Monday, March 19, 2018

No time for grief - Volunteering with the nurses at the Vilanculos hospital

[I originally wrote this post in September 2015 and kept it private. I am posting now for your review].

The first thing you always noticed when walking through the double doors and into the darkened hallway was the smell. The sickeningly sweet wash of formaldehyde, the slight bite of antiseptic, and a weighty, warm, sour aroma I eventually realized was the smell of rotting flesh.  It was a smell that embedded itself into your clothing, into your hair – so pungent and domineering that upon arriving back home after my first shift, I in a frenzy and on the verge of tears, stripped off my clothes and threw myself into the shower. My white lab coat, crumpled dejectedly on the floor, glowered, accusingly in silence as I scrubbed my naked, sunburned, sweaty body and scalp with such ferocity I imagined the molecules of disease, death, and heartbreak washing down the drain with the hot suds. 

I volunteered at the Hospital Rural de Vilanculos for two months in early 2015 and it was during this time that my understanding of the true nature of Mozambique’s poverty deepened tremendously. Because, as one woman told me, “As pessoas chegam aqui para morrer”- people come to the hospital to die. It's safe to say Mozambican's don't expect much from their healthcare system - one of the main reasons cuninderos - witchdoctors - remain so influential.

As I’ve written before in other posts, the problems plaguing the Mozambican health care system are numerous and complex. From the theft and selling of state-sponsored medicines on the black-market, to doctors having to bridge the gap between science and popular beliefs in witch-doctors and magic, to a lack of consistent patient education crucial for patient treatment adherence -  each of these topics could easily boast their own million dollar research grants.  This post is not to dissect those problems. It is instead to document my observations and people I met there there. 

My day would start with a brisk walk to work along the palm-treed sandy roads of the bairos, curling my toes through deep patches trying to keep the sand out of my not-so-white shoes. Dressed in my bata, I would get nods from other commuters, nods sent as expressions of respect to the white coat and all that it symbolized - education, authority, knowledge, power. "Doctora!" they would shout, waving. "Nao sou uma doctora... I'm not a doctor," I would reply abashedly. But they'd already be gone, dodging behind the next corrigated metal loja for a shortcut.

Walking through the gates of the hospital and through the open-aired waiting room, my eyes would be met with the sight of hundreds of people already waiting for  consultations. These consultations are served on a first-come, first-serve basis, so unless you are literally dying, you have to wait your turn like everybody else. But of course, you don't really just "wait your turn." The minute anyone with any sort of VIP status, whether its the friend of the second-cousin twice removed of one of surgeons, or the son of the mayor,  receiving prompt medical care is largely who you know. And if you don't happen to have any connections, then resign yourself to finding a bench or what little standing room is left.

I was able to drift through the hospital unquestioned - my presence tolerated because of my estrangeira privilege, and because frankly the nurses could use as much help as they could get. Even a white girl with a soft heart and soft hands.

And so, I did as I was told - to fetch this and grab that. Traga this, traga that. Consequentially, I was given an unparalleled opportunity to observe and witness the stories of the men, women, and children from across the northern province seeking care.

My mentors were Nera and Hortencio - bright and pragmatic nurses who ran the front-lines on the TB, HIV and infectious diseases ward. I was their shadow - glued to their hip, like a child clinging to a mother's skirt. Sights, sounds, and smells I often found overwhelming and upsetting caused them to hardly bat an eye. I wouldn't say that they suffered from compassion fatigue (but maybe). Rather, there was simply no time to grieve for each new life-changing diagnosis. They delivered HIV diagnoses to patients like one gives their spouse a routine honey-do-list. Mana, you are not pregnant. But, oh by the way, the test indicated that you are positive for HIV. But don't worry, we can treat it. Let's start with this... And you need to stop by the farmacia...

No time for grief. Just triage.

Next person. Next day. Next fight. Next life.

Heal them. Lose them. Either way another bed will become empty and be filled again tomorrow.

What struck me more than anything, was the degree of such meaningless loss. From loss of limb to loss of life. That as amazing and heroic as the hospital staff were, they could never give their patients the best possible care because the system in which they were operating gave them insurmountable odds. I remember how typical it was for the electricity to go out in the middle of someone's surgery. Nera would say a little prayer under her breath when it happened. If you were lucky, the generator would be started up. But that would only happen if someone had filled it up with gas. Gas costs money and the little money the hospital had may or may not have gone toward filling the generator.  I saw a grandmother in her 70s get her leg amputated with only minimal morphine. The doctor didn't want to "waste" any more on her than necessary because she was old, and he'd rather it go to someone young with many more years left to live. Her pain and agony is something I will never forget.

Add to that the death of my dear friend Hermenigilda in childbirth a year into my time in Moz.

And the near death of my friend Joana from sepsis that was poorly diagnosed and treated.

There are too many other stories to count. Loss adds up, especially when it's personal.

It's these encounters with preventable death, preventable loss that make me angry. Angry that this injustice is a reality for so many. Angry because even a few minor changes would have a huge impact in saving lives and improving quality of life.

