One, two, three strikes…you’re out!

Out of condoms, out of HIV test kits, out of 2^nd line AIDS treatment…

At the moment, 6 shipping containers – literally millions of condoms – are sitting at the airport here in Lilongwe. They were donated by the Global Fund, as always around here, but they have not yet been distributed. They are just accruing airport charges that no one wants to pay. In fact, 1 of our two clinics was out all last week. Yes: no condoms in a clinic for HIV+ patients! The condoms are waiting for someone or some organization to come distribute them now that the Central Medical Stores (CMS) is temporarily shut down for a top-to-bottom reorganization and rebuilding process (read: corruption reduction). The decision to revamp CMS is great; the abyss left in its wake is terrible for the health system.

Compounding, or complementing, the dearth of condoms is a severe, nation-wide shortage of HIV test kits. See problem source, above. I guess if you can’t prevent infection, why test for it anyway? In an effort to help others laugh (uncomfortably) and not cry, I’ll tell a quick anecdote. Last week, a bigwig from the World Health Organization (WHO) came to visit the antenatal care center next door, Bwaila Maternity – the largest labor and delivery center in the country. We went with them to show the linkage to HIV care. The Bwaila team was showing the WHO delegation how they do HIV testing: a group education session, lining the women up conveyer-belt style for the HIV finger-prick test, and then individual post test counseling for results. The WHO folks were very impressed until they noticed that the women were holding cardboard strips rather than HIV tests. When asked why, the Bwaila team responded, “we wanted to show you what we do when we have test kits, but these days we have none.” So, they just line the women up for their tests, and then just put them back in line. Arghhhhh.

One last thing: there is also a severe shortage of 2^nd line HIV treatment drugs in the country – the drugs used to treat people who had severe side effects to the 1^st line drugs or who did not get better on those simpler treatments. Same ordering and distribution problems above. This leaves the sickest patients temporarily without drugs or temporarily (we hope very temporarily) back on the 1^st line drugs they failed previously. Because our clinic was one of the first clinics to have drugs back in 2002, we have a disproportionate number of patients on these later-stage medications. Our nurses and clinicians have to ask patients to come back next week (and the next) to get drugs. This week, a former head of the defunct logistics team (above) had the gall to make a personal plea to the director of my clinic to beg for 2^nd line drugs for a family member. Of course, there are no extra meds just sitting around and no personal favors. That’s karma for that guy, plain and simple.

To balance the news from the trenches, Jon and I have a big group of friends headed over tonight for a potluck. Do you know what turns a stressful week into a great weekend? MARGARITAS! Ole!

On finding our happy place(s)

Of the things we miss here in Malawi, relaxing coffee shops and inviting restaurants are on the list. Recently, we’ve come across two places to fill this gnawing gap. The first, Don Brioni, is an old Lilongwe institution right down the street that we somehow overlooked. Not only do they have great soup, delicious garlic bread, and tasty hummus, but the friendly owner and the quiet front porch make it a perfect date night. Who knew? Not us until now apparently....

The second, Ama Koffe, is a new coffee shop in the fancy garden/shopping complex, 4 Seasons. We were so excited by our Saturday morning find, that we actually had to take photos. Lovely tables with real flowers inset in glass; comfortable chairs, wi-fi, coffee served with homemade sugar cookies, a sweet stray dog to befriend, and flowers everywhere – it’s right next to the nursery. They serve fresh, hearty salads with more than iceberg lettuce, and a roasted vegetable sandwich that almost made me cry with glee. Plus, we ate the most delicious chocolate cake we have had in over a year! Honestly, it’s these moments that make us thankful to be here and thankful for places that make here feel more like home.

What's in the yard? A triangle-headed snake!

Bonus points for anyone who can identify what type of snake this is. This is a baby one, gray in color with red eyes. It got into this menacing striking pose when we approached it (but I still had to take its photo, right?). Identification anyone? Someone will come visit, right? We are certain this is the only snake in the yard...Should I go back to posting photos of the puppies?

TGIF!

Formula to turn a bad week into a good weekend = wine+ cheese+ crackers (+bug spray to enable enjoyment of outdoor time on porch with said ingredients)!

