A new culture?

One of the advantages that I saw in coming to Mozambique for my practicum was the fact that I was already familiar with the culture, which would mean less time spent figuring out how things work and more time getting work done. And although my familiarity with Mozambique and Mozambicans has (I think) limited the amount of stress and confusion that I might have experienced during this type of transition, my time here has not been without a few surprises.

For one thing, I have settled into a Mozambique that is quite different from the one I lived in as a Peace Corps volunteer. I am now in the capital. My Mozambican colleagues go to South Africa on the weekends to buy cars and spend the same amount of money to get into a discoteca on a Friday night that I used to spend on food for three weeks. Granted, many things are the same – and it has been easy for me to slip back into old habits like greeting people with a kiss on each cheek and always having some way to keep myself entertained while on African time – but people, we are definitely not in the village anymore. And it is a bit of an adjustment.

Another interesting thing about living in the capital is that there are a lot of other foreigners around. As I walk to and from work every day I see cafes full of people who are clearly not Mozambican enjoying a coffee or a meal. The point being that – although I do continue to stand out (the blond hair and the fact that I walk or use public transport do not help), it’s not in the same way as it used to be. People who live in Maputo are used to seeing foreigners, and many of them are used to interacting with them. Which means that my interactions with Mozambicans have shifted from the innocent curiosity of villagers who may have never seen or met a foreigner, to a much more direct and sometimes more aggressive approach.

But as I mentioned before, many familiar aspects of Mozambican culture remain. It is still easier to befriend men than woman (those who are my age are married with children and thus have responsibilities in the home), there is still always a mid-morning tea break, and men still don’t care whether I’m married or have a boyfriend....they are apaixonado after half an hour and are more than willing to be my man on the side :)

While I am enjoying immensely my time in Maputo, loving the culture I knew and learning new sides to it, I am starting to feel homesick for the village and my old province of Inhambane. I have been here almost two months now and have not yet gone back to visit.....and it is starting to make me a little crazy. With a three day weekend fast approaching, I am hoping take a little trip and spend some time revisiting the culture and lifestyle of the village.

Some of my favorite aspects of Mozambican culture (whether in the city or the village)....

• You can’t ever get lost. I mean, technically of course you can get lost, but all you have to do is ask someone and they will either drop what they are doing to accompany you to your destination or, if for some reason they can’t do that, they will find someone else who can.
• Greetings and saying goodbye are very important, and take up a ridiculous amount of time. People greet one another with two kisses (one on each cheek) and a good amount of small talk before actually launching into the subject at hand. As for goodbyes, it is essential that if you are leaving a room, you say goodbye to each person individually before leaving. This can sometimes get frustrating, but once you get used to planning on the goodbye process taking 15 or 20 minutes, it somehow becomes really nice.
• People tell it like it is. There is no such thing as political correctness (unless, of course, you are actually talking about politics or important political figures, in which case there is a right thing and a wrong thing to say). Now, experiencing this aspect of Mozambican culture isn’t always pleasant – for example, when one person after another happily comments on the fact that you are getting fat (which to them is a good thing and is something I am trying to avoid this time around here in Mozambique) – but there is something refreshing about not having to tip-toe around reality.
• Mozambicans love to dance. And they are good at it. And they do it everywhere. Enough said.
• Mozambicans love having guests, and culture dictates that said guests must be fed. Again, enough said.

But the way, I finally posted the answers to Name that fruit :)

TARV - A description of what I actually do here

It occurs to me that I haven’t actually explained to anyone what I am doing here. I mean, I think you all know that I am completing a six-month internship that is part of my master’s program yada yada yada....but I realized the other day after receiving an email from a friend that started with, ‘so what is it exactly that you are doing in Mozambique?’, that I had kind of neglected to provide any details on my actual job. So for those of you who are wondering what public health people actually do....read on.

I am working for an organization called ICAP, the International Center for HIV/AIDS Care and Treatment Programs (yeah, so they got a little creative with which words to include in the acronym), that is supported by Columbia University. For those of you who feel like doing your own research, you can go to their website is http://www.columbia-icap.org/, where you will see that ICAP “works with host countries and other organizations, principally in sub-Saharan Africa, to build capacity for family-focused HIV/AIDS prevention, care, and treatment programs”. In Mozambique, this translates into ICAP supporting the Ministry of Health and government health centers (clinics and hospitals) in their efforts to roll out ART (Anti-Retroviral Therapy, or TARV in Portuguese). And within the ICAP-MZ team there is a group dedicated to Adherence (i.e. people taking their TARV correctly) and Psychosocial Support. This is the group that I work with.

