Malaria in Mutare

I’m told that malaria is not usually as much of an issue in the highlands, where Mutare is, than in the rest of the country.  Most people identified iwith malaria in and around Mutare have recently been in the lowlands, and are presumed to have been exposed to it there.

 My experience with mosquitoes has been in the US Midwest, where the hotter and more humid it is, the more mosquitoes there seem to be.  Here it’s a bit different.  I got about four bites my first week, then only one in the next three weeks.  However, when the evenings began to get a little cooler (in the 70’s in my apartment at bedtime, as opposed to the low to mid 80’s), the mosquitoes seemed to proliferate.  I’m not sure why that would be—I didn’t notice any difference in the amount of rain we were getting or anything else that would account for it.  Maybe mosquitoes like it in warm apartments on cooler evenings.  Along with the proliferation of mosquitoes was news that within a two-week period, three people I know (2 from home group/Bible study and one who is the owner of the garden restaurant I’ve been to twice) got malaria without leaving Mutare.  That has people a little concerned. 

My pastor’s wife, who was over at my apartment, pointed out that I had a mosquito hook on the ceiling (I didn’t know that was what it was), and asked if I had a mosquito net.  I do—it had been sitting in the bottom of my closet ever since I got here.  So I got it out, stood on my rickety chair, and used one of my very expensive hangars as an extension to get it onto the hook.   Sleeping under it took a little getting used to--it usually touches the top of my head, and that felt like something was crowding me the first couple of nights.  It holds heat a little, so I'm glad the nights are a bit cooler.  I must admit that since I've been sleeping under it, I do a lot less bug slapping.  I thought you might like to see what my bed looks like with the net on it.  I call it my “princess bed” and think of Carla’s daughter, Lexy, when I look at it!

Shona Customs Related to Reproductive Health

One of the projects we’re doing in my graduate class is comparing information related to reproductive health in various cultures.  The class decided that each person would pick one country to become an expert on, and that they wanted me to model what I wanted them to do for each step of the project.  This seemed reasonable to me because I’m asking them to really think through reproductive health issues in cultural, family, social, scientific, political and economic contexts, and they come from an education system that traditionally relies more heavily on memorization than on reasoning and applying knowledge.  I agreed if I got to pick the country first, and I picked Zimbabwe.    As a result, I’ve been learning a lot about how the health system is structured here, and how it is viewed by people, particularly more traditional people in the rural parts of the country.  Sixty-three percent of Zimbabweans live in rural areas, so there are a lot of those folks.  Of the people living in Zimbabwe, 82% are Shona.  One part of the assignment was to learn about cultural practices that would affect people’s use of medical clinics and hospitals, or their reproductive health.  I learned some interesting things, and thought I would share them with you.

Zimbabwe has a high rate of neonatal mortality (24 per 1000 births, compared to 4.2 for the US), and is trying to improve that figure by having more women deliver in clinics or hospitals where there are skilled medical attendants for deliveries.  A significant barrier is that it a Shona custom to deliver the child, particularly a first-born child, in the home of the mother’s mother.  Shona will travel from Mutare or Harare, where good medical care is nearby, 50 km or more to a rural area with no running water or electricity to have that baby, because to do otherwise would be disrespectful of the maternal grandmother of the baby. 

 There are two other Shona customs that can impact reproductive health in this time of HIV/AIDS.  Traditionally, if a woman becomes a widow, she will be offered a choice from among the brothers of her deceased husband who are willing to have her as a wife and to assume responsibility for any children she has.  Reciprocally, if a man becomes a widower, he is allowed to ask for another woman from his deceased wife’s family (or her family may offer him one) as a replacement wife.  These customs have served to guarantee the viability of the nuclear family of the surviving spouse.  With the current high rate of HIV/AIDS infection, and the fact that most individuals don’t know their HIV status or have money to be tested for HIV, this is a conundrum for individuals whose spouse has died.  If a widow marries a brother of her deceased husband, she may bring HIV to his family (he may already have a wife and children, so she would be an additional wife).  With so many individuals of childbearing age dying from HIV/AIDS, there is often an underlying question when someone dies in that age group whether HIV/AIDS was a factor in the death.  That concern and a trend toward greater gender equity have undermined this custom, and increasingly people are waiting to choose whether and whom to remarry.

Visit to the Tariro Project

I’ve been hearing about the Tariro Project ever since I got to Africa University.  Tariro is the Shona word meaning “hope”, and the project is a service project of the Faculty of Health Sciences at Africa University, serving people living with HIV/AIDS and their caregivers.  It’s been in operation for about a year, with offices at Old Mutare Mission within a mile of campus.  The program lasts for about 15 weeks, and is on its third cohort of participants, cohorts ranging in size from 15-18.



