow.

I did another brief tour in the dispensary in the morning and added at least three more Chinyanja phrases to my repertoire: Tubili ngat vamvela kupweteka for “Take two whenever you feel pain”; Mumwe yonse for “Take all of these at once”; and Kupanga, which apparently means “Mix this packet of oral rehydration salts with one liter of water and drink.” Yeah, no, that can’t be right.

“Kupanga?” I ask Temba, holding out the packet of salts.

He nods. “Kupanga.”

“And they know what that means?” I ask, scratching the word into my notebook.

“Yes, it means make, to make,” he assures me.

“And that’s all you say? Kupanga?”

“Koo-PAIN-ga,” Jacob pipes in from the counter.

“Koo-PAIN-ga,” I repeat to myself, reading from the notebook.

Temba looks at me as I recite. “I think now you can even dispense without the notebook,” he says, then gestures at the new pile of completed scrips by the dispensing window.

“Oh, I don’t know about that,” I protest. “I think I probably still need the notebook.”

“Ah, but you can do it!” he insists.

“No, seriously, Temba. I don’t want to mess it up. I need the notebook.”

“No, no! You can even – ”

“She needs the notebook,” Jacob says from the counter. They laugh.

*****

I spent the afternoon at home studying the user manual and working on the project plan and tonight I got the email reply I’d been waiting for from the mSupply developers in Nepal.

Oof.

Yeah, it’s gonna be a reeeaally busy weekend. And not just for me, incidentally – the hospital lost two more doctors today. And by “lost” I mean that two of the volunteers finished their tour. I swear, this place is hemorrhaging personnel. But then, they depend mostly on volunteers to staff the place and no volunteer can stay on indefinitely. That makes eight that have gone in just the last week, though (there were a bunch of Irish medical students who left last week), and no replacements have arrived - nor do there appear to be any on the horizon. Plus another one of the doctors has been in Lusaka at a training workshop so the burden has shifted to the three remaining docs (all but one of whom are volunteers) and a handful of medical students. These guys are exhausted – I am awed by their commitment and, frankly, their stamina. I really don’t know how they do it.


Day 12 – Friday

So there was a chicken in the hospital post today. Moffat’s dinner, I suspect (Moffat is the sweet elderly man who mans the post office). I was in the office emailing my reply back to mSupply when Moffat came in with the thing, its feet bound with string, and placed it in a shallow cardboard box in the corner whence it began squawking in protest and flapping its wings, hopping and stumbling in a vain attempt to escape. I must have looked stricken, because Moffat laughed and chided me “You can just keep working! It will not harm you!” Pshaw. As if I thought it would.

And Stan was officially back to work today – and still in good spirits – although he tried to tell me that the wounds on his face were the result of a bike accident. I was glad to see him smiling, though.

Oh, and Chris and Amy are back in the States now. Er, they left yesterday, so they should have arrived by now. I talked to them a couple days ago. Apparently Kondwani is developing at lightening speed – she’s making new sounds and is more engaged than ever. And a Fatty McCheeks now, too! Chris says she’s up to – oh, shoot I forget how many kilos he said… Seven, maybe? I don’t know. I can’t believe it’s been almost two weeks since I’ve seen her. Feels like it’s been months.

Aw, man – now I’m all mushy. :-(


Day 13 – Saturday

Had an unexpectedly productive day today. I love when that happens! I spent most of last night trying (unsuccessfully) to reason my way through a concept that I couldn’t wrap my brain around – an incredibly simple concept, I should add, to do with units and pack sizes of drug products, but one that is critical because the whole mSupply system sort of hinges on it (units and pack sizes are what the system uses to calculate the total stock of a particular drug item). Anyways, I was trying to figure it out so I could put the data in the right format for the import file but I kept getting stuck. I finally gave up about midnight and decided I’d just wander over to pharmacy in the morning and see if looking at the actual stock and having a visual representation would help me grasp it.