Living with anger ultimately however makes you humble because you know what it means to feel powerless. Ultimately, it makes you realize that there are only a few things in this crazy world that you have any actual control over. Suddenly those few things give you hope. Hope that if you act to the best of your ability in the things that you have control over, you can stare down these everyday cruelties. Stare them down and fight them back into the abyss.

Hospital rural de Vilanculos taught me all these things, and affirmed my desire to pursue nursing school. One day, I hope I can give back all that it gave me and more.

Monday, August 31, 2015

For clarity, gaze from the hilltop.

Moments of clarity.  It's two girls sprawled over a fluffy green comforter in a sunlit upstairs bedroom, discussing C.S. Lewis and Tolkien, and agonizing over what it means to live a meaningful life. It is the elder who, at the end, looks back and forgives. And it is the addict who wakes up one morning and never takes a puff or drink again. Clarity. It’s the smartest scientist in history who labored over theories of relativity for years but didn’t connect the dots until he got on a bus. The moment the fog clears, the static dissipates, and time is stretched like a slingshot, tight to bursting and released in a roaring trajectory that, upon threading a single poignant realization, begins to stitch together ones heart and soul to reveal greater truths.

Humans strive for clarity because we’ve grown to dread the alternative.  In a world that barrages us with injustice and confusion, clarity, we believe, tries to bring us back to core values and ideas. To what "really" matters. Reality broken down into its simplest juxtapositions for when we feel so overwhelmed with life's complexity we would rather just crawl back to bed or morph into a Kafkian cockroach, than start muddling through all the contradictions. What will we tolerate and not tolerate? What will we fight for and not fight for? And if we stand for one thing, doesn't that obligate us to stand for another? What truths do we want to define us? At the risk of oversimplification, clarity allows a way of stripping away our fear, our doubts, and instead encourages us to act.

I have felt overwhelmed, as I think many Millenials have, at the host of national and world problems we will inherit, let alone the ones we are already dealing with as we come into adulthood. As CollegeHumor's Onion-esque post "Why It's Socially Unacceptable To Do Anything in 2015" suggests, in our age of interconnectedness and globalization, there's nothing we can do, even at our best moments as social-justice-allied-fair-trading-human-rights-advocating-small-carbon-footprint-creating humans that doesn't negatively affect someone else in another corner of the globe, or even our own neighborhood. 

And that is SO DEPRESSING, right?

Massive national debt. A visibly shifting global climate. Unemployment. Rising housing costs. Gentrification. Children bringing guns to shoot their teachers and classmates in school. Abundant racism and structural violence against minorities. An ever-widening gap between the rich and the poor. The list goes on.

I graduated university with a Bachelor's in Politics, and so for years I held a deep conviction that the answer to social change lay in policy reform and populist movements. Change the rules the privileged play by using the system, or change the system through grassroots activism (apathy remains greatest pet peeve amongst my peers - How can people just NOT care about the state of the world or their community? I will never understand...). Because I am passionate about cultural exchange, activism, and human rights, I believed studying Politics would lead me one day to a position within a NGO, embassy, or international development organization that would help people help themselves, or at the very least put me in a position to help indirectly redistribute the imbalance of wealth that plagues largely the global south. I knew my journey would begin with Peace Corps, but I didn't know where that journey would lead me.

Until now.

Peace Corps offered me many rich moments of clarity. Moments that shocked me, angered me, turned my conceptions of the world, the pretty theories I'd learned as a scholar at college, and my ideas of what was "right," upside down. I saw corruption first hand, and saw the shakedowns pass from the obesely privileged down to the poorest peasant granny. No one was immune. I saw presidential elections bought with cases of beer and free t-shirts. I struggled to reconcile the fragile morale of my students, who had so little faith in their own intelligence, that even my best and brightest thought they had to cheat or bribe their teachers to pass. And then I had to look my students in the eye everyday, and tell them they must fight for their education knowing full well that it very likely would lead them nowhere. I mourned the death of dear friends who died from completely preventable and horrible diseases. And for the first time in life, I knew what it felt to feel utterly helpless.

And I hated it.

Did I really want to become a development worker (foreign or domestic) who was stuck in some big city somewhere writing briefs and reports about a community I'd never met, making 10-100 times the wages of people I was supposed to be serving?

Or, did I want to have an actual practical skill that could visibly contribute to the betterment of health, wellness and education of a community in need?

When you put it like that, the answer becomes obvious. Clear.

My love of politics and public policy is real, but I know my place is on the ground, working hands on with people who policies fail to reach. As one of my most beloved professors' and life mentor in college reminded me, people have never been a number to me, they've always been personalities, faces, laughs, and feelings. They are characters who's stories have energized me, scolded me, and gentled me. It's the people who I miss most about Mozambique, and it's the people who have taught me that where I belong is where I am needed, nothing more, nothing less.

It was this clarity that solidified my transition into medicine and caused me to restart my career from scratch.


With seemingly impeccable timing, a hometown friend loaned me Tracy Kidder's Mountains Beyond Mountains, a powerful narrative describing the life of Dr. Paul Farmer, a fierce global health advocate and one of the primary founders of the now well-known"Partners in Health" (PIH).
From its initiation in 1987 in response to health projects begun in Haiti, PIH has expanded across the globe, unrelentingly advocating health as a human right for all peoples.