The song leader, and Violet, the director of Project Tariro, greeting the DSWC Mission Team

In this project, clients come to the site twice a week (once a week now that it’s crop season and there are more farming duties).  They learn better gardening/farming practices from an agricultural specialist, spend time sewing sanitary pads and infant diapers from old t shirts, and do sewing and bead work that they can sell to earn a little money.  Even more importantly, they support each other emotionally.  They laugh, sing, and are encouraged to be consistent about their anti-retroviral medications.

Project Tariro participants dancing for the DSWC Mission Team

The DSWC mission team visited the Tariro Project last Friday.  Graduates of the earlier cohorts came to participate.  The DSWC group was warmly greeted with song.  There was time together for singing, dancing and prayer.  The lyrics of one of their songs spoke of praising God “for as long as we live”, which especially poignant when sung by people living with HIV/AIDS. 

Some of the Project Tariro participants I talked to

We were served refreshments and had time to interact with some of the Tariro participants individually, and to buy some of their crafts.  The DSWC group had brought a small mountain of old
t shirts to give, and a prayer blanket for the group.  One of the DSWC people talked to the Tariro folks about how we have been covering them in prayer.  The whole experience was very moving.  I have made myself a promise to return to the Tariro Project by myself on a regular day to learn more about how they spend their time.  Expect to see another post about this project later on!

Project Tariro participants singing a song about the vegetables they've grown

Dedication of Health Sciences Chair

Today was a very special day at Africa University.  The Desert Southwest  Conference (DSWC) delegation arrived, 41 in all, to participate in the dedication of the Joel Huffman Endowed Chair in Public Health Medicine.  The DSWC raised $500,000, which will be invested so that in perpetuity the income from that money can pay the salary of a distinguished African scholar to provide leadership for the public health program at Africa University. 

Just the delegation’s arrival was a small miracle.  They’d missed a connection in Johannesburg Monday evening, and so arrived in Mutare after three grueling days of travel at 11 pm Tuesday evening.  Bishop Carcano preached for the regular Wednesday morning chapel service.  Then came the dedication ceremony, with remarks by Bishop David Yemba (Zimbabwe) and Africa University’s Vice Chancellor Fanuel Tagwira. Bishop Minerva Carcano (DSWC) told about the work of Mr. Joel Huffman, and then Mr. Huffman himself spoke about the meaning of the dedication of this chair, both for DSWC and for Africa University.  Bishop Yemba led the order of dedication, and then there were responses by Dr. Peter Fasan, Dean of the Faculty of Health Sciences, and Ms. Chipo Kamuti, representing the students in Health Sciences.

Part of the Africa University Choir performing

 

The chapel during the dedication ceremony

Mr. Joel Huffman speaking at the ceremony



Mrs. Huffman talking with one of my graduate students

The rest of the day was celebrated with tours of the Health Sciences building and the agricultural programs of Africa University, which emphasize teaching students to develop sustainable commercial farming enterprises in their local areas. 



Mr. Larry Kies teaching us about agricultural programs.



In the evening, there was a cultural night for the guests of DSWC at the university, with a variety of African music and dancing.  It would’ve been great to get photos, but the lighting wasn’t good, and my camera has limited capabilities in low light.  My favorite was a dance by a half dozen men from the East African Student Association.  They did a dance that’s a re-enactment of their rites initiating a boy into manhood, which includes circumcision for them.  At the end of the dance, they all helped the newly made man off the stage, and he was walking with the wide-legged stance you’d expect if he’d actually been cut.  All of the dancing was wonderful, and the costumes were spectacular.



Things that Creep, Slither and Buzz in the Night

There are all sorts of interesting lizards, snakes and insects here in Zimbabwe!  I have a family of lizards, each less than two inches long and a very plain brown, who live in the valance (what a fancy word—if only you could see it!) of my curtains.  They’ve never touched my food, so I figure they eat some of the insects that are around.  From my point of view there are too many insects, so that’s good.  There’s a fairly large lizard (I’d guess most of a foot long) living in the yard below my apartment.  I can see him moving from the third floor, and most of you know that eyesight is not a strength of mine, so I figure s/he’s about a foot long.  I’ve tried to get a closer look by walking through the grass, but this critter is shy, and immediately goes down one of several holes s/he’s dug in the lawn, so I’ve never had a good look.  There are 3 or 4 other varieties of lizard somewhere between these two in size.  All are a bit timid, though there’s one kind out by the front gate that I see regularly and can get close to.