Well, I got lucky, because Jeremiah (who doesn’t typically work on weekends) just happened to be at the hospital casting out a demon that was troubling a patient who’d been admitted to the wards (yep, you read that right) and popped by the pharmacy when he was through. I spent a couple hours with him picking his brain and made serious headway on the import file; even managed, based on some of the things we discussed, to finally reason my way to understanding the concept that had been eluding me. Weee! Anyways, I got so much more done in the morning than I expected that I decided to take the afternoon off and go for a gorgeous hike up a nearby escarpment with some of the other volunteers. It was a bit overcast so the pics I took didn’t really come out, but it was fantastic!

After the hike, though, it was back to the salt mines and another late night on the computer. I am in bed now, scribbling this entry in my notebook by the light of my headlamp and I am, I must say, plumb tuckered.

Dear Diary

Day 1 (er, 2…) – Tuesday

So I’m at Saint Francis now. Got here yesterday after saying my goodbyes to Chris, Amy and Kondwani (they were headed to Katondwe for a week and will leave for the US while I’m here) and hopping a bus for the torturous seven-hour ride to Katete. I’d have slept (I’d only gotten about two hours the night before) but I managed to find myself on the only bus you’re supposed to avoid when traveling to Katete and I was too busy hanging on for dear life.

Anyhoo, but I made it. And I’m not staying with Shelagh this time. This time, I’m like a real, honest-to-goodness volunteer (weee!), which means I’m staying in one of the short-term volunteer houses (got a roommate, even – an older Canadian mid-wifery teacher who’s here for a couple weeks with her students) and taking meals at the mess. The house is small and spare, but it’s got running water (although not hot), power (although not all the time), a stove (although it doesn’t turn off unless you unplug it and then sometimes it won’t turn back on) and even a fridge. We could cook, if we were so inclined, except that the closest grocery store is nearly two hours away. And there’s no shower, so we boil water (when there’s power, which there wasn’t tonight, which also meant there was no dinner) and “take a bucket”, crouching, in the tub. It’s a total pain in the ass, but I kinda friggin’ love it (although ask me again in three weeks how I feel…).

This morning, I attended the weekly Tuesday morning clinician’s meeting where I met Jeremiah, the head pharmacist (and my new best friend), and then spent the day in the dispensary; my sole aim was to begin building relationships with the guys and to start to understand the general workflow process. But they were short-staffed (no surprise there) so I got a crash course in pharmacy tech and was soon counting pills, fetching stock, and even dispensing scrips to patients (Tubili tubili katatu pa tsiku, if you’re interested, is Chinyanja for “Take two pills three times a day”). It wasn’t terribly complicated (although I have to say, I suck at doing math in my head), but it was terribly chaotic. Open pill bottles scattered randomly across the counter, half-filled prescriptions strewn about, pharmacy assistants running around, stock movement sheets sliding out of the three-ring binders where they're kept… So far, it seems, the only system in pharmacy is that there is no system. But given the number of patients to be seen and the number of pharmacy staff to see them, I’m just amazed that anyone walks away with a scrip filled at all.

From managing the stock to moving the stock to dispensing the stock, every single process is done manually – and only if there’s time – which generally means that, with the exception of the last part (dispensing to patients), it doesn’t get done at all (or at least not with any accuracy or timeliness). One could argue, I suppose, that they’re at least attending to the most important piece, and one would be right…sorta. Except that now there is an even bigger issue – drug shortages. When you don’t have time to manage your stock, you don’t always know how much you’re using or realize when it’s time to order more. And if you don’t order more, you can’t (duh) get more, which means – ultimately – neither can the patients. This is an especially critical matter when it comes to ARVs, which require strict adherence not only to work effectively but to reduce the chances that a patient will develop resistance. At Saint Francis, they’re having particular trouble managing their stock of Truvada, the drug that is the government-recommended first-line therapy for all HIV patients. They ran out of it a few months ago, so they stopped prescribing it, which meant that their reported consumption of it was artificially low and, since future drug orders are typically based on historical consumption, they haven’t been able to order as much of it as they really need so they keep falling deeper into the hole – all of which means that the folks who really need it, the patients, aren’t getting it.