Mozambique ranks #178 out of #187 on the United Nation's Human Development Index primarily due to the lack of access to medical care. So, it's not surprising that Mountains Beyond Mountains also offers one of the most concise analogies of the challenges met by global health workers. As Kidder writes during his visit to Haiti,

"I offered him [Dr. Paul Farmer] a slightly moist candy, a Life Saver from my pocket. He took it... and then went back to gazing. He was staring out at the impounded waters of the Artibonite. From here the amount of land the dam had drowned seemed vast. Still gazing, Farmer said, "To understand Russia, to understand Cuba, the Dominican Republic, Boston, identity politics, Sri Lanka, and Life Savers, you have to be on top of this hill." The list was clearly jocular. But I had the feeling he had said something important. This view of drowned farmland, the result of a dam that had made his patients some of the poorest of the poor, was a lens on the world. His lens. Look through it and you'd begin to see all the world's impoverished in their billions and the many linked causes of their misery. (44)

Oh, messy inteconnectedness! A decision made by a few leading to the destitution of millions.

Yet, despite all this, Dr. Farmer responds by treating one patient at a time.

This time, I believe I've chosen well.

Sunday, December 14, 2014

Mozambique's Nirvana - Benguerra Island, and the Bazaruto Archipelago

My fingers carefully ply the leather straps, cinching up the girth inch by inch, making sure the saddle pad stays smooth and flat against my mount’s reddish-brown sides. As I do this, Slash, a beautiful yet mischievous chestnut gelding, turns to eye my handiwork and tosses his head in impatience. “Alright, alright, I’m going,” I laugh as Slash whips his head forward again, ears propped lazily backward to express his perpetual annoyance with the slow, two-legged kind. He takes a big breath and sighs dramatically. I swear, if horses were people…

Finally, with my helmet on I swing up into the saddle. It’s a little black McClellan saddle, incredibly lightweight with high clearance to my horses withers, and named after the American Civil War officer who used its antiquated relative in combat. Wedging my feet into the stirrups, we set off, with Squib, our gentle giant senior, in tow.

We take a right out of the stable “gates,” an aperture hacked from the thick surrounding bush, and head south through the local fishing village. Our easy amble takes us past excited children who herald our arrival with cheers of “Cavaloooo! Mulungo!! Cavalo!!” We pass the quintal or circle of huts of the chief – a well-dressed, older gentleman named Arone – and wave hello to his wives. I yell over the hedge row to one of the wives Adna and ask if I can come buy fish from her later that afternoon. We agree on a general time determined not by hours, but rather by the height of the sun in the sky.

Moving beyond the village now, a new quiet settles in around us. At first, there’s nothing but the sound of Slash and Squib’s hoofbeats muffled in the sand, the creak of warm leather, and the occasional coughs of Manuel, the head groom, from behind.  But after a few moments, my ears adjust and the bush begins to come alive. Song birds conversing across the rolling dunes, scuffling lizards, darting doe-eyed Suni, and the rustle of the salty wind carrying whispers from the mainland. Soon we come across some wild fruit, shaped like small orange plums. I swipe some as we pass and pop the sweet fruit into my mouth, breaking the delicate skin with my tongue and sucking the sweet flesh from the seed.

I marvel.

I marvel, like most nature lovers do, at the incredible bounty of life throughout the Bazaruto Archipelago. Benguerra Island itself, where our horses are located, boasts 11 different ecosystems over 34 squares miles. And that’s not even taking into consideration the life below the ocean’s surface, where coral reefs explode from the sandy bottom to host an abundance of reef fish, giant turtles and Devil rays Moreover, the Dugong, an endangered relative of the American manatee, is now being actively monitored and protected by National Park staff. Thus Benguerra, and her 6 other sister islands, make the Bazaruto Archipelago an absolute nirvana of biodiversity… and a conservationists dream job.

Now rewind. Two weeks ago. I was in Maputo to sign off on all the paperwork that made my Close-of-Service with Peace Corps official. Passing me on the stairs one day, our Country Director Sanjay Mathur, invited me up to his office for a quick chat. “Please,” he said gesturing toward the round table at the base of a giant map of Mozambique – l sat like a child at her mother’s feet. Mocambique, what surprise do you have in store for me today, I wondered. “Karina, I have an incredible opportunity for you. I had lunch with Greg Carr last week and he has a colleague who is in need of a Community Liaison Officer for her brand new conservation project. I don’t know much about it, but that the job will operate between Benguerra and Vilanculos, and I thought since you’re interested in staying on in Mozambique a little longer, this could be a good fit for you. Shall I write you an email of introduction?” I couldn’t believe the words. Sanjay, having lunch with Greg Carr, the millionaire who’s made his life work rehabilitating Gorongosa National Park?? A colleague who wants to hire? This could be the big break I’ve been looking for! An opportunity to launch me into an actual career doing work I care about!  Somehow, I stuttered out a few excited syllables along the lines of “Yes!” “Please!” and “Perfect!” Sanjay leaned back in his chair grinning and said, “Well great then, consider it done!” I practically danced out of his office.

