31 May 2007

Dear all,

A note of context. I wrote this March 11 and 12, 2007, during and after a voluntary community HIV testing campaign we did in Amvom. (Amvom is about 40 km, or 2-3 hours, from Mvangan, going towards Gabon. It's another one of the health centers in the district). This was the first time I've practiced HIV counseling on a large scale (counseled about 25-30 people that day). Sylvain was the chief nurse in Amvom, and when he worked there, he and I did an HIV peer educator trainer for Amvom and surrounding villages. We taught many times together. Since February, he's been at the district level, as chief public health officer (replacing the previous one who hasn't come back in about a year and a half from Yaounde, where he's doing his MPH). For the first time, I have an actual counterpart - "supposed" to be part of PC work but I hadn't had a viable one close to me before. He and I planned the 11 March testing together. It was free, we used our peer educators to do pre-test counseling, and first gave out results of the initial testing he had done there, for them, in December. 11 March, we tested 65 people. All results were given that day (takes about 5-20 minutes to develop results in the laboratory, with the newest tests we have) The Amvom health committee (one of 2 in the district that really functions) prepared food for everyone who got tested, and after, all of us who had worked ate and drank together at "Homme d'Amvom"'s house (Man of Amvom. Usually called just "homme" (man). Context as I may write more on him later).
I haven't been able to send this since…March. Internet problems, same as I have not been able to upload pictures to send since December. Still working on this. Useful people and things to know:
Depistage - HIV testing
Sylvain - CBS - chef du bureau de sante, my counterpart. Also HIV counselor
Essola - nurse/ HIV counselor from district hospital; helped at depistage
Honoré - nurse/lab tech from Catholic hospital; helped at depistage
Pastor Elom - pastor/HIV counselor from Mvangan; helped at depistage
Ebolefou - head of lab in Mvangan; see "Zoebefam"
I think those are the relevant notes.
Will write more soon, as actual "updates". All next week, the African Development Bank (BAD - see entry from end of September) will be in Mvangan holding meetings and then having us run around the entire district to give them statistics, surveys, analyses of all health and otherwise problems. Hopefully this will lead to funding. But it should, in the least, be an interesting week. That and Sunday (tomorrow) is May 20, national independence/unification holiday.

12 mars 2007
Dépistage - Amvom
Put on my best Mary Sunshine face and lie. I've never been an optimist. Now I have no choice. I'm petrified. I tried to bow out. Essola do counseling, me work in the lab with Honoré. Sylvain refused. He said he'd work with Honoré, Essola would take his place - he's too close, knows the people here too well. It was his aire de sante for 4 years, after all (good lord, he's wasted en brousse). No being chicken now. Terrified to give people results? You make others do it. You want to be a doctor? Suck it up and be one, now.
My first positive. First counseling, in fact. I am a LIAR. He's thin and sortof sickly. LIAR. "You don't have AIDS. (yet)" Oh, but, you probably do. I saw him earlier. Councillor for the municipal council. Almost shouted "dude, you have the HIV!" Not really. But sometimes I'm afraid the pressure, the stress will bubble it out of me. Rage and frustration.
When we saw E this morning, thinking "today's the day you find out you have HIV. Better stop smiling, now…" I've thought it every time I've seen her, past few months, which has been a lot. What a secret. To know someone else has the virus when they don't know. And she's a nurse. Hoping, hoping she's using gloves to do births. That she hasn't been infecting patients, unknowingly.
Then again a nurse at the HDM has "it," too. That's at least 3 district nurses, now. And I don't even know how many of the others have been tested.

I re-did the district stats today. 11.2%. Eleven percent, of those we've tested, anyway, which is voluntary but fairly extensive. About 20% when you remove the sixth graders (I tested ..one hundred? Kids? Last year). 17-30% prevalence for women. This is the "lesser affected" part of Cameroon. Of Africa, even. Yeah, right. Are statistics only adult population? We're not counting babies, right? (Though they have it too. I can diagnose AIDS in babies. I've seen the OIs enough times, now. I shouldn't be able to do this). Among the Amvom group, of the ones tested, it was 20%, I think. Sylvain's had the test results, we just couldn't all coordinate to return and do counseling. It's his village, his village, his call on whom to tell and when. Amvom is on the trucking route to Gabon---that's why it's higher. That's frequently why.
Every time I hear someone's been sick for awhile - laid out - diarrhea or whatever - I assume AIDS. In the US it's the flu. But it's not just jumping to conclusions. Often enough, I've been right. Here. I'm usually right.