A little background for those of you who don’t eat, breathe, and sleep public health....helping a country provide ARVs to its HIV+ citizens is no simple task. Because taking ARVs is no simple task. The pills must be taken (generally) every twelve hours (so twice a day, always at the same times), and once you start on ART, you have to continue the treatment for the rest of your life. ARVs often cause side effects, and some of the medications have dietary restrictions/requirements. And...as if all of that doesn’t make things complicated enough....you have to take 95% of your doses (correctly) for the treatment to be effective. And even then, you aren’t guaranteed that it will work – drug resistant strands of HIV are popping up all over the place that no longer respond to the more commonly used medications, making treatment that much more expensive and complicated. An important thing to note....drug resistant strains are one of consequences of people not taking their ARVs correctly. So clearly, it is very important that they do so.

And that is where we come in. Our job is to try and figure out how to improve people’s adherence levels. Also no simple task. Especially in a country where there is a terrible shortage of health care workers, a poor health care infrastructure, a huge amount of stigma associated with HIV/AIDS (to give you an idea....many people hide their HIV status from their families – including from their spouses – when they find out they are HIV+), and a health care system that was designed to treat people and sent them home (not to follow their care forever).

So what have I been doing? Most of my work thus far has revolved around two things. The first is a patient tracking and tracing system. This is part of a country-wide effort to shift the health system from one that is focused on simply treating a patient and sending them away, to one that can monitor a patient’s care and treatment over time (all of this in response to HIV/AIDS). What this tracing and tracking system tries to do is enable a clinic to know when a patient didn’t show up for a scheduled appointment (could be with a doctor, with a counselor, in the TB clinic, etc.) or to pick up their medications, identify that patient, and attempt to bring them back to the clinic by sending someone out into the community to find out why they didn’t come when they were supposed to.

As I already mentioned, this country has an enormous shortage of health care personnel. In fact, the situation is so bad that I felt the need to look up some World Health Organization statistics to give you guys an accurate picture of the problem (and if there is one thing I have learned thus far in grad school, it is the exact location of this kind of data on the internet). I’ll even make you guys a little table (heaven forbid anyone forget what a huge nerd I am while I am gone)....
**note....I wrote this in a word document originally, and I did in fact make a table. However, it didn't quite work out when I cut and pasted it onto the blog. But not to worry.....I put my table into a powerpoint document, saved it as a picture, and was able to upload it....so enjoy.
Compared to the rest of the Africa Region, Mozambique is looking pretty pathetic. And compared to the US.....well, let’s be honest....there is no comparison there. And don’t we (in the US) currently have a shortage of health care workers? Right. Point made.

With so few medical professionals in the country, I think it’s pretty obvious that you are not going to be able to send them out looking for every patient who misses an appointment. Especially when you throw in the fact that finding patients in the community is no simple task. Communities aren’t quite put together like they are in the states....people here often have no street name or house number. In fact, when patients fill out their addresses on their medical forms there is actually a big empty space for them to include “reference points to help locate your house” (like, next to the house with the big cashew tree.....or behind the methodist church......or by the barber shop that’s painted green.....you get the idea).

So who’s going to go looking for the house next to the big cashew tree or the green barber shop? HIV/AIDS activists (or peer educators). These are HIV+ patients who go through a one or two week long training that covers a variety of topics related to HIV/AIDS (from basic medical info about the disease to counseling techniques to facts about treatment, etc) and work in clinic waiting rooms with patients who have just learned their HIV status to provide them with information, answer their questions, share their own personal stories and struggles, and to listen. In clinics that have patient tracing and tracking systems up and running, these activists are also the ones that go into the community to try and recover patients who have gone missing from care and treatment. And this has implications for how the system is put together and how data are collected, as most of these activists have limited formal education and aren’t used to having to record information on spreadsheets. Throw in the lack of material resources (paper, photocopy machines, pens, etc.) and you really have to make things as simple and short as possible.

But we have to monitor this system in order to know whether or not it is working, as well as why patients are dropping out of treatment so that we can prevent that from happening in the future. Which means we have to collect data on how many people are not showing up when they are supposed to, why, if someone went to look for them, if they were found, and whether or not they came back. It’s amazing how many forms are required to collect that kind of information....as I have been discovering over the past 6 weeks. I have been working to develop the data collection instruments for this system, as well as the data collection instruments for monitoring the activities of the adherence and psychosocial support staff at the various clinics. In other words, I am now an expert at making tables in Microsoft Word and Excel (perhaps another reason for the table above).

The other major component of my work revolves around a research study that ICAP-MZ is hoping to carry out. The study is part of an advocacy effort to convince the Ministry of Health that, considering the dearth of health care professionals in this country, it behooves them to consider formalizing the use of lay people in the health care system – i.e., peer educators/activists (which thus far they have refused to do....most peer educators are supported by international NGOs). The study goal is to determine the impact that home visits by peer educators have on adherence levels among patients....i.e., if you send a peer educator to a patient’s home every other month to check up on them and provide them with support, will they have better adherence levels? We think the answer is yes, and that the Ministry of Health should officially recognize peer educators within the health care system. I’ve been working with my boss to develop what exactly these home visits will involve, and how they will be measured and monitored.