I scheduled an informational interview with this colleague the following day. The woman who answered was friendly and engaging, clearly passionate about her project and interested in getting similar minded people on board. As she described the work of her company (who's name I've omitted for the sake of professionalism) I couldn’t help but start feeling excited too. “We want to develop Benguerra in a way that’s environmentally responsible and also beneficial to needs of the local people,” she explained after I’d summarized my work as a PCV in Mozambique the last 27 months. “While we want to build a lodge, yes, we also want to offer islanders employment and skills training. And ultimately, we are hoping to forge a partnership between our company, the National Park officials, and American universities to develop an exchange program for graduate students to collaborate with Mozambican scientists on environmental and marine research. The Community Liaison Officer would be an educator, community organizer and negotiator between shareholders of the project and the Mozambican community.”  

A job where I can bring groups together for common goals? Where I can use my Portuguese and cultural knowledge? Where I could do environmental community initiatives and coordinate skills training sessions? Where I could be the shepherd of big money backing social justice and progressive development work? Develop better park conservation strategies through promoting scientific research? All while guaranteeing that Mozambicans could participate fully in the process? I knew that as long as my work didn't devolve into a token position as the bringer of bad news and disenfranchisement to a people I just spent the last two years serving, I was hooked.  We've been in employment negotiations ever since.

Now, back on Benguerra for December riding Slash, I see the island a little differently. As the “dona de cavalos,” I am trying to learn all the little caminhos and bairros, and befriend some of the families. Surprisingly I discovered that the islands were uninhabited before the war. Thus, most current local residents are leftover civil war refugees, living on the island for only the past twenty years. In the longitude of Mozambican cultural memory, that’s nothing. But the population on Benguerra is growing, putting stress on the resources of the island. Over-fishing, slash and burn deforestation… It ultimately makes me ask the question, how can we mitigate the effect of humans on nature? Benguerra is still a wild place. And as a National Park we should want to keep it that way. I suppose if I had it my way, we’d leave the island alone completely, provide strong financial compensation to islander families to relocate to the mainland, and rehabilitate the Archipelago as a true, pristine National Park like we have in other parts of southern and eastern Africa. As long as this process was done carefully and in consideration of all human rights (as in people were willing to leave, not being forced), I think it would be a proud moment for conservationists worldwide. Because on the path we’re on, we've got to get smart about development, or we'll start seeing the rapid deterioration of Mozambique’s Nirvana.

So the question is, can we create a system people will adhere to that manages resources effectively enough to keep the quality of human life high, with low environmental impact? It’s a question any company that wants to invest here will have to answer to if they hope to succeed. Yet National Park or not, Benguerra – whether one likes it or not – is going to be developed. That’s just how Mozambican politics work. All it takes is the right "incentive" to the Ministry of Tourism for lands to get set aside for special interest groups. While investors cannot buy land from the government, they can certainly "borrow" it. And so, knowing that this is the game we are forced to play, I personally hope a company focused on equitable development practices has the first say, for everyone's gain. 


Slash and I are moving faster now, breaking into a light canter up the sandy chute to the lookout point. His ears are pricked forward in equal parts curiosity and vigilance. At the top we come to a halt. The view takes my breath away even now. To the north, Flamingo Bay named for its feathery occupants, and the Great Dune of Bazaruto island, a shimmering sentinel in the afternoon heat. To the south, the wind-swept moonscape of the southern point. To the East, a panorama of the interior lakes and on the horizon, the white foam of lazy ocean rollers smashing into Two Mile reef. To the West, the cerulean blue waters of the mainland channel, swirling sands shifting with the tides. 

This is a place not even words can properly describe, nor camera capture. It is an experience that must be lived, touched, breathed, smelled, seen. This is why we must protect it from the urges of necessity, from spoiling, so that others may too travel to this special world and understand the value of Nature free from the binds of humanity.


Looking West - Across the Channel to the mainland

Local beach criancas, messiing around :)

The interior lakes and big Dune.

South point! 

And introducing our horsie stars, Slash (above) and Squib (below)

Thursday, November 13, 2014

Bartering with Goodbye.

Two weeks. 14/756 days.

Two weeks and my service as a Peace Corps Volunteer in Mozambique will be over.

Two weeks and I’ll be handing back the keys and saying goodbye to the Hut, Mozambican friends and colleagues, my ever faithful dog, Fenda, and hopping a plane to Maputo for medical exams (poop cups, our favorite!), a language proficiency test, exit interviews from PC Mozambique Country Director (let’s talk about our feelings!) and oodles of government paperwork. My RPCV (returned peace corps volunteer) status even comes with a few perks upon American reintegration, including (but not limited to) complete ineptitude in discussing social and cultural phenomenon after 2012 (looking at you Tinder and Snapchat!! wtf?), “shock and awe” syndrome upon entering a supermarket (I will probably schedule a day to just wander around Costco), and total communication breakdown when trying to bargain every price and realizing my wide spectrum of tonal grunts usually used to win over the stern market ladies for extra tomatoes in my basket make me look like a crazy person instead. I can see the future and it terrifies me haha.

