Tuesday, October 8, 2013

August 1: Last full day in Pommern.

(As written in my journal that day; grammar and minor edits only. Italicized portions are additions written after the trip.)

It's CTC day - and through Meggie's excellent manipulative conversation skill with Edward, she's gotten me out and about, assigned alone to the Clinic, and herself over to the primary school - where she has wanted to volunteer since we arrived. 

CTC means Counseling and Test Centres - the HIV/AIDS clinic that serves seven villages, including Pommern. My energy is too low to do justice in describing the inefficiency with which 62 AIDS patients were seen today, at this monthly clinic. It is actually every Thursday, but each patient is on a monthly rotation - first Thursday, second Thursday, etc. They get ARVs or other drugs. And it wasn't the plain, pitiable, understandable inefficiency of no shelves, drawers, computerized lists of patients, or drug inventory. It went far beyond that and I want to do it justice when I have the patience to walk through it in each excruciating detail. 

After a long morning of work, and a late lunch, Meggie and I said our goodbyes to the tech and athletics team at the secondary school, who made Zumba possible, Adrian and Flavian. And then to Nurse Patricia. Meggie's totally hellish morning in the primary school has moved her to an interesting place - from guilt or pity to frustration that people are not helping themselves. I remember my brother being there, then in another phase of compassion, and finally he moved into a sort of Zen acceptance. Acceptance by attrition, maybe!

To try to do this description justice... first you have to imagine a cold morning, and the cement clinic. People "line up" to be "checked in". I use quotes because they sort of stand or sit around, near the door to the children's ward - no kids here today, so apparently it will be the CTC clinic. Every person has already waited outside on the far side of the clinic - the shaded, coldest area - to be tested (I can't see this happening; is it a blood test? A weight on the scale? Something else?) and given a number on a scrap of paper. Then they mill over to the yard in the sunshine, in front of the children's ward, where I sit at a table with another huge bound book in front of me. 

The nurses bark, "Next! Next!" and snap fingers at each patient to hand over their CTC card. They shuffle in, sit down, hand the nurse their card and slip of paper. (Or they don't, appearing as if they've never done this before. The nurse snaps for the scrap of paper, then, too.) A CTC card is a battered piece of card stock bearing their name, village, CTC number (it's a national registry) and instructions on when their clinic meets (what week of the month, what location).

This second line I'm helping with is to create a hard copy record of who showed up today, and whether they'll be getting ARVs or not. So I write their CTC number down, reading it from the card, and then the nurse tells me their village and their age, to fill in the next two lines. The age is asked for (why is it not on the CTC card!?) and if the person does not know, it is guessed at. Then their mystery number is written down and by science I don't understand, I'm told whether to check "ARV" or "No ARV" on the sheet of paper. 

The person is sent out, back into the yard, to mill around in a large group. No order is kept. 

We get through all 62, recorded in the book - the youngest patient is 9, the oldest is 72 - and most are female. The average patient is a woman in her 30s or 40s.

The young man diagnosed on Monday, in front of me and Meggie? He was in the line.

Then, everyone - the nurses, me, all the CTC patients - are herded to the very front part of the clinic yard. We spread out on the ground and on the few benches, sitting just in front of all the junk that's been mysterious to me since we arrived (rusted bed frames, broken old-fashioned wheelchairs, rotted boards, smashed bookshelves), not just for the content, but also because I look at it every day and wonder, in a village with so little, what is the social contract that prevents any item from being stolen? These are not useful wheelchairs or good boards - but surely someone could repurpose them and get great value. However, that sort of theft seems to be neither considered nor allowed; the village rules are clear and illustrated to me, if definitely unspoken.

What we attend, I start to understand, is a lecture on the importance of treating HIV and AIDS. Taking medicine, getting partners and family members tested, and then the longest segment on how it is possible to give birth AND breastfeed, without passing the disease to the baby. There is a young mother, who has AIDS, nursing her baby, and she seems to be telling everyone the baby is regularly tested but is negative, since she is taking her drugs and taking care of herself (she mimes eating food). The lecturers are Nurse Nema and Doctor Elton - and it's not fair that I am hard on Dr. Elton; I mean, yes, he's a dentist, and so that's an easy thing to point at and tease - but he's probably had enough clinical experience to push himself right into internal medicine, right?! 

The lecture is about 30 minutes long - and I'm glad for a seated break, I won't lie. Plus the sunshine warming me a little; it is another cold morning (though the sun is back out today, after being hidden by clouds and drizzle for both days I was home sick). 

Then, all the patients form another half-assed line, and I go back into the children's ward with the nurses. We sit at a table with boxes of drugs, and each person comes in with an old pill bottle. They show the kind they've been taking for a month, and are given a new bottle of the same kind. They also might have a scrap of paper with other prescriptions written on them - usually antibiotics, ibuprofen. 

The people getting ARVs are shit out of luck today; there are none. I'm told the government didn't supply them. No nurse appears to explain whether they should come back next week, out of their usual rotation, or what they should do for a month, being out of pills and all. In my head, I'm screaming, "Of course there is a contingent of Africans who think AIDS drugs don't work and that Americans and Brits are just poisoning their minds! The drugs DON'T work if you don't take them properly!"

A couple people don't have their old pill bottles anymore. We spend 15 or 20 minutes trying to decide what to do. We have to give them what they are used to taking - how can we possibly know if they don't have the old bottle, nor can remember? (There are two choices, friends, of pills to take. Two.)

Nurse Patricia leaves for 20 minutes by my count, with no reason, and comes back so we can pick up again with distributing. While she was out, the other nurses chatted on their phones. The line just stopped outside our door. Meggie said later she saw Patricia having a Coke and a snack at the little coke stand. 

These other drugs are available, for those not getting ARVs - getting what I think is a simpler protease inhibitor combination pill. And hey, they don't send the CTC ARV patients away empty handed... they all get vitamin B12 pills! That'll cure your AIDS.

Charting & Pill Dispensing:

I stay at the Clinic until about 1:30 PM. So in 5 hours, we've made people line up three times. Once to get their number determining ARVs or no. Another time to get registered at attending the clinic, in the big useless book. Then they attend a lecture - and all I can think is, is this something required by USAID or the Tanzanian government, and is the same lecture every week? - and we've made them line up AGAIN to get handed the right pills. When I leave, 9 of the 62 have their pills. It takes until about 4 PM to get all 62 through the lines and process here.

It appears as if this is the first time such a clinic has happened - and we know that's not true. We know this happens Every Single Thursday

Why line up three times? Why not see one patient at a time? Why not have pills counted out in a 30-day's supply, instead of waiting to count them out for each person? Why ask their age each time - why not ask them to be ready to supply it? Why record the check-in process in one large useless book, and then record who gets what drugs in a SECOND large useless book? 

And the best part? The second book records only what was prescribed. ARVs? Check. They were prescribed. The fact that they're not fucking available is not recorded anywhere. Check the books, and all looks well. This is Tanzania. 

So - I'm writing this so long after the actual day, I know I've forgotten some details of all the other tiny inefficiencies I witnessed. And as frustrating as it was - and, oh, lordy, it was! - in the middle of it, I sat there, patiently, for hours, waiting for bursts of activity, waiting to be told to record certain data, and generally not trying or wanting to tell anyone what to do. I just took it all in, and with the exception on the one mental scream above, I felt useful in recording the data - because it was something. It was freeing up a nurse's set of hands to actually chat with patients, and touch their shoulders, and look into their eyes. But for me to not want to tell someone what to do, how to do it faster, better, more efficiently... well, that's basically an African miracle! 

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