Back to Sunday. My first counseling. I was shaking when he, MT, came in. One of my most useful gifts is concealing stress, apparently. Good. Of the 5 tan envelopes - Sylvain's December dépistage - 2 were positive. I knew which 2. And I knew them. Had trained them, taught them to be peer educators, back in August. So MT walks in and I was wishing it was an easier one first. But I knew.
So I spent time. First (as in all counseling) asked what he knew, thought about HIV/AIDS. Then made sure I covered the basics - HIV vs AIDS, role in the body, prise en charge, transmission, prevention, possible test results and actions to take after each. Are you ready? Opened the envelope. Kept my voice calm and neutral. Read results. 1st test - positive. 2nd confirmation test - positive. Conclusion: positive. And here's what we're going to do. Association of PVVS. In Mvangan. Financed. Training. April 8 (dumb me chose Easter. And the Pastor didn't see fit to tell me until that evening, when we were all having dinner. So we'll do it the 9th - add. now 13th and 14th). And - it went well. He accepted it. He understood. But do I believe what I'm saying??? Screaming inside. There's no other way. I have to believe this is better than ignorance, I have to. And I do, most days. Most.

Sylvain comes in from the lab with new envelopes. White. I don't know what these say. I'm staring at the white envelopes. Carefully marked - by me, yesterday. Coded. AM00__-B. That's me, counselor B. I'm afraid. What's in here. How many time bombs are on my desk.
Sylvain. I'm not used to this. I remember science labs, first semester of college, when I suddenly had lab partners I could count on. Shouldering the burden - even pushing each other to each do more of the work. Not like before when I ended up doing everything because I knew that was the only way it would be done.
But this is like work, or life, or something. (Like Life- good book by Lorrie Moore).
I can count on him.
My real counterpart in every sense.

I'm not used to this. He's the first person here I can really depend on - I think, I'm afraid to say that - in terms of work. Or most things. Doc means well. He really does. And he's one of the smartest and best people I've ever known. As a doctor and a person (Sylvain, too, is always 3 steps ahead of me. I'm the dunce in this team. I tell myself that at least I work hard and try hard). But Doc - like today, promised to come then something else came up. Like during la Semaine du SIDA when every person I had counted on - besides PCVs, my saviors - left. And in PS days (pre-Sylvain at the district level, CBS), that would mean I was left alone, floundering, without resources (transport, finance, material), and without the hierarchical - I'm your boss and I can sanction you-power to make other people help. I'm getting better. Because I learned with that. And now I have help so with 2 of us - we can conquer the world. Or, fix this health district.