Sooooo clearly someone’s not ready to leave Mozambique. If you haven’t heard by now I’m staying on an extra six months (maybe more) to do online pre-reqs and volunteer at the Vilanculos hospital to prepare for nursing school applications due in Fall 2015. Moreover, I’ll get to continue improving my horsemanship with Pat and Mandy by continuing as a horse volunteer, and I’ve been tentatively offered an ocean safari guiding position with a local dhow sailboat company taking clients on overnight sailing/snorkeling trips around the Bazaruto Archipelago. It’s going to be a blast, and I’m SO excited to start this next chapter.

Because I’m trading in my Peace Corps privileges for complete autonomy (and maybe even a real living-wage) here in Mozambique, my Close-of-Service experience is very different than for most PCVs. I’m leaving Mapinhane, yes. But I’m moving only 50km north rather than 12,000 miles northwest.  I expect to be able to keep in touch with my students, help the new volunteer in Mapinhane take on the library project, and visit Sarah and Maria, my site-mates and best friends, regularly.

I’m allowing myself a transition time. For one, to not go back to Washington in the midst of a dreary, grey, cold winter (hellooooo depression!). But also, to fully savor and make the most of the friendships I cherish with my whole heart. It scares me thinking of what saying goodbye will ultimately mean when I finally do climb my way into that sky, looking to the next horizon.  Saying goodbye means going away and leaving people behind. Going away means throwing yourself into the next crazy venture and eventually, inevitably forgetting.

And I don’t want to forget!!

I don’t want to forget the smells after an electric, crackling summer rain, nor the sounds of my students gossiping in Xitswa while doing their English exercises (wahemba!), or the sight of another spectacular sunset silhouetting the ancient embandeiro (baobob) trees, striking and burning the earth into a magnificent orange. I don’t want to forget the cheers of “teeeeecha karinaaaaa” and little pitter-patters of flip-flopped feet of the criancas that race to greet me when I arrive each week to work on the library.  I don’t want to forget the old man across the barrio who’s soft heart helped me save Lisimu’s paw from infection and who later that day tore down an aggressive vine strangling an old papaya tree others were too lazy to save. I don’t want to forget the value of open space, of clean air, and drinkable water. Of working with what’s available, making the impossible possible on a daily basis. I don’t want to forget how sweet the first mango tastes after the dry season, and the stickiness of the juice running down your greedy chin.

Most of all, I vow never to forget the people who made my experience worth the struggle. Pat and Mandy, who I will forever love as my family away from home. Director Marculino Bambamba, a visionary, albeit a bit of a well-intentioned square, who believes in his students and loves his country. Chefe Samuel who was my first and most trusted friend. Angelica and little Junior who is very quickly growing into a little man, meu homininho. Joana and Crimilda, my Mozambican maes. The innumerable community members, from mischeivious vovos to bandito carpenteiros Tomas and Obedias that repeatedly taught the American mulungo a thing or two about the “real Africa.” And of course, my favorite students whose names I write down in my heart, names that one day I hope to see doing something as great as the potential I see in them. Adelson, Celso, Edio, Gervasio, Bento, Helton, Jeremias, Erdito, Rui, Nelio, Domingos, Edilson, Zacarias and Gercia, Hawa, Inazardina, Anelca, Assucena, Greta, Dorca. They represent the next generation of Africa’s quiet community leaders.  As many times as I wanted to give up, they keep going. They believe in the value of their education, and so how, even on my worst days, could I not?

We barter with goodbyes because we can’t stand the idea of walking away from something we love toward a future we yet cannot see. No, I’m not yet ready to leave Mozambique. But, “this is the time to remember because it will not last forever; these are the days to hold on to because we won’t although we’ll want to.”

Saturday, October 18, 2014

Teacher's Day!

Mozambique has many national holidays... so many in fact that it seems we can rarely go a month without the total disruption/interruption that such holidays bring. Yet, the celebration of National Teachers Day seems perhaps the best excuse, if any to take valuable class time and commemorate the work of educators across the country.

I'll give you a nice view of how we celebrated Teacher's Day here in Mapinhane.

Friday, September 26, 2014

Agua e' vida: The (quick) Borehole Story

My host school, Escola Secundaria de 25 de Junho in Mapinhane, boasts an enrollment of 700 students spanning three grade levels and nearly 30 teachers and staff members. Yet, despite being a school of this size, until a month ago we didn’t have accessible clean drinking water on campus. As such, students needed to walk 10+ minutes across the village and stand in line to wait with the dozens of community mothers collecting water to simply get a drink before heading back to class. Consequentially, getting a "quick drink of water" always delayed and disrupted student learning, as students always somehow seemed to disappear after their trip to the community well, skipping the rest of their class period(s). Moreover, because of the gendered labor distribution practices in rural Mozambique, if the school needed to collect water for their at the time small, pathetic, scraggly attempt at a garden, it was the girls who seemed to always be pulled out of class or away from their male peers to fetch water.

Back in May, I finally decided to run by my observations with the school director, Marculino Bambamba. A well-educated and incredibly serious man, he listened to my concerns with intense gravity. "Infelizmente filha," he sighed after I'd finished speaking, "The government cannot allocate us the money yet to install a borehole. We simply don't have the money. We can't even buy books! But I agree, it is one of our most crucial school needs." We sat silently for a minute. "But if I could raise the money," I said "you would support the installation and raise community and parental support?" "Claro." he said. And with that the meeting was over. But, at a time when the library was faltering, I knew I'd found my next secondary project to tide me over - one that would also directly benefit my primary project too. Because as everyone knows, agua e' vida- water is life.