Which is where this new software that I’m meant to implement comes in. Shelagh and Ian (her husband, who is also the hospital administrator) are hoping that if we can put something in place that will help to automate some of the processes, we might more effectively manage them. My plan, then, is to spend the rest of this week working alongside the guys and learning more about the way it all works so that I can evaluate whether or not mSupply is indeed the best solution and, if it is, begin developing the implementation plan for it and banging out the tasks.

Day 3 – Wednesday

Spent the day in pharmacy again. Met with Jeremiah briefly in the morning, and then the sh*t hit the fan and they were still short-staffed so I got to literally get my hands dirty again (I was covered, head to foot, in the bitter, powdery residue of the pills) helping to fill and dispense scrips. Then the truck came from medical stores (the government supplier) with the monthly delivery (although no Nevirapine, another important ARV; and still no Truvada). I helped unload and pack the storeroom and by the time we finished I was a complete mess. It was fantastic! My shoulders ache and my feet are killing me, but I finally feel like I’m doing something. Something tangible anyway, something I can see and measure.

I also met the hospital’s purchasing officer and learned about how they procure the drugs (and other medical supplies) that are not provided by the government or donor countries and how they receive and track those (manually, of course, in triplicate, in a carbon copy Goods Received notebook which frequently disappears, along with the invoices that are meant to be entered into it). mSupply, in addition to being a general stock management tool, also tracks supplier quotes, purchase orders and invoices, so this is another area where we could improve processes.

Oh, and I think I’ve solved the Truvada crisis for the hospital. Nothing particularly imaginative or creative – I just made a phone call. Called Robb (my brother’s boss at AIDSRelief) and asked him if he knew where we could get our hands on some. He said that AIDSRelief was sitting on so much that they were afraid it was going to expire and that he’d email Lameck (the procurement officer for AR) that night and authorize the immediate release of 1000 bottles (roughly a three-month supply) for SF. J Given the number of patients already on it and how many more are being enrolled in therapy every day, they will more than likely burn through this supply in little more than a month. But – the good news is that this increased consumption will be reflected in their reports, which means they’ll be able to order more, which means that (at least theoretically) they’ll get more and they’ll be back on track.

Day 4 – Thursday

Started today counting pills for pre-packs in the OPD (outpatient) dispensary, then got bumped to the ART dispensary working with Stanislas. He dispensed the ARVS and I recorded each scrip in the computer (in the spreadsheet I built for them when I was here last February – their interim solution until mSupply is up and running – but which apparently they haven’t been using. Sigh…). I dig Stanislaus, although I am a little worried about him. He’s kind of crotchety (totally atypical for a Zambian, as they are generally a really happy people) and he always smells vaguely of alcohol. And today I noticed a tremor in his leg when he was dispensing to a patient and saw him try to cover it. I don’t know – maybe it’s nothing. There’s just something about him that makes me sad, though, so it’s kind of my sole aim to make him laugh as much as I can every day.

We were slammed, though (again) and worked straight through lunch. I spent the day swinging wildly between feeling frustrated by the way things (don’t) get done here and being totally awed that they do at all. It never stops being overwhelming, the stuff these people have to deal with. And it’s always the sh*t you take for granted, too. Like having a reliable power or water supply; or a car to get you where you need to go; or, I don’t know, tech support. I mean, if your cell phone breaks you have to take an entire day off work so you can ride the nearly two hours to Chipata to get it fixed (or buy a new one). If your computer crashes or your internet goes down, it’s literally weeks before anyone can take a look at it. If the patient information system that the really nice Dutch (wait, is it Dutch?) volunteer built for you bugs out, well, you’re pretty much SOL – even if you really need the reports it’s meant to generate – because he’s back in Holland now and not exactly available to provide ongoing system maintenance and so you’ll just have to manually generate them now.

