Good afternoon folks,

I have been trying to decide how to write this post for a long while now, and I can honestly say that it has been a long time coming, but is unfortunately a dark and difficult topic at best. I think it is fair to start with recent events, which have been the catalyst that brought me to writing about the subject. This week, while I was working on some presentation materials (about nutrition, breast-feeding, prevention of mother to child transmission of HIV, and danger signs in pregnancy) we had a young child delivered to the clinic. The child, at 5 months was severely dehydrated, and obviously malnourished. Thin arms and legs with a swollen belly, and subtle signs of anemia, the child was in bad shape. Eyes sunken and so tired the baby could barely move or cry. That morning we had also had a young pregnant woman arrive who was in labour and ready to deliver (she had actually arrived at 02:30AM but was not admitted to the delivery room until 4:30 am, and then did not deliver until 10:45). We knew we were in for a busy day, and the line of forty or so people sitting outside the small clinic building waiting to be screened and receive basic treatment, ranging from painkillers, ORS for diarrhea and coartem to treat malaria. It is worth noting that at this time there was only one clinic staff on duty – Joyce, our Casual Daily Employee or CDE – she was being assisted by a trained Traditional Birth Attendant (TBA) and a trained HIV/AIDS Psycho-Social counselor. These two women were working to support Joyce, and I stayed out of the way, tucked into a corner as our limited human resources strove to meet the changing needs. Joyce was running between the end office, the screening room, and the delivery room to oversee the labour of the young woman who was in contractions.

People waiting outside the clinic hoping to be screened

Then things started to take a turn for the worse. The woman in contractions had been tested for HIV in the past but had refused to collect her results, (she was positive). She refused the Preventative anti-retroviral that are used to decrease the chance of transmission during birth to the child, and had refused the drugs during the pregnancy as well. There was a prolonged argument (mind you the woman is screaming at the TBA and Joyce while in labour) and she eventually fully refused any treatment. The child was delivered, and tested positive (the child will test positive regardless of their status due to the passing of immunities from mother to child). The child was started on a post exposure routine, and will be tested again at six months. The mother however began to throw a fit, (having just delivered you would be amazed at how much energy she had). She accused the health staff of lying to her, and a myriad of other inappropriate things regarding her status. This argument took valuable time from the child, slipping away at the other end of the compound. I was summoned into the child’s room by a concerned community member, and found that the child had, unfortunately stopped breathing and had expired (I did not know for sure at the time). I immediately went to the maternity wing (which we are working on rehabilitating) and summoned Joyce, who came to certify that the child had indeed passed away. It’s at this point that the day really starts to shift from tragic but familiar, and become truly frustrating, the combination of the woman’s fear and stigma, and the accusations and foul name calling that came as a result, and then Joyce’s refusal to certify the death. Granted she is not qualified or entitled to sign off on the death of the child – technically the child needs to be seen by a doctor or nurse, and time of death certified etc – none of those are available. So instead, the child’s mother after having a painful argument with Joyce and I, started the process of wrapping up her infant for the 14km hike back to her village where proper burial and mourning could begin. The immediate processes was to take cotton and plug all orifices, and then wrap the head in a strip of chitenge to hold the mouth closed, and then the child is wrapped in cloth on the mothers back for the hike.

I sat down on the veranda and sorted through my feelings, and this little guy sums up how I felt:

Child Dressed up in a jacket sitting on the cement veranda

Brutal, heart wrenching, frustrating, and emotionally charged. It had been a terrible day. I felt anger, frustration, determination, pain, and sympathy in a charged whirlwind – I felt completely helpless, unable to intervene, unable to lay hands or help. I felt like my service was in vain. Here I had spent the last 19 months working to combat HIV stigma, to encourage counseling, to reach out and demonstrate through example, drama, and information that HIV was not the end of the world, it was a new start, a new beginning, and not a death sentence. I had been working to teach and encourage the use of homemade Oral Rehydration Drink and treatment of dehydration, the warning signs, and how to help a child who had diarrhea or vomiting. I had been working in prevention and behavior change – a process that takes years. I was a witness, a pair of eyes, ears and a voice, not a participant. I could not interact in the curative side; I cannot express that feeling in words. I cannot articulate the pain or frustration I feel. The hopelessness compounded with faith a belief in a better tomorrow, in a future where the next generation, and those that are sick tomorrow or the next day have received some of the knowledge and behavior I am trying to spread and encourage. I’ve worked to avoid lecturing, focusing on participation and translation from knowledge to action, building on what people know, to encourage self sustainability, independence and confidence all of which are making a difference. But at that moment what did it mean? Set against the backdrop of a mother wrapping her limp lifeless child to her back, preparing to walk hours in the sun to have a single day of public mourning. It felt all for naught. Now, today, later I can say what I am doing is making a difference, my work here is helping people, and people are becoming stronger. In the general sense all I can say, is that unfortunately I have had some experiences during my service, more so in the last few months, which have made this an all too familiar tempest. One that I am getting better at riding out, I am feeling hopeless and lost at sea for shorter and shorter periods. I am coping faster. Nevertheless, this was the fifth case that I had witnessed since October.

A few short hours later, we received a team from a local NGO, two midwives, and a nurse to help us for a few hours as they did record collection. They brought us a motorcycle ambulance. The ambulance is an amazing gift from USAID through the NGO. It replaces our current methods of transporting sick and wounded in our 56 km catchment, a bicycle or a wheelbarrow. The difference it will make is huge. So thank you to the American people. That ¼ of a percent of our budget that supports foreign aid, and the fraction that supports health development – you have just fundamentally changed over 9000 people’s access to health and emergency services.

USAID Motorcycle Ambulance for use in the Catchment

It was back on the rollercoaster for me – the amazing drop and low low downs of the morning, countered by the slow climb offered by the new ambulance, all I could do was take the hands and support of my neighbors kids, call it a day and walk together back home.

Walking home from the clinic with two of my communities children