At The Clinic

I have been circling the notion of ‘public health in Africa’ for the last…six and a half years (!).  First I was a Peace Corps Volunteer assigned to be a “School and Community Resource Volunteer” – a title I am incapable mentioning without using either print or air quotes.  I loved my time serving as a PCV, and I think I did make some sort of difference somewhere, but as job titles go that particular one is magnificently nonsensical.  It means I hung out in primary schools, and went on walks, and had a lot of conversations with a lot of people, and saw what 30% HIV prevalence really looks like on a daily basis in a rural South African village.  And eventually I found my way to this idea: “Huh…If ‘hey baby’ is an effective pick-up line, there is probably a self-esteem problem happening in the teenage girls around me.”  As nuanced indictments of the gender and economic structures that contribute to HIV risk and vulnerability go…there have been better summations of the problem.  But it was my step one.  And I’ve read a lot more, and listened a lot more, and I like to think I’ve got a slightly more multifaceted understanding of the situation now.   And I know just how much I still need to keep learning, reading, and (mostly) listening.

In the time since I COS’ed (that’s Close-of-Service to those of you who are unfamiliar with Peace Corps vast, impressive sea of acronyms) I’ve spent a lot of time reading, thinking, and listening about all those social things that go along with public health and HIV in southern Africa.   I got a masters degree in the social and behavioral aspects of international health (hint: you should spend some time listening to the people you’d like to help before you start helping).  Now I’m working on a doctorate in behavioral sciences in public health (bonus hint: make sure you’re listening the right way, so that when you tell other people what the folks you want to help had to say, those other people believe them/you).  I spend a lot of my time thinking about gender, and inequality, and how people respond to or are constrained by the social landscape around them, and how those responses and that landscape affect their health.  (I also spend a lot of time talking about this.  Certain people who have spent the last few years in close contact with me probably now know more about gender and HIV than they ever, ever wanted to learn.  That first date was a tip off).

Even though I have spent the last six years engaged in public health in southern Africa in some way or another, this past month is my first time spending a lot of my day in and around clinics.  Two years ago I spent a day navigating different aspects of the health system with a sick acquaintance, but that was only a snapshot, albeit a vivid one.   From March through June, I’ll be spending every. single. weekday. recruiting pregnant women in a couple of different government run antenatal clinics in urban and rural parts of the country.  Which means that my research assistant and I spend a lot of time hanging out, chatting with nurses, watching each day go by and catching the rhythm of the place. 

Partially because we are spending most of our time in the antenatal part of the clinics, and partially because all over the world women just tend to interact with health care more often than men, the clinics are spaces full of women.  Pregnant women.  Women with infants, toddlers, pre-school aged kids there for their check-ups and immunizations.  Women waiting for family planning (mostly injectables, as far as I can tell).  Women getting counseled on how to prevent mother to child transmission of HIV, pre and post HIV test counseling, with impressively true to life models on which male and female condoms are demonstrated.   Female nurses, of course.  (But a few men, too!).

Outside, I sometimes see people sitting.  They sit quietly on a set of cinderblock bricks that have been abandoned there.  These people are usually bent over, looking down, almost always alone.  Maybe they are tired after a long process of getting to the clinic, or from sitting in the hot waiting room all day.  Maybe they are waiting for a ride home.   But I know that another service at the clinic is HTC (HIV testing and counseling), and I know that every day men and women are learning their status for the first time, and I know that that news is not always good.  In fact, that’s why I’m there.  I ask women to share their results with me, and now my study has biomarkers and it is Much Better than if I had just asked about behavior.  I try to give these quiet, alone people their space.  I feel empathy and compassion, but I don’t want to intrude.  They are out in the open, but I try to give them whatever privacy I can.

There are women everywhere, and there are babies everywhere.  Toddlers roam the halls of the clinic mostly at will.  Their moms keep an eye on them, or know that all the other nurses and women in the clinic will redirect them if they get up to anything too nefarious.  They come and get their childhood immunizations -- I have figured out the word for ‘shot’ recently, it is usually the thing that a child is whimpering over and over again while they rub their arm and get reassured by a nearby nurse/grandmother/aunt/mother.  There is exactly the amount of screaming, crying, and general wailing that you would associate with a couple of adjacent buildings full of bored and/or in pain infants and toddlers.  There are far, far fewer tantrums thrown than if these buildings were in the US.  In the last month I have seen exactly zero child meltdowns that were not related to falling down or getting a shot.  (There is a good deal I could also say here about the luxury of liberal, rich world parents shunning childhood vaccinations that literally save lives in Swaziland and around the world.  But instead I will simply link you to this website that comprehensively explains how vaccines cause autism and other diseases).