 Now, let me tell you about the snakes.  So far I haven’t seen one, but I’ve heard some great snake stories I’d like to share with you.  The first is that a visiting faculty member who is staying in the farmhouse (the original AU building) is interested in snakes, and has asked the night watchmen to rouse him whenever they see one.  He then rouses everyone staying at the farmhouse to go help him catch the snake so he can see what species it is, record its weight and length, etc.  There’s a hen house nearby and boa constrictors like eggs (and probably chickens), so there have been several middle-of-the-night escapades there to capture boas.  I’m glad I don’t live at the farmhouse.  I don’t think I’d mind the snakes (as long as they’re boas) as much as the lost sleep.

Our lab scientist, Wietske, tells of coming into the laboratory one day and finding a black mamba.  If there’s one snake I’d never like to run across, this would be my candidate!  If one bites you, I understand life expectancy is figured in minutes, not in hours.  She didn’t know what to do about the black mamba, so she called security.  Some guards came down and started throwing rocks at the snake.  This only made the snake angry, and the rocks were breaking laboratory glassware, so Wietska sent the guards away and managed to open a window, through which the snake helpfully went.  The only problem is that the snake didn’t go down to the ground, but up to the rafters.  It’s probably happily living there to this day.  I don’t go to that building if I can help it.

Outside of, and sometime in, the Health Sciences building there’re some creepy crawlies that are either centipedes or millipedes, about six inches long and very black.  I keep meaning to try to find a glass jar or take a glass so I can catch one and see how many legs it has per segment, but so far I haven’t managed.

I've seen a wide variety of insects.  There are some pretty butterflies and a large number of kinds

of moths, some of which are quite attractive.  One of my favorites has a wingspan no more than an inch and is a dark green.  It would be practically impossible to see if it were sitting on a leaf.  I have lots of moths in my apartment, since it isn’t exactly air tight.  They come in, as all moths seem to, when I have the light on in the evening.

 Both my apartment and office have occasional wasps or hornets that come in through open windows, but they’ve never bothered me and soon find the windows and fly out again.  My apartment is also home to “white ants” (termites), various smaller insects that fly, and an occasional cockroach that’s bigger than any I’ve seen in a long time.  Most of the insects seem to be passing through, but there’re several that would like to take up residence in my garbage can.  I have to keep all food in sealed containers, and I keep some rather strange things (like flour) in the refrigerator so that nothing can chew through a plastic bag to get to it.  Particularly annoying are a couple of species of very small insects that seem to like to crawl up and bite my ankles when I’m sitting in the evening.  Their bites don’t itch and don’t leave any welts, but I slap at these a lot.  Once my light is out, a variety of insects that have been happily cruising in and out all evening seem to target me for their attention.  It isn’t at all unusual for me to kill 8 or 10 that are buzzing around me before I go to sleep. 

 I’ve seen and killed only two mosquitoes in the whole time I’ve been here, but I occasionally have had a mosquito bite me during the night.  I’m glad I’m taking an antimalarial drug so I don’t have to worry about these.  A mosquito net would be very uncomfortable during this season, when I often go to sleep in a room that’s around 80 degrees.

A Refugee Story

Today one of my undergraduate students came to my office, and wanted to tell me a little about himself.  In class I had mentioned visiting a refugee camp in Nablus, and said he thought I might understand his story.

He is originally from the Democratic Republic of Congo (DRC).  In 2007, he and his wife fled after she was “violated” by soldiers of one faction of the fighting that was going on at that time.  He explained to me that if it was known in the community that a woman had been raped by soldiers, her husband’s choice was either to divorce her or to leave with her.  He and his wife first went to the Union of South Africa, but there experienced what he would only describe as “xenophobia.”  In 2009 they came to Zimbabwe, and settled into a refugee camp in the southern part of Zimbabwe.  This camp, which currently houses about 1000 families from a variety of other African Countries, is run under the auspices of the United Nations.  He described a situation in which 40- 50 families might be housed in one large building without any privacy to speak of.  In the past, a full month’s food rations per adult were: 10 kg maize, 2 kg rice, 2 kg beans, 1 kg sugar, and .75 liter cooking oil.  In January, the rations were cut in half, and as of February, there is no money for rations, according to this student.