Reflections and rants on my one year anniversary with Malawi

Is this an occasion for celebration or consternation? That is the question! As I swiftly approach my 1-year mark in Malawi and at the HIV/AIDS clinic in which I work, I’ve been taking some time to reflect. Actually, the malaise that settled around me like warm blanket forced me into this meditative state. In a vicious cycle reminiscent of Groundhog Day, or like a bad tune (Les Mis’ “On My Own” anyone?), I have been having these recurring thoughts: Why I am here? Why do I work here? Why do I stay in a country and in a career field that is always a mix, but never a balance, of pleasure and pain? I haven’t even been writing in my Oprah-circa 1996-inspired gratitude journal (the horror (on many levels))! To exorcize these demons, I’m writing some of my thoughts down here. It’s not so much to soothe myself as to give my thoughts a place to reside other than on constant-repeat cycle in my head.

To be clear: I love what I do. But my work place has its consistent challenges. First, as I’ve noted before, sharing an office with anywhere from 3 to 8 Malawian colleagues means no head bashing stress release, no mental-health skype calls, no secret shopping during work hours, no naps! Plus, I’ve come to recognize that although I value working in a foreign NGO, not having any other expat colleagues (other than Jon) is really limiting as far as enjoying work and feeling like there are people with whom to commiserate. [Note to self: I will not work in an organization overseas again if I am the only expat staff: I require outlets for sarcasm and comic relief!]. Unlike graduate school or my previous jobs , there is no flexibility. Everyone here figuratively clocks in and out, in part due to a previous employee who was “working from home” in Zanzibar. To rub salt (and oil) in those wounds, I eat the same lunch every day at the clinic “cafeteria”: greasy rice, greasy greens, fried cabbage, and 2 boiled eggs. I stare sadly at my plate every day before applying copious amounts of hot sauce and mindlessly chewing…

The hard truth is that this job can often feel thankless and stagnant. My boss and colleagues sometimes thank me and appreciate my work. Things are also improving, albeit at a glacial (sustainable?) pace. But, the reality is that as an “adviser”, I cannot (and should not) take credit for positive changes. To the contrary, it is my job to build capacity (i.e., not take credit) and stand in the back while others move forward. It is gratifying to see improvements and know that I “facilitated”, “motivated”, “encouraged”, and “other buzz word-ed” these changes. But, sometimes (frequently) it’s like I am a ghost writer or speech writer: I have literally heard my colleagues say something in a meeting repeated, almost verbatim, from something I previously suggested. Yes, yes: imitation is the highest form of flattery, and blah blah blah. But, it’s tough (and contrary to my nature, maybe human nature) to be a technical advisor, and not get that sense of accomplishment that comes from putting your name on something or leading a successful project start to finish.

And, there continue to be infuriating things about working in HIV in Malawi. Although they allocate about 12% of their total budget for health (not too shabby), only 1% goes to HIV-related programs (for 12% HIV prevalence). The other HUNDREDS OF MILLIONS of dollars needed to care for over 300,000 people on antiretrovirals comes from donors like you/we tax-paying Americans and our European friends. The result of this generosity is a feeling, a nagging feeling, of growing dependency and entitlement, rather than pride resulting from hoped for increases in Malawian capacity and quality of care. As an example of the unexpected gains in inefficiency and graft, the Malawi national drug storage facility (Central Medical Stores) is a laughing stock: their inability to manage or distribute any drug led the donor community to create an entirely parallel system of HIV-related commodity distribution (all AIDS drugs, malaria nets, etc.). This second system goes against the golden rule of development: Do strengthen existing systems; do not create parallel systems! Of course, it is hard to manage drugs when the apparent purpose of Central Medical Stores was to fill the coffers of its directors! I cannot help but feel dejected by the unknown, but significant, proportion of folks who work in HIV to have a donor-funded car, a donor-funded training, a donor-funded job. It’s like my colleagues and I put all our 10 fingers in the dike, but 8,257 holes remain leaky with hundreds of folks just watching (and waiting for someone to pay them, aka “train them,” to help)! Still, thankfully, mercifully, the majority of our work colleagues actually want to be do their jobs well and the organization, as a whole, does an excellent job. Hallelujah for a reminder of what quality services, in really resource constrained settings, can accomplish! [repeat to myself, repeat to myself].