And so began the fundraising research, contractor borehole installation quotes, and application submissions to both independent NGOs and Peace Corps alike. Months passed. Finally, we got our break. We were awarded one of USAID's "Small Project Assistance" grants – nearly $6000. From the day we broke ground, it only took a week to drill and install the school borehole... a relatively quick process that yielded an tremendous and immediate impact upon our community.

The "before" photo, taking soil from the digging point to bless the ground and water through a traditional ceremony conducted by the village chefes.

The village chefes conducting the traditional blessing before we're allowed to break ground

Celebrating the start of the drilling process! Let's drink! (The chefes got wine, the rest of us orange Fanta haha)

Day 2: Doug in the captain's seat!

Day 3: After striking a dense rocky layer, we finally broke through. So much water!

My two counterparts, Sr. Director Marculino and Doug - PCVs uniting people and resources to get the job done!!

One week later. The official ribbon cutting ceremony! 

Now, not only do students have access to clean drinking water throughout the school day, the school garden has transformed from a withered yellow cluster of dusty vegetation to a vibrant and flourishing garden, with an incredible boom of staple crops. With time (and the next PCV at my site), the easy access to water will empower Director Marculino to make even greater changes and growth to our school garden and nutrition programs. We've also discussed introducing an income generation project by expanding our peanut production and selling the peanut butter as a means of fundraising for school resources. We've also partnered with the Agro-Percuaria teacher to begin improving the biological and nutritional diversity of the garden by introducing vitamin rich foods such as covi and orange sweet potato into his academic lesson plans.

Using our education and specialized skills and experiences in grant writing and fundraising to empower local counterparts to meet community needs - to me this is the heart of Peace Corps service. Helping people help themselves. The borehole may only be the first step towards bigger school development projects, but it is the FIRST STEP. A million different community projects can grow from this single foundation. Because water is life. And life is meant to be nurtured like a garden. Let's see what our garden grows. 

Tuesday, August 19, 2014

Better the Devil You Know.

This past weekend presented me with two incredibly weighty and humbling life experiences. The first: I chanced to help save my Mozambican friend’s leg (and possibly, life). The second: I spent a full day watching the great Humpback whale migration from the prow of a catamaran. And while the former reminded me of the huge power a small act of human courage can have in changing the course of another's life, the latter dwarfed any suspicion of self-importance with the feeling that with every crest and fall of ocean waves, we were a tiny spec teetering on the surface of a much greater and mysterious world below.  Least to say, it was an intense few days.

Friday afternoon I popped into the library for a quick look, and took some measurements for the mural that we’ll start painting next week. It was there I ran into Raulina, a teacher at the primary school and my new library counterpart.  As usual we chatted about the weather, our families, her chique new hair style, school gossip, and our plans for the weekend. It wasn’t until I was on my way out however that she caught me by the arm, and told me that “by the way, mana Joana is very sick” and “could we go visit her now?”

Being in a hurrying mood, I’m ashamed to say that I felt a bit annoyed. Mozambicans are always complaining dramatically of some malady or another. Teeeecha. Estou suferir. Estou com fome. Estou doente. Estou com dor de cabeça, ou barriga, ou pé. Estou com constipação. The list goes on. They’ll have a pain in their stomach and say they have cancer. If they’re sick, they say they’ve gotten it from the dust in the air, from the trash in their neighbors yard, or that a witchdoctor has cursed them. I’ve never met a nation of people so poorly educated about the transmission and general cause of disease, let alone a complete lack of taking personal responsibility for disease prevention and treatment. Even Joana, a very well educated matriarch of the primary school, had been sick for weeks already with a swollen foot… I’d seen it the month before. Yet she had just been tolerating it, expecting it to get better. Perhaps the only thing equal to Mozambicans ignorance of disease is their tolerance and patience with pain. Since I hadn’t heard anything from her, I guess I’d just figured she’d recovered and gotten busy again. Still, a little voice in the back of my head argued, you should go and see her to make sure she’s ok. Sighing I wheeled my bike back around, away from home and towards the huts behind school grounds. “Sure, Raulina. Vamos.” I said, now walking at her side. “Thanks for inviting me.”

While I’m quite conscientious about listening to my inner little voice, I’ve rarely felt more fortunate for having heeded it than I did in visiting Joana that day.

Immediately as I ducked into the darkness of her hut, I knew something was horribly wrong.  A mound of blankets erupted from the cold cement floor a foot from the doorway. I knew Joana was under that huge plaid mountain of felt, but I couldn’t see any hint of her.  “Mana Joana,” I called softly into the darkness, my eyes adjusting to the dim, my toes slowly picking their way around hidden obstacles, moving closer to where her face should be. Finally, kneeling down, I waited as her son (one of my best students) Adelson, worked to rouse her.  “Mãe, Teacher Karina and Teacher Raulina are here to visit you.” Moments pass. Again.  “MAMA. Teacher Karina e profesora Raulina estao aqui. Levanta mama!” Finally the pile began to stir and grumble and a hand reached out, grasping. So I took it. It was burning. As the blankets peeled away from the top, I finally found Joana’s face and gasped. It was a feverish face, a bleary-eyed, leathery brown face aged and etched by pain. “Joana,” I breathed, scared and shaken now. “What’s happened?” She began to cry.