… If Sylvain ever gets paid. Damn PPTE (HIPC - Highly Indebted Poor Countries Initiative), World Bank, and corrupt Cameroonian government.
All morning I kept reminding myself I didn't have to stress. Making Ebolefou give us the lab keys to get tests. Getting people together to leave, 3 hours late. Rain. Wondering if Caroline (nurse in Amvom) was there.
There were two of us worrying. And two of us prepared to fix things.
(This is, ideally, how PC works. PCV + Host Country National (HCN) counterpart. But I've had no counterpart for the first 12 months. Now. I win).
"Yes, I understand all that. Jenny, I love my husband. I'm faithful to him. But he's president of the COSA and goes to Mvangan all the time now and I don't know what he does there."
This was one of the easier ones. Fidelity! Condom! Get your husband to use a condom with you. Yeah, RIGHT. Refuse sex if he doesn't. Yeah, RIGHT in a machismo culture where women don't have that right.
I know her husband. And I promised to talk to him. (Did. Check. He didn't have time Sunday, was working with us. He said he will next time he's in Mvangan. I need to keep him to that).
Language barrier. I wish I knew more Bulu.
Woman who gave birth December 25 (Daughter named Noëlle). She's probably not positive. Got tested during pregnancy. And - she's not.
I've done 3 now. Each 10-15 minutes. 20 more to go. Scary with white envelopes. I don't know how to counsel, so it's neuter. Fine if they're negative, but positive?
Another woman. Faithful to her husband, etc. But he has 3 wives. One of the co-wives is with her. We discuss. I say that's good, but now go back and convince your husband and wife no.3 to get tested. She's negative. Goes out smiling.
…later, older woman. Doesn't speak French. (or rather, my Bulu sucks. Need to keep reminding myself that I'm the dumb one here). Get Pastor Elom to help me. Other woman, in polygamist marriage, from before comes back and says to me "Jenny, this is my co-wife!"
…And she's positive.
Watching Pastor Elom talk to her, I almost cry. It's harder, watching. Doing it - you're in it, you have to be strong. Now -I can only think of her co-wife. There are so many factors, intrinsic and extrinsic to the culture here, that increase transmission rates of HIV. Africa just gets the short end of the stick, time and time again. And polygamy is a major factor in this. It's great to talk about fidelity between two people (though reality/"feasibility" of that in this context - well. Marginal at best). But when you add in a lot of other people to that equation, the risks go up. Though, there is a cultural difference (in Cameroon) between Christian polygamy (oxymoron? No. Churches here - including the Catholic one - have adapted their doctrines to include this. It would have been difficult to find many willing converts, otherwise) and Muslim polygamy. Rates of HIV in the mostly Muslim north of Cameroon are far, far lower than in the Christian south. Alcohol is another factor in this, but alcohol(ism) and poverty is another den of mosquitoes.
Girl sitting before me. Breast-feeding a one-year-old, about. Tells me she's been tested twice. So I'm feeling confident…only question is she says her last test was the "good" result. (Positive? Seropositive/seronegative is highly confusing. This is why we try to clearly explain the results and what they mean in counseling, before actually giving the answers). I ask if she has questions. Yes, about how to live with someone with AIDS. Can you eat together. Can you share clothes. I give her my "4 fluids" speech, feeling a little awkward about "breast milk" as that's what she's doing right now…
I end with "so unless the clothes are soaked with blood, you can wear them. But I don't think you'd wear those anyway." We laugh. I open the envelope.
Good lord, she's shocking. I try to calm her down. Try. Tell her about the association we're going to form. The meeting. Tests we're going to do. She's not okay. I keep trying. She leaves. (later, I talk to Sylvain about her. He says she's lying: she never got tested. He had to drag her to prenatal consults. And he's not surprised. Every man who passes through the village - loggers, builders, cocoa, whatever - goes to her. She's 17).
And her baby's sick, that was the first thing she said, she wanted me to consult her baby. Too bad I'm not a nurse. What if…oh gods.
Another woman. 30s, maybe. As we're talking about protection…she tells me she's faithful to her husband. But he has all these girls who "go out" a lot, too. She wants to protect her health. She wants to raise her children. She's trying to divorce him. Because what's she supposed to do, insist he use a condom? (If the anti-HIV spermicide is every developed, in a way that doesn't make women more susceptible to HIV because of abrasions, oh, I know the women I'd give it to. All the women here). We talk. We open the envelope. She's negative. But. He refuses to get tested, she says. Do I encourage her in the divorce proceedings?
I do. I don't know if I should have done that. Few more to go.
I go to see Sylvain in the lab. I'm tired. I think everyone's done. He hands me an envelope marked "A". I tell him, "This is Essola's." He says, "No, I want you to do this one." And I'm too dumb to figure it out.
So I go. Kerosene lamp now, it's 7:30 pm. JP. Late 20s. We talk. He knows nothing about HIV/AIDS, he says, just that "SIDA kills." I go into my chronic illness spiel - AIDS becoming treated like a chronic illness, diabetes, like sickle cell anemia, etc. We talk a lot. I know he's my last client, and I'm in no rush.
Positive. He's taken aback, but he takes it ok. I see he wants to talk. So we talk. Maybe 30, 45 minutes. No idea how long. He's not married but he has a "woman" and kids in Gabon. Oh, Gabon. I'm in a frontier zone - the border with Gabon is about 30 km from Amvom. And everything I hear about Gabon is kinda wild. So many people go there to get money and return with HIV…Lindsey's friend, S…anyway.
But I feel good about this one. Counseling. It feels so familiar…I'm trying to remember. I trained to do it in Boston, but I didn't really get to practice. And I was rejected the once - twice? I applied to the peer counseling group in college. Poets are trained to listen. That's one thing, I guess. I keep thinking of the 17-year-old. She said it was January that she was negative (Why do people lie so often?) I was shocked. Felt a little like (gods, so minor) my first failing test results. Sophomore year, organic chemistry (and continuing). Disbelief. No, this isn't happening. This can't be happening. And if I feel like that, how many times the person faced with the result? I had a dream, few months ago, that I had HIV. Probably the scariest dream I've had (here). Trying to make it not true. Trying to get someone, anyone, to take it back.
That morning, before leaving, Pastor Elom told me Etitan's baby (ooh, good place to hyperlink) was from a teacher. Gods. She'd told me it was a high school kid. Maybe I asked her leading questions. Maybe she was embarrassed. But I'd been afraid it was this. Angry. She told me…when, so long ago, that one of her teachers (was it the Spanish prof? German? Which is she taking?) gave her a failing grade on a test and she didn't know why and told her she had to come to his house to make it up. Back then I was afraid I knew what that meant, but unsure. How stupid was I.
I can't forget the conversation with Gaston (wonderful PC language trainer) during Stage. About students sleeping with teachers for grades. We read an article about it. So I asked him - a high school French teacher, we'd even visited one of his classes - what his experience was, with his colleagues. And he grew visibly uncomfortable and evaded answering. That was one of the first moments of reality, here.
Being in PC - a totally, totally different place - is like growing up again. Language. Culture. Reality. Life around us. I think I might be a young teenager now, maybe. I'm starting to realize so much of what really goes on around me. It's like veils have been torn, thrown aside, these past several months. I'm starting to get it, now. It's a funny juxtaposition to being in a position of power in a health district, planning and executing policy along with the district medical officer, supervising, teaching. A more "grown-up" job than I'd have in the States for awhile - in some senses, and in some senses not at all. Yet the neighbor kids still laugh at me for being white (and, therefore, doing everything weirdly and probably wrongly). Lately I work 8-5, if not longer, 7 days a week. I have my own house. I have more money than most of my colleagues (if they got paid, they'd get about my salary. But…they don't. PPTE. Can I hyperlink that? I make $320/month, by the way. On par with a highest level nurse's salary, and some high school teachers.
Then again, even if they got paid, I still have more, because I'm not supporting anyone. Me and the cat. Speaking of, I need to go look for her.
- more in the next.

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