Not to mention what the patients themselves face. Most of them can’t speak, never mind read, English and yet they’re expected to strictly adhere to complicated treatment regimens with only written instructions in English to guide them. And then there are the meds that require refrigeration to keep from spoiling, except – oh wait – the average villager doesn’t even have electricity, never mind a fridge (the pharmacists don’t even bother telling them that they need to be refrigerated which initially pissed me off – until I realized how pointless telling them would be). Or how ‘bout something as simple as the mother who’s expected to split a tiny 5mg pill into quarters for her child. Do you think she owns a pill cutter? The pharmacy doesn’t even have a pill cutter. I almost cried when I was filling a scrip for this one kid and I realized that we didn’t have the dose the doc had prescribed. He was supposed to get 100mg but the caps only come in these tiny 200mg rounded tabs (in other words, not the flat, pre-scored tabs that are conducive to splitting). “How will this mother give her child his medicine?” I asked Stan.

“Ah, but I think the mother knows how to break in half,” he told me.

“Right. Of course,” I said, nodding. “Sooo…can you do it?” I asked, holding out the pill. I didn’t mean to be cheeky, and I know it was “just” ibuprofen and not, say, life-saving ARVs or anti-malarials, but it wasn’t the first time I’d seen a patient handed a scrip with a dose they were essentially going to have to figure out on their own and it was starting to frustrate me.

He took it from my hand and tried to break the rounded pill to no avail. “Ah, but she will just use a knife,” he said, then set it aside and went back to counting the pills for the fifty other scrips he was trying to fill at the same time.

“But…will she have a knife sharp enough to cut it without smashing it?” I persisted. He looked at me for a second then disappeared, then was back a minute later with a surgical blade he’d scavenged from the storeroom. “This’ll do,” I said, and then sliced every single one of those pills as close to in half as I could manage.

It’s maddening. And I imagine if Stan thought he had time to cut every single pill for every mother that needed him to he would; or that Temba would explain, to each patient that needed to know, how they might create a small refrigerator out of a clay pot, sand, and water. But there’s no time for that here. Or anywhere, for that matter. Every hospital I’ve visited since I’ve come here has been wildly understaffed and stretched almost to the breaking point, although Saint Francis is among the worst (if only for how huge it is – their catchment area is ginormous). I honestly don’t know how it’s still functioning – except that there really is always someone who puts forth some Herculean effort to get you over the hump, to get you through to the next day. Because, I mean, who wants to be the guy that tells the patient who was brought to the hospital in the middle of the night in the back of a pick-up truck, bleeding from the head, “Yeah, sorry. I’m just too tired – I’ve already been on call three nights this week” – even if you have? Who wants to tell the patient who just walked seven hours just to get their next three-month supply of meds, “Sorry, my friend. Pharmacy’s closed now – come back tomorrow” – even if you have been on the clock for almost ten hours already and you still have however many kilometers to walk back to your own house?

There’s a quote that I’ve read before, which has been attributed to a million different people, that I keep thinking about: “Do all you can with what you have in the time you have in the place that you are.”

That really is as much as you can hope for.

Day 5 – Friday

Ok, I’m pooped. Spent almost the entire day helping Thomas move and shelve the stock that we unloaded on Wednesday. Scarcely had time to break for lunch or even pee. I loved it, though. I feel like I’m finally, I don’t know, “earning my keep”; like I’m finally doing what I came to do. But I’m pooped.

Oh, and my roommate left today, so now I’ve got the house all to myself.

Day 6 – Saturday

So it was just Thomas and me in pharmacy today. It was the weekend, and it was slow, so we spent much of the day cleaning and organizing and pre-packing meds for the coming week. And Stan came by, drunk as a skunk, and wanted to “talk.” About what, I couldn’t determine. “America,” he said, leading me out into the hospital courtyard. “I want to ask you questions about America.”