The next 20 minutes were a blur, a whirling of action and response. Trying to keep my voice calm and positive, I sent Adelson and his little brother for buckets of cold water, a wet cloth on the forehead, and juice from the market. Joana was shivering uncontrollably and was so weak she couldn’t prop herself up. Meanwhile, I knew I had to take another look at that swollen foot of hers she’d told me about the month before.  What I saw when I rolled back the blankets took my breath away. The slight swelling that had been in her foot before, had spread all the way up her leg and into her groin leaving clustered, dark, almost pustule-like, spotting along her entire inner thigh.  I was looking at an elephant leg.

Part of Joana's freakishly large and swollen leg. The foot (not pictured) looked like a massive club.
Moreover, in talking to Adelson, I’d learned that Joana had already gone to two hospitals – the health clinic in Mapinhane as well as the Hospital Rural in Vilanculos. The first had turned her away with a prescription for Tylenol, while the second had prescribed her a pain killer, fever reducer, and the anti-biotic Erythromycin. The only problem was that whoever had diagnosed her at the Vilanculos hospital didn’t take the time to explain what each medicine was for. And so because Joana could only afford two of the three medicines, she bought the first two on the list and left the final prescription, Erythromyacin – the one medicine that could actually do any good – unfilled. Clearly, it wasn’t that the nurses and doctors at the Vil hospital didn’t know what they were doing… they simply just didn’t educate their patient about her own health and how to help herself heal. And now with Joana shaking and moaning under that pile of blankets with a horrible infection roaring in her body, I figured she was in a really fragile state… that she would be too far gone in another 48 hours, maybe even less, to be able to bring her back if I didn’t take action. I was really scared. But I’d already lost Hermenigilda in a way that made me feel helpless. I felt determined to do something, anything. There’s no way I was just going to stand by and watch her suffer like that, especially for something I guessed was super treatable.

So, within a few texts and graphic photos exchanged with my mom, who’s a Nurse Practitioner with nearly 40 years of experience, back home, we had a diagnosis. Because I’d first seen the swelling in her foot a few weeks before, we realized just how aggressively the infection had spread up her leg. Joana was suffering from an advanced stage of septicemia, or blood poisoning.

Doing some research on it later, septicemia is actually one of the biggest killers in the underdeveloped world. Infection and the lack of access to basic antibiotics and controlled treatment plagues the poor across the world. As explains:

"Sepsis arises when the body’s response to an infection damages its own tissues and organs. It can lead to shock, multiple organ failure, and death, especially if it is not recognized early and treated promptly. Between one-third and one-half of all sepsis patients die. In developing countries, sepsis accounts for 60-80% of all deaths."

Perhaps the greatest tragedy of it is that infections like Joana’s are some of the easiest to control and treat if caught early.

Yet with the lack of education and understanding of disease transmission and control, coupled with the fact that most of the world’s poor can’t afford treatment or even have access to a medical provider, most people with very treatable injuries or diseases just sit, rest, and wait, hoping their malady will pass and thus instead allow the infection to set in and take over. They don’t even have a fighting chance.

Anyway, we finally had a diagnosis thanks to mom. So I hopped on my bike and shot out of that barrio like a bullet, pedaling for home and the extra stash of kick-ass antibiotics my mom had brought me from home a few months before (I’ve always loved being a Nurse Practitioners daughter!!). With a new flurry of texts, Mom and I settled on a 1000mg / 12 hours pusher dose of Amoxcycilin for the first 36 hours, then a switch to 500mg / 8 hours of Erithromyacin. I threw in a pack of dehydration salts and Ibuprofen for good measure. Then I hopped on my bike and shot off again through the sand and onto the main road. Fenda must have thought I’d gone crazy. His wagging tail quickly drifted back only a few steps into his pursuit.

On the bike ride back to Joana’s, I prepped myself on how I was going to explain treatment. One of the things we’ve learned through teaching about HIV and malaria prevention is that you can’t make assumptions about what people “already know” because most likely they actually don’t but say they do.  What I had going for me was that I knew Adelson, the son, was a super diligent student of mine – the rare kind of kid that copies every word on the board and asks clarifying questions in class. So I crafted a list of detailed, descriptive instructions. Pacote branco, I wrote, referring to the silver packaged Amoxcycilin, Adelson perched religiously on my shoulder. 1 pacote cada 12 horas para 2 dias. Aleve. 1 medicamento cada 6 horas quando tem febre. I had him describe back to me the treatment until he could do it from memory. Then in an attempt to push program adherence I told Adelson I’d count each empty packet he had the next day. Then I had to tell him to push fluids into his mom despite her resistance. “Have her drink 4-5 cups of water or juice every hour,” I explained him, guessing we’d be lucky if he could get even half of that. “The medicine needs fluid to work,” I clarified, giving a very abridged reference to the horrors of dehydration. I didn’t really know how to describe kidney failure.

