News flash: men prefer having sex to raising healthy kids!

Or, at least in Malawi, some men do. In a report a few weeks ago from the Daily Times, which I read bemusedly (humor over tears is my frequent approach here), the practice of spraying DDT in homes for malaria prevention was discouraged because it led to reduced sex drive among men.

There is a current ban on DDT in Malawi, so this article is rather mute. However, I guess some men got wind that health experts are trying to lift the ban as DDT has been shown highly effective in reducing malaria when sprayed (in low concentrations) on the walls of homes - check out an older CDC article here.

Malaria is a huge problem here. I don't know how many men die of reduced sex drive, but an estimated 12,000 people die of malaria every year in Malawi, most of them children.

Now, if you reject DDT use for its destruction of the environment or its general toxicity, I am fine with that. But, if you refuse to use DDT to fight malaria because you might have libido issues, I am slightly sickened.

And, that is why I need a vacation (and why I eat Pepto like candy).

Namibia, here we come! Happy holidays and Happy New Year to everyone!

One step forward, two steps back

One of Malawi’s (and the world’s) toughest obstacles in the fight against AIDS is that some HIV-infected individuals do not want treatment or seek treatment too late. The reasons for not wanting, or delaying, treatment are of course complex and multifaceted. I do not pretend to understand them all. But, some of the most common reasons are: 1) denial about being infected even after a positive test; 2) fear of disclosing HIV status to someone (you MUST bring a guardian to get HIV treatment in Malawi - more on this later); 3) lack of desire to take life-long meds; 4) believing that you only have to start meds when you are really sick – a time for some that is always in the future. There are hundreds of other reasons why people do not start, or remain, on treatment.

Still, a man died from TB today in the hospital –his lungs were so bad that people described the Xray as “looking like corn in the lungs.” He had started TB treatment 3 days previous. He also had AIDS but was not yet on treatment. He had tested HIV positive months, if not years, ago. Clearly, it was too late by the time he got treatment.

This situation is not unusual -- it happens dozens of times every day -- and almost 70% of people in Malawi with TB are also HIV infected. However, this case was different: the deceased man’s brother runs an HIV clinic in the capital.

Now, if even the close family members of Malawi’s best trained and most motivated AIDS clinicians can die from accessing treatment too late, what does that mean for others? I know it is not the clinician’s fault in any way. But, in the abstract, this shows that the challenge of getting people into treatment, and into treatment on time, is not as simple as increasing knowledge about HIV and TB or improving access to care. As all of us in this profession understand, we have a long way to go in winning this battle. Sometimes, it feels like the war has barely started.

Puppies 1, Horton 0

And they call it, "Puppy Love"....

What NOT to do: Tips for interviewing in Malawi

Yesterday, I helped interviewer 4 candidates for an upper level financial management position at my organization. The evaluation panel consisted of 3 people: the Executive Director, the head of the Board of Trustees, and me. After 7 hours of torture, and one possible candidate, I have some tips for future interviewees:

1. Please spell check your cover letter and resume. If I am editing while reviewing your materials, I am clearly distracted from appreciating the contents.

2. Please come on time. 30 minutes late for a casual dinner? Fine. For an interview? Forget the job and go home. I know you did not tell your boss you were looking for a job, but can’t you make up a funeral or a bank errand and get here on time?

3. On the flip side, please do not come 3 hours early. This seems over eager and desperate.

4. Please dress for an interview. I know that folks here are poor. But, if you want to be in charge of millions of dollars, you have to look like you don’t immediately need money for work clothes. Wearing a pink striped shirt, red tie, and jacket made for someone 100kg larger than you will not inspire confidence from our donors.

5. Please do your homework. If you are asked what you know about the organization, please do more than read the Mission Statement off the wall in front of you. Please at least peruse the website. Please do not say, “I don’t know much.”

6. Please limit the length of your answers; be concise. This is especially important when the interviewer says, “please tell me briefly……”. The 15 minute regurgitation, verbatim, of your resume is not appreciated.

7. Please speak up. There are only 4 of us in the room, seated around a small table. If I cannot hear you, I will make up what you are saying, and you will not like it.

8. Please know the job you are interviewing for. When you give lengthy examples of your experience in agriculture and church organizing as the reason we should hire you as our finance manager, you are not doing yourself a favor.

9. Please refrain from drawing repeated attention to your distance education MBA from Somalia. I think I can print out that same certificate myself.

10. And, when someone asks you for your salary requirements, it is not advisable to say, “the higher the better.”

There are two places like home

Ever feel like life’s roller coaster is moving faster than the speed of light? I could swear that I was just in the States for a visit, but it also just feels like a sweet, sweet dream. Did I actually get to see my friends and family? Did Red dog and I snuggle for 9 solid nights? Did I really eat all that??? Seems it happened, and I have some photos to prove it.

Despite the 67 combined hours in transit, it was blissful to be home. I got in some good time with my STL friends, spent lots of quality couch time with my dog and family, and even managed to get some exercise between mouthfuls by playing Wii, ping pong, and jump rope with my nieces and nephew. I received an original tri-color masterpiece from my 3-year old niece, and my 97-year-old grandma was able to enjoy the holidays with us all. My mom and I managed to avoid almost all seasonal craziness by shopping only (yet repeatedly) at the 3 local grocery stores and Target, and my dad led us in our annual pilgrimage to a labor art show. Jon joined me in STL after spending some time in VA and NC, so we got some (not too bored) board gaming in with the whole family to boot. I even played 3 whole games with barely a pout. A new record!