It sounds unpleasant, but I’ve made some lemonade out of these lemons. Earplugs are my new best friend and lifesaver! Work hours from 7:30 to 4pm makes mornings early, but late afternoons at home with Jon on the porch [wine in hand, fresh tomatoes, balsamic vinegar, and crackers in mouth] are wonderful. And, if I really think about why I took this job, when else am I going to be completely immersed in a foreign NGO, gaining remarkable and under-appreciated insight into AIDS in sub-Saharan Africa? Maybe I will value working in my pajamas more when I get home, therefore enjoying my next job? In other encouraging steps, not only have I learned to be audibly enthusiastic about exchanging eggs for beans when available (YES! Bean Day!), but the cafeteria recently started making me bacteria-laden fresh salad and boiled greens – a work coup with a moderate side of intestinal distress. I also found a way to diplomatically get myself included as an author onto several of those papers and presentations I “supported”, and I spearheaded 3 projects which I firmly believe will leave the organization better than when I found it. Yeah for relatively-sustainable change!

Those of you reading, or still reading, might think me depressed. I actually think not (and it is not denial). I think that it is desperation. Desperate to get over the 1-year hump. Desperate to make new friends to fill the void left as old friends move to new posts. Desperate to make an impact and not feel like these 2 years are for naught. And the thing is: I do like it here, I do love my work, I do make friends easily, and I do actually think that I am “fostering positive change” (bonus jargon points!). But, I also do hysterically, ravenously, need a vacation before I chew my nails down to the knuckle with angst. April 30^th cannot come quickly enough! I’ll see many of you during our 2 week Bar Mitzvah/Peace Corps reunion/wedding (not ours) whirlwind of a USA visit. Others, 2012 is just around the corner! And, some days (like today) it cannot come soon enough…

What's in the yard? Lovely moths!

This morning, this gorgeous moth greeted me on my car door. It is/was stunning and about the size of an adult fist with a hairy back. It would not move voluntarily off my car door even when I less-than-gently tried to brush it off. Still, when I finally gave it a more forceful shove, it landed on the ground right in front of the ravenous puppies. Not good. I fought them off swiftly enough to rescue the less than grateful moth, and I placed the fluttering bug nicely on the windowsill. I wonder if it will be alive when I get back home? Regardless, its beauty is immortalized here. Enjoy!

Jon and Peanut's fight

For those of you who know Jon, you know he loves board games -- the fancy, intricate, detailed European kinds with the unique pieces and price tags to match. Also, for those of you who know Jon, you know he likes, but does not love, dogs. Or, he does not love dogs as I love dogs.

This morning tried his patience. Sorry about that, Buddha.Peanut escaped, surprisingly, with barely a muffled, "bad dog." Jon says he was not that upset. I say what saved her was timing: it was 7:15 and we were late for work. Plus, who could yell at her???
But, Peanut be warned: if this happens again, it will not end well for you. That sweet face can only protect you so well...

What’s in the yard? You likely don’t want to know…

Big hairy spiders! These are very unlike the kind that we all loved in Charlotte’s web. I’ve seen these around a few times, but I finally caught one on camera. Don’t worry: I got close and lived to tell the tale. Come visit!

On living brownish green

Malawi poses some acute challenges to my desire to live a more green life and have a smaller impact on the planet. Sometimes I can silence my disdain or minimize my vitriol about things like black smoke pouring out of vehicles and plastic bags littering roads and walking paths (although, if you asked Jon, I am not very good about holding back comment). When Jon and I talk about these things, we often wind up exchanging all sorts of semi-patronizing, Western thoughts about development, discussing the leisure time requirements for an environmental movement to grow, and lamenting (for me) the desire for many to adopt the same type of consumer and convenience lifestyle perfected in many developed countries, most notably my own. I can almost feel some of you stop reading… But, wait! A quick look at two photos shows these issues more acutely.

As an example of my brown life, I went out for Indian food last night, and asked to have the leftovers boxed. I should have known better. The contents came individually bagged in plastic, then placed in a plastic box, and then put in a plastic bag. I almost died. All I could do was at least return the plastic bag, much to the mortification of my table mates.

In contrast, Malawi does have ingenious indigenous solutions to a greener lifestyle. While returning from a conference at the lake last week, my colleagues wanted to bring back some fish. The thought of 4 hours in a hot car with dead fish and no cooler almost made me gag. But, putting each person’s fresh fish in plastic bags, as the seller suggested (for my benefit, he said), would be equally (ok, not *equally*) distressing. So, what to do? Hang the fish from the car’s sideview mirrors using reeds! Did they only suggest the plastic to my friends because I was in the car??? They seemed like experts on the window hanging, so I can only presume that they wanted the extra $.30 for the plastic. Arghh.

So, that’s a little insight into the greenish brown of life around here.

ps: the car still stank