“Ok…” I said, slightly apprehensive. It was not yet 10 o’clock in the morning and he was blitzed. “What would you like to know?” I asked. But he couldn’t really say, or if he did, I couldn’t understand him through his slurred speech. “But I must get back to work, Stanislas. Maybe we can talk on Monday when we are working together?” I suggested.

“Or maybe we can talk some other time, when you are not working, and I can ask you some questions,” he fumbled.

“Ah, but I’m afraid I will be working every day,” I said. “And I really must get back now. I’ve left Thomas all alone. I will see you on Monday?”

“Yah, ok, I will see you on Monday.”

“Be careful,” I said, then wagged my finger. “Don’t get into any trouble.”

“No trouble!” he grinned, and staggered away.

Sigh… poor Stanislas. Sometimes I hate when I’m right.

****

I worked until five, then went for a run before dinner; then worked until about 11pm on the mSupply project plan. Now that I’ve spent a week packing pills and dispensing scrips and shelving stock and whatnot, I feel like I’ve got a fairly good handle on the way things work. Now I’ll start digging more deeply into the actual software and figuring out the nuts and bolts of how each of the processes it manages works, what modules we’ll employ, what import files I’ll need to prep, and blah blah blah.

Day 7 – Sunday

Kind of a frustrating day today. Worked the morning at pharmacy, with Thomas again, which was cool, then met with Shelagh, which is always a hoot, because you never just “meet with Shelagh” when you go over there – you meet with Shelagh and Chiko and Jim and Josh, and play “What’s Your Favorite Movie” and “Can You Fix My Leggo Gun” while Love Actually plays on loop in the background (yep, aGAIN – or no wait, maybe that was yesterday…). Anyway, so I met with Shelagh to update her on where I am with the project and then spent the rest of the afternoon and the whole of the evening doing battle with the friggin’ internet. It’s only dial-up here (and at 500 kwacha a minute, friggin’ highway robbery), and I had to re-download the nearly 10MB user manual for the mSupply software because the one I had downloaded back in Lusaka disappeared off my laptop. Or expired or something, I don’t know. All I know is I clicked on the link for it on my desktop only to get a message that said “Sorry, this is not the user manual... To download a copy, visit our website” and blah blah blah. Anyway, so I needed the internet and it took me, I sh*t you not, no fewer than three hours to track down the key for the room, find a power adaptor (I managed to lose mine somewhere in the 50 yards between my house and the hospital), and configure my laptop for the connection. When I finally got it all set up, it took almost 25 minutes to load the first web page and then nearly five hours to download the damn manual and by then it was too late to do any work.

Tomorrow I meet with Shelagh, Ian and Jeremiah to review the workflow process as I’ve understood it and fill in any gaps, suss out the priorities for the next two weeks (I think I will end up staying for three total, instead of two – there’s just too much to do), and talk the issues/potential obstacles I’ve identified and brainstorm possible solutions. I’d hoped to have more prepared for them, but I’ll have to work it out in the morning, I guess.


Day 8 – Monday

Ok, it’s friggin’ cold here. I mean really friggin’ cold. Have I mentioned the cold yet? It’s freezing! I know it’s winter (and didn’t I say once that we’re at about 4,000 feet here?) but it’s sub-Saharan Africa, man – it’s not supposed to be this cold.

Anyhoo, so I met with Shelagh, Ian and Jeremiah and it went really well. I also managed to connect to the internet and shoot off the draft project plan to the mSupply developers in Nepal to get their feedback and their input on the best next steps to take, so it looks like we’re on our way. I’ll spend less time in the pharmacy this week and more time holed up at my house banging away at the plan. Weee!

Ooh, and I’ll also, when time allows, be doing some writing work for a small, newly-incorporated independent record label in New York – West Avenue Records. Their first artist is set to release his album at the end of July and I’ve been hired to help with copywriting and PR and whatnot. Check him out at http://www.michaelnappi.com/!

Lions, and hippos, and zebras! Oh my!

A few pics from my safari in South Luangwa National Park... :-)