The student had been in medical school in DRC before he and his wife fled.  He found a benefactor while in the refugee camp in Zimbabwe who is paying his tuition, room and board at Africa University. (God is with him—what is the likelihood of that!)  He struggles to find enough money to make copies needed for classes.  He has looked unsuccessfully for part-time work in Mutare.  He is separated from his wife (now pregnant) and 2-year-old child.  They are 3-4 hours away by motor vehicle, but by bus the round trip would cost close to $50, which is prohibitive for him.  He sees them only when he can find a ride for the university’s extended holidays. The student is in an undergraduate program which will lead to a job running a small reproductive health clinic somewhere in Zimbabwe, and he plans to settle here.  He says his father was killed in the conflict in DRC, and he has no idea where his mother, brother and other relatives are, if they survived.  He is very serious about his studies, and does well in my class.  He hides his refugee status from the other students, even the others from DRC, because there is stigma attached to that which he fears would be harmful to his chances of success.

Health Issues in Zimbabwe

I haven’t been in Zimbabwe very long, but I already have a feel for how frustrating it is to deal with the medical system.  (I hope I stay healthy while I’m here!)  I thought I would give you a few examples:  

• A colleague was called because one of the boarding school students she supports financially had been taken to the hospital with a high fever.  It turned out to be a simple infection, but the hospital didn’t have a basic antibiotic that was needed to treat it, so my colleague ended up getting the medication in Harare and taking it to the hospital the next day.
• Monday of last week, a 57-year-old woman went to her local health clinic with a high fever.  The staff wanted to test her for malaria, but didn’t have a quick test kit, so they sent her home.  The next evening she was taken by family to the nearest hospital because she was much worse.  There they tested her for malaria, got the positive result, and were about to start an IV treatment when she died.
•  A colleague who trains lab technicians to do microscopic examination of urine, stools, etc. for diagnostic purposes went to a nearby high school in a relatively rural area and asked to get urine samples from students who have observable blood in their urine so that her students could practice looking for schistosomiasis, a parasitic condition that often develops into a chronic illness that can damage internal organs and, in children, impair growth and cognitive development.  More than half of the high school students asked acknowledged having blood in their urine, and we can only expect a higher prevalence in elementary school.  She’s now trying to find money to get the medications needed to treat these students.
• A pregnant student came to the attention of faculty because she was having fainting spells.  Her hemoglobin was checked, and was 6 (11 is the bottom of the normal range, if I remember correctly).  Then began a two-day search for a bottle of iron (ferrous sulfate) to treat her anemia.  Someone finally found an unopened bottle which was outdated early in 2010, and she is taking that in hopes that it is still good enough to help her condition.

It must be very frustrating to everyone, both patients and staff, to work in a system without basic necessities.  There is no early detection with simple tests like Pap smears, and conditions that are not debilitating can go on for years without being diagnosed or treated, even when the consequences of failing to treat them can include major organ failure and death.  The system is particularly overwhelmed with the needs of the population with HIV/AIDS, now estimated to infect 15% of the population and to cause over 140,000 deaths a year in Zimbabwe.   There is further fallout from the losses due to HIV/AIDS:  half the population is under the age of 15, and there are many children who are being raised by members of their extended families or in orphanages under not so good circumstances because their parents have died or been disabled by HIV/AIDS. 

Current Weather in Zimbabwe

Someone asked me what the weather is like here.  Zimbabwe has a rainy season, which runs from roughly November through March, and then is dry the rest of the year.  It doesn’t have a rain pattern like the tropics (where you can tell time by the afternoon rains).   Instead, there are mornings that start out clear and cloud up, possibly producing rain, and others that start out quite cloudy and then clear off.  Sometimes the rain is accompanied by thunder and lightning, and sometimes not.  One morning this past week driving from Mutare to AU, we encountered fog going through Christmas pass.

 On Thursday I had my second closest encounter with lightning ever.   I was hurrying across campus carrying my clean laundry, trying to get to my building before it began to rain, when there was a sudden bolt of lightning and crack of thunder that shook the ground beneath me hard—enough for me to momentarily lose balance.  I was quite near a building and ran for it, assuming (though I’m not sure accurately) that it would have been built with a grounding device.  There was kind of a sizzling feeling and sound when the lightning hit, and my hair stood on end.  The good news I wasn’t hurt at all, and was on my way after taking a few deep breaths!