Sometimes people hand me babies.  My assistant tries to coax me to tie them to my back, since I have expressed doubt about the standard method that women here use.  A woman leans over, slings her child around and onto her back, wraps a towel around herself and the child, with the kid clinging to her back and both legs sticking out on either side of her back, and ties a couple of knots in the towel to make the whole thing stick.  I thought maybe this could be a bit precarious -- doesn’t the towel ever slip?  This was apparently a ridiculous question, and now my assistant is on the lookout for any woman who will let me give it a shot with her baby.  There have been very few takers so far.  Last week I was handed an infant so that mom could, well, enjoy not holding an infant for a little while.  The baby was very calm, it did not seem at all worried about the strange new face color that was now looming over it instead of mom.  We all agreed this was hilarious.  Then it spit up some liquid aspirin all over me.  I chatted with the baby’s sister – I told her that the woman on the poster on the wall was a doctor.  Her mother and my assistant reassured the girl that the woman was probably a nurse.  She asked me in siSwati if I was still a student, then where was my school uniform?  I do not have an adequate siSwati vocabulary to explain that constant mild panic and ongoing uncertainty are my uniform.  Then she commanded that I tell her a joke.  Or sing a hymn with her.  I didn’t know the words, so she sang it herself.  As far as I can tell, the words were “Jeeeeezus….Jeeeeezus.”  There may have been more.  Unclear.

Later, in the hallway, I stopped a little boy who was trying to make a break for freedom out the clinic door.  Despite repeated interrogation (uyaphi?  uypahi? -- where you going?  where you going?), he did not seem fully clear on where he was going.  Or where his mother was.  Or what his name was.  Probably because he was two and preferred chattering about...something? birds?...at length instead.

A nurse walked by and stared at him, and stopped in her tracks.  Wow!  She said.  Miracle baby!  She told me that when he was 18 months old, his father had refused to put him on ARVs until she had forced him.  At 18 months the little boy couldn’t hold himself up in a seated position.  She had thought he was going to die.  And today he was roaming the clinic, making friends with random Americans while his mom got her (their?) treatment.  The nurse just kept shaking her head in amazement at the power of ARVs.  I was amazed by her power -- she saved that little boy’s life.

 The morning starts with singing and prayer.  My assistant and I set up our computers, our juice, our cookies, and our paperwork, and listen to the hymns coming from the next room.  They are beautiful.  They are the same four part harmony that I remember from Steenbok, from the way the teachers would begin every morning meeting, from the choir rehearsal in the church next door to my house.  I miss those hymns, and I love listening to them every morning.  Then there is a prayer and a sermon.  I can’t quite tell, but I think there is one for the nurses, and a separate one for the women who have queued up in the waiting room.  The praying is out loud, all the nurses praying together at the same time, loudly and repetitively and urgently.  I think it is the thing that collective effervescence became, the thing that transformed into football cheers and really good concerts.  It is intense, and unified, and driven in a way that can make the hairs on your arm stand up, if you happen to be sitting in the middle of it in a hot tiny church that has lost power and is sitting in twilight in a rural village somewhere.  The sermon is usually loud and strident, and bordering on shrieking.  Here is where I lose interest, and become annoyed.  Really, I told a friend of mine over email, you would think that if Jesus was actually there he would get on with the business of ministering to all the sick and pregnant ladies  -- a third of whom have HIV – rather than going on about the gospel of how one should minister to the sick and pregnant, and how one will then someday triumph in heaven.

Fortunately, I have friends who are smarter than me.  Sometimes, I email them snide comments, and sometimes they offer me wisdom in return.  You know, my friend told me, all of that sounds like a ritual.  And rituals are powerful, and important, and we all need them in our lives.  He’s very right.  The nurses I have met – they are sometimes rushed, and they sometimes speak briskly, but they are there every day.  Day after day they convince parents to put their children on ARVs.  Day after day they tell women who are living with HIV not only that they can prevent the virus from being transmitted to their child, but they give them the tools.  Every day they tell somebody that they have HIV.  Every day they provide health care and counseling to women who are rushing to work and women who have never been to school and never had a job.  Every day, I can guess the stories they hear from their clients.  And every day they keep coming.