And with that, my lesson was done, the immediate crises of deciding what course of action to take, over.  I watched Adelson administer the antibiotics and Aleve to his mom and felt really proud. But I knew we weren’t out of trouble yet. Joana now just needed time to let the antibiotics work. And while later that night I still felt really self-assured in the decisions I’d made earlier that afternoon, I couldn’t sleep. While we didn’t really talk about it, I knew that my sitemate Maria, who had done pre-med at university thought I was out of line for helping the way I did. That, for one, I was putting myself at risk with the community if Joana didn’t make it and I’d been the last person seen with her giving her mystery pills, and for two, she thought that I was in absolutely no way qualified to make the judgment calls I’d made that day, even with my Mom’s help.
Both were valid points. It’s true there could have been backlashes from Joana’s family if things had gone badly. Because I’m white. Because people don’t understand how medicine and disease work. Because I’d make a convenient scapegoat for a mourning community, and that I was trying to treat an infection that was too far along. It’s the sad side to medicine in a developing country that the odds are against you. And as to the second point, sure, I wasn’t qualified at all, but with 40 years’ experience my mom is. And with technology these days, essentially I got to present to my mom the symptoms with photos and descriptions with real time accuracy. It was truly amazing, honestly. Without the power of WhatsApp and GoogleVoice calls, my story would have been different. I would have tried to take Joana to a second rate hospital by public chapa, where we would have been forced to wait for hours to be seen by a doctor, and for what? To be told to go home again? No. Way.

Essentially to me it all came down to this: I could play it safe, stand by, do nothing but try and make her comfortable and watch Joana lose her leg or die from a treatable infection. Or I take a risk on both our parts, make my best judgment based on expertise from someone I trust, and try to save a friend’s life.
I stand by my decision to this day. I couldn’t have lived with myself or looked Adelson in the eye ever again if I’d knowingly made him and his brother orphans.

So, I let time take its course and kept myself busy. I had a new roof on my hut installed that next day. I later sent myself to Vilanculos with Maria, Sarah and Victor to relax and go whale watching for the weekend. It was splendid to have my worries juxtaposed to the magnificence of the humpback whales. Any anxiety suddenly seemed miniscule and was forgotten in the scheme of things. For nearly an hour, a pod of four young males circled our catamaran and put on a show, splashing, fluking, and diving. Dolphins played at our bow. Witnessing these creatures felt more sacred than probably anything I’ve ever experienced (besides wild elephants). They were letting us into their lives and engaging us, and when they were done, they just flipped their flukes and dove. Here we were bobbing on top, hundreds of meters above them, yet the whales came to us not because we wanted them too, but because they did. The magnificence of the whales was awe-inspiring. And it reminded me of the importance of perspective.

Yet I called and checked in on Joana twice a day, even from the boat, and we started seeing signs of progress. After the first 24 hours, Joana rated her pain level a 5, down from a 9 the day before. And it was on the third day, when I got back to Mapinhane, that we rejoiced to see that the swelling had started to finally go down too. The skin on her foot and ankle that had been once taunt and stretched to bursting had begun sloughing into flappy layers of loose skin. 

This time at my visit she had her church lady friends sitting around her bed, and Joana had propped herself up to receive them all. What made me happiest though was that Joana was once again smiling that huge, toothy grin of hers. She was herself again. “You saved my life,” she said, in front of everyone, taking my hand, hers healthfully cool again. “I only did what I knew I could do,” I said, suddenly embarrassed. “It was nothing.” I then told her she wasn’t allowed to get sick again. Right on cue, all the ladies cackled, then proceeded to overwhelm me with their own medical worries. A woman with a lump on her eye, another’s swollen foot, another complaining of chronic stomach pain. I waved them all off. “I’m not a doctor,” I said. “I’m a teacher. And anyways, mana Joana isn’t even on her feet yet.” Thankfully, they all chuckled again and I left in a wave of “obrigadas” and “gracas a deus” also escaping any further inquiries by stepping out into the winter rain.

As a kid, and still even now, my mom and I have a little thing where when I ask her how her day went after working at the clinic or  running hospital rounds, and she’ll sigh dramatically with a grin and go, “Oh you know, just saved a few lives honey. No big deal.” It’s played off as a joke. Because how else can you talk about everything inbetween the lines? The people you can help versus the people you can’t. It’s easier to have a punchline instead.

On my path to becoming a nurse, hopefully one day with Médecins Sans Frontières (MSF), it honestly feels like I’m doing everything out of order. I’ve had to confront and will confront a lot more of these harsh realities of third world health care next year with my volunteer position at the hospital without formal medical training or knowledge. Yet I know that the type of work M.S.F does is the type that works in similar or even worse conditions of stressful, undersupplied, impoverished, undeveloped or war-torn nations than Mozambique. I actually met an ex-M.S.F employee on the whale watching trip and he said that getting posted to Mozambique is almost like a holiday compared to the majority of other M.S.F posts.  I’d like to think that it will help me a lot in the future to be able to think back to the amazing people here in Mozambique that only needed a little education and guidance to turn a serious illness or complication like what killed Hermenigilda only a few months ago, into a survivable one like Joana’s. I expect the people we preserve in our hearts, we find again in future chapters of our lives, and what better way than to have a real skill to offer, and a real, tangible way to help.