The temperatures are variable.  We have occasional hot and humid days; I’d guess the highs then to be in the low 90’s Fahrenheit.  More days are probably in the low to mid 80’s and somewhat humid. After sunset it seems to cool off pretty quickly in the evenings most of the time.  Only the first night I was here did it seem uncomfortably warm when I went to bed.   (That night I was so jet lagged I slept anyway!)  It’s often in the mid-70’s in my apartment when I go to bed, and a few degrees cooler outside.  Last night we had a good rain, and rains tend to produce cooler weather for at least ½ a day, so it was a little chilly outside when I woke up this morning.  Most mornings are cool but not chilly.

I guess overall, the weather here seems a lot like living in the Midwest in the summer, at least so far. 

My Academic Work at Africa University

As most of you know, I’m teaching reproductive health to graduate students working towards masters’ degrees in public health and family health to undergraduates who are in a program designed to make them managers of reproductive health clinics throughout Zimbabwe.  The need for health professionals is great.  Because the economy in Zimbabwe crashed in 2007-2008 (yes, much worse than the US’s crashed in 2009), salaries for all kinds of professional workers are quite low.  As a result more than half of the professionals trained, at least at the level of MD’s, have left the country for places that can pay them better within a few years. 

I’ve been quite impressed with the students.  I have nine masters’ level students, eight from Zimbabwe and one from Milawi.  There’s an MD who has worked in the public sector with AIDS issues for some time, who wants to be able to do a better job, three people with nursing or midwifery backgrounds, all with a lot of experience, and several people from social sciences backgrounds who have been doing interesting things like working with child protective services, the agency that investigates disease outbreaks and the National AIDS Council.  Only one of them has come straight out of an undergraduate academic program.  The age range and variety of experience in this group makes for really interesting discussions.

The sixteen students in my undergraduate course include one each from Angola and Mozambique, and about half of the rest from Zimbabwe and the other half from Democratic Republic of Congo (DRC).  For the DRC students, English is at least their third language (behind Swahili and French), which puts them at a disadvantage relative to the Zimbabwe students.  Most of the students work really hard, though.  I just gave a quiz on the anatomy and physiology of the human reproductive system, and almost all of them did really well.  My only complaint about this class is that people talk way too softly for me to hear them, much less for the rest of the class to hear them.  Almost all of them are actively participating in the class (with a little help from participation marks). 

I’m learning a lot about reproductive health in Africa.  Surprise, surprise—the continent was hardly mentioned in my masters’ program way back when.  I have to study a lot to prepare for my courses.  I teach the graduate students for two hours each on Mondays and Thursdays and the undergraduates for two hours each on Tuesdays and Wednesdays.  I’ve been trying to get started on course preparation over the weekends, but then I have Bible study on Mondays, so by Tuesdays I’m barely ahead of the students.  Tonight is Thursday night, and I’m taking the evening off, since I don’t teach tomorrow.

I have two other assignments.  One is that I’m team teaching a course about trauma in the masters’ program in Child and Family Psychology.  That will begin this Saturday.  That degree program is still working on its inaugural class.  The seminar will have five or six students.  They all hold full-time jobs, many of them in Harare (more than 2 hrs. away by car).  They come down on Saturdays weekly and have classes from 8-10, 10-12, 1-3 and 3-5.  That doesn’t make enough contact hours, so they also gather for one Friday a month on the same schedule.  Their classes are starting late this semester because they were late starting in the fall and took finals after the semester was officially over, which resulted in the recording of their grades being held up.  They couldn’t register for spring semester courses until that happened.  I don’t know if they’ll add some Fridays or Sundays to make up the time or whether this semester will run late again.

The other assignment is helping a senior student in the nursing program with her research project.  All the students in that group presented their research proposals during the first week I was here, and had difficulty with that task.  They’re all on assignment (internship) scattered around the province, so they’re not very accessible at this point.  I’m doing most of my supervision via email with the student I’ve been assigned.  Her project is looking at attitudinal factors associated with the low rate of hospital deliveries in the jurisdiction of her assignment.  It’s in suburban Mutare, and only 29-30% of women delivered in the hospital for the years 2010 and 2011.  The infant mortality rate is very high, so it’s important to understand why people avoid the medical care, which is free.  I know one factor from discussions with some of my colleagues: it is a Shona tradition to deliver the first baby in the home of the maternal grandmother, even if that means traveling to a rural area and delivering without benefit of skilled medical assistance.  Needless to say, maternal mortality is also very high.

My greatest frustration with the work I’m doing is that I have internet access on average about 2 hours a day, usually first thing in the morning.  Today we figured out that I didn’t have access when everyone around me did, so I plan to go to IT tomorrow and try to see if they can improve that.  The university computer in my office doesn’t work at all, and there must be a setting on my notepad that is goofing me up.