All in all....very interesting stuff!

Adventures in Taxi-ing

After a rather amusing chat with my roommate the other night, I decided I needed to compile the following list and share it with you all....

Reasons why your taxi ride home might take longer than expected (based on experiences that my roommate and I have had here in Maputo)...

• Your taxi driver is intentionally driving slowly in order to make the ride last as long as possible, giving him more time to express his love for you and secure your love in return (If you guys get tired of the recurring love theme.....let me know).

• One of the taxi’s wheels is precariously attached and the driver is going slowly so as to avoid having it fall off.

• The taxi driver has taken a wrong turn that conveniently leads away from your apartment and towards his (surely if his place is nearby you are likely to accompany him there rather than going all the way home, right?).

• Generally the way home for us involves driving a long road that is slightly (and I mean slightly) uphill. But as slight as that incline may be, sometimes your taxi just doesn’t have the horsepower to go any faster.

• You had to call for a taxi (there aren’t so many spots around Maputo where you are guaranteed to find a taxi waiting, and they don’t drive by quite as often as they do, say, in NY) and when the driver said, “I’ll be there in 5 minutes” what he really meant was, “I’ll be there in 25 minutes”.

• Your taxi gets stopped by the police and you have to wait for the driver to pay his bribe.

Luckily, this stuff doesn’t happen all that often...but it makes for an amusing story when it does!

Name That Fruit

These are some of my favorite fruits in Moçambique. My mother recently pointed out that I had never given the answers so here they are......

These are passion fruits (maracujá)


Some other favorites...this is called an ata in Portuguese and in English apparently is called a custard apple.

The Commute

I walk to and from work every day (usually twice a day, with the whole going home for lunch thing), and was recently taking note of the interesting things that happen to me along the way....

I have finally settled on the optimal route from my apartment to the office. What does the optimal route entail, you may wonder? Well, it is the route...

• where I spend the greatest amount of time walking on actual paved sidewalk as opposed to walking in the dirt (there is some very specifically timed street crossing that goes into this – because really, who wants to show up to work with dirty feet?)
• where I have the least chance of getting squashed by a chapa (mini-bus) while trying to cross the street, something that can be quite difficult to avoid considering that chapas...
• do not yield to pedestrians
• do not slow down for pedestrians
• do not swerve to avoid hitting pedestrians
• sometimes drive on the wrong side of the road
• where I avoid the majority of the trees that are likely to have a boy or man peeing behind them (behind being a relative word of course, as many of these trees are actually located in the middle of the sidewalk)
  

The things that are most frequently offered to me – for sale – while walking down the street

• credit for my cell phone (99% of cell phones here are on pre-paid credit plans)
• plug adaptors and extension cords (I think because I walk down a main street where there are lots of cafes frequented by foreigners?)
• really bad mass-produced “African” art (for the same reason)
• roasted peanuts (delicious!)
• fruit out of a basket that is skillfully balanced on some woman’s head
  

The things that are most frequently offered to me – for free – while walking down the street

• random men’s phone numbers
• random men’s eternal love (okay so they may not use the word eternal, but the feeling is there)
• marriage proposals (don’t get too excited mom....I don’t think these are the guys you had in mind for me)

My Office

Some Basic Details
* Number of people who work in the ICAP Maputo office: ~50
* Countries represented: Mozambique, Brazil, U.S.A., Italy
* Normal work hours: 8-6 with a two hour break for lunch during which everyone goes home
* Normal work hours (in the ICAP office) for my boss: 2-7 (she spends the first half of the day at the Ministry of Health; unfortunately, sometimes her extended evening hours become my extended evening hours)
* Amount of time I spend per day waiting for my internet to come back so I can email/communicate with my boss/do research/use free online translation/chat with my friends around the world: 1 hour
* Percentage of documents that I am able to successfully download on the first try: 50%
* Amount of time I spend per day trying to download stuff for work: 1 hour

And now for a little story....

The Conference Call
* Amount of time my boss and I spent on Monday waiting for everyone to be successfully connected to an international conference call: 1 hour 15 minutes
* Total duration of said conference call (including wait time): 2 hours 40 minutes
* Number of participants on the call: 14
* Percentage of participants who were dropped at some point during the call: 100%
* Percentage of participants who were dropped at least twice during the call: 100%
* Number of times my boss and I were dropped from the call: 3
* Number of languages being spoken during said conference call: 1 (English)
* Number of dialects/accents of said language being used during said conference call: 6 (American, Brazilian, Tanzanian, Kenyan, Nigerian, Rwandan)
* Percentage of call I could understand on our speaker phone: ~50%