For Thanksgiving, we had snow! Eating those lovely white flakes was calorie free and delightful. Dinner, also delightful, was slightly sturdier. I had Quorn meatless cutlets, roasted root vegetables, vegetarian dressing, some asparagus, and apple pie. Snicker, you may, but it was heaven to me. Jon devoured the meaty treats with the rest of the carnivorous family. There was plenty of wine and Wild Turkey (not kidding) to go around. Red enjoyed her role at cleanup, just resting her head on my grandma's lap, ever hopeful for something dropped. Other edible excursions included multiple Thai food stops, Vietnamese, and BBQ for Jon (while I ate sweet potato fries and Diet. Dr. Pepper). You know it’s love when a vegetarian suffers a meat eater dining on ribs… extra credit for that!

Then, with bellies full, and bags stuffed to the gills with more food and some toiletries, we left STL for our adventure back to Malawi. With a brief stopover to see my favorite roommate in Johannesburg, we were back home in Malawi. Greeted by a secure house and well cared for puppies, it felt good to be home. It also felt great to be home in STL just a few days ago. Which one is really “home”? I’ll take both, thank you.

Red, sweet Red

After 36 hours in transit (an extra 8 in ATL, thanks Delta....), I'm home. Or, my body is home. My brain is slowly trying to catch up to whatever time zone I am in. My family is happy to see me; Red dog slept peacefully next to my bed. So far, I've eaten: a quart of slaw, a giant bowl of 3 bean salad, Kashi cereal, cherry yogurt, Chex mix, Shabbat cupcakes, veggie lasagna, a bag of spinach, goat cheese, Diet Dr. Pepper, baked potato chips, and some Hot Tamales. I took two hot showers.

It's good to be home.

A much-needed injection of dorky bliss

So, I know that monitoring and evaluation (M&E) are not thrilling words, and I know that I might well be my only reader who actually finds M&E interesting. That’s ok: It’s my job, likely not yours. Still, I think that everyone can understand the nerdy elation that stems from conducting a highly successful workshop. And, yesterday (Saturday), feeling sick as a dog and medicated to the nines, I led a 10-hour M&E seminar for the managers, coordinators, and senior staff at work. Not only did all 20 people who were suppose to show up actually show up on a weekend at 7am, but they even worked through their tea and lunch breaks to complete their tasks by 5pm. Granted, they were bribed with their usual “allowance” (fodder for another post); mollified with donuts; and numbed by constant provision of candy, but they participated actively, debated with each other, and provided amazingly constructive comments throughout the long day. Even the Executive Director noted that the day far exceeded his expectations (harrumph and yippee!)! End result: departmental planning frameworks and a forward-thinking strategic plan for 2010-2013. Plus, their end of the meeting wrap-up session comments made me feel like I am actually making a difference. Paraphrased, people remarked things like:

“It helps us take pride and ownership in our work to participate in a planning day”

“It helps me feel accountable for my work successes and failures”

“It was nice to help plan our M&E activities versus having our M&E activities planned for us”

“We really learned a lot and got to put your weekly M&E workshops into practice (special rush of happiness and pride!)”

I know this may seem like small potatoes, but this really does set my workplace and my work colleagues apart from 99% of all other health workers here in Malawi. Now, I can go home for Thanksgiving and be excited to come back to Malawi for the next 17^th months. International health folks: you know this is a coup! Hallelujah! I needed it.

On surviving the 7th month slump

In recent days, several of my local expat friends asked me how long I had been here. I wondered why that question kept popping up? On each occasion, I noted that I had been here 7 months (!!!). My inquisitors responded with something like, “ahhhh, the 6 month slump.”

What? Is there something new on my face (aside from the pimples from the heat and dust storms)? Do I ooze a well recognized scent of frustration (other than the sweaty smell of working in a hot office with 9 other people)? Am I holding myself in a new way (other than to accommodate the added pounds of the carb-infested Malawi diet and sedentary lifestyle of office work)? I wondered. I soul searched. I napped on it.

As it turns out, 6 months is an expat milestone of some sort. It is about the time the excitement and elation of being in a new place wears thin and the successful glow of conquering all the settling in tasks begins to fade -- leaving a dull, puffy-eyed look of exhaustion and disconsolation. The work becomes overwhelming (find $40,000 or people lose their jobs); the thrill of early work coups diminishes in the face of all the barriers to success (how to treat 10,000 new people on ART without any new staff); the sadness of life with Diet Coke becomes overwhelming (nationwide shortage).

Still, I love it here. I love my work, and I make sure to remember (or have Jon remind me) that all the little successes will eventually lead to some tiny piece of sustainable progress (still optimistic! Still idealistic!). In the mean time, I’m taking extra time for foster puppy licks; finding giggles in the street signs (read closely – first column); enjoying the flame trees in bloom in our yard (and in the country); trying to document the amazing birds that play in our birdbath (when the puppies are not bathing in it); and taking moments to watch blue-headed iguanas hang out in our trees. Jon and I recently commissioned some tree-chairs (like upright hammocks) to put in the yard – forcing me, we hope, to spend time just swinging away. Between a little blog therapy (thanks!) an upcoming vacation (Red dog: here I come!), things are already well on their way to an 8-month upswing.

Service (dis)integration...

I thought you all would like to see the complexities involved in trying to treat people who are infected with both HIV and TB at our clinic. This is, in theory, how a patient would “flow” through our care model. It was actually hysterical to make this drawing as a participatory mapping exercise: everyone in the room (providers, data monitors, managers) could not help but laugh at the absurdity. No wonder only 66% of co-infected people actually get treatment for both, and that is at the best clinic in the country! In rural clinics, I would think it is much, much worse. Still, getting it down is step one in making it better. Wish us luck!