Welcome to the Jungle

I was not initially thrilled to receive the third assignment of working at the Chicumbane hospital when I already have my hands full with CBO's CACHES and Tsembeka and secondary projects REDES and JUNTOS. I have a full plate and Peace Corps is asking me to take on another course. Okay then, bring it.

Working at the biggest health center in the Xai Xai district can be kind of overwhelming. There are a million new faces and names for me to learn. From the outside, the hospital looks like a simple arrangement of round cement huts with thatched roofs. It's not There's the pediatric ward (by the way, "ward" sounds fancy. Don't think fancy, think as I said, about identical huts), the maternity ward, the pharmacy, the TB ward, etc, etc. And everywhere, there are patients (mostly women, and a good majority with babies slung on their backs) waiting around outside.
You'd think that I'd be great at the integration process by now (remember: escolinha, Chibuto, CACHES, Tsembeka, Chicumbane) but I dread it. The awkward questions about who I am and what I do. "Should we call you Doctor Vivienne, or Nurse Vivienne, or…?" "Just call me Vivienn," I say, because I'm not qualified for a pretentious title. It's hard to explain because as a Community Health Promoter and a volunteer, I don't fit into any of the very specific health roles that can be found at the hospital. And I'm not here to give money. And I'm not Chinese. And I speak Portuguese. And I don't have a car. And I'm married, thank you very much.

The first day, I show up (15-20 minute walk to the hospital from my house) sweating profusely at the hospital director's door. He takes one look at me and laughs, ushering me into his nicely air conditioned office so that I can "refresh myself." He comes back with three hospital staff members: Patricia, in charge of the HIV/AIDS department, Luis, in charge of Community Health Interventions, and Ricardo, nurse and head of the GAAC program in Chicumbane. (GAAC is an interesting initiative in Mozambique, currently being pilot tested in Gaza province. HIV+ patients form small groups in the community of 6 or less, and every month they take turns going to the hospital to pick up meds for the group.) These are my new counterparts at the hospital.

My first day "on the job" I shadow Ricardo while he does consultations in his hut for a variety of sick people. Despite the small crowd of people waiting outside his door, he spends the first 20 minutes chatting with me about the challenges of his job. Mainly, the lack of resources. The photocopier has been out of toner for a few weeks so no one can make the necessary copies of forms. "Who's in charge of fixing the copy machine?" I ask. Ricardo sighs, and launches into an explanation of how in the past, the I-NGO's (in this case, EGPAF) were the ones who bought and donated materials. Now, I suspect in some crazy launch for more sustainability, the I-NGO's give money and the hospitals themselves are in charge of the annual budget. Which means that no one's buying more toner because someone probably spent money on something that the hospital didn't really need. (Ahem, air conditioning?) "Things were perfect when you guys were in charge of your own money," Ricardo says sadly. I have no idea what to say.
Eventually, patients are ushered in to the hut and Ricardo speaks with them in Changana or Portuguese. He has no problem having lengthy side conversations with me, though, which makes me feel bad but the patients don't say anything about it. They just sit and wait. They're obviously used to it. At some point, a man barges in to the hut to talk to Ricardo and, ignoring the patient sitting in the chair, apologizes to me for the interruption.
Other patients come in with their chest X-Rays rolled up inside another piece of paper, which Ricardo unrolls and holds up to the window. Very technical. He writes prescriptions out on pieces of scrap paper folded in half with carbon paper in between.

After the first couple of patients, Ricardo looks at me out of the corner of his eye. "Do you think you can fix all these problems we have?" He asks slyly. "No. Definitely not." is the truth and my response.
"What should we do about the AIDS situation?" I respond that if there were a simple answer to that question, Africa wouldn't be in the state that it's in.

A pretty young girl walks in for her consultation. Her blood tests show that she has malaria and HIV and now we've got to break the news to her.
She's in 10th grade and she's very informed about HIV, as shown by her answers to Ricardo's pop quiz about transmission of HIV. She's very quiet though, in the manner of most Mozambican children and women when spoken to.
"How many partners do you have?" Ricardo asks. "One," she says. "Who?" He asks (nosily, in my opinion). She gives his name (apparently, he is a friend of Ricardo's).
Ricardo: "Have you ever taken an HIV test before?"
Girl: "No."
Ricardo: "Would you be willing to take one?"
Girl: "Yes."
Ricardo: "Would you want to know the results, regardless of whether the news is good or bad?"
Girl: "Yes."
Ricardo: "What would you do if it came back positive?"
Girl: "I would start treatment."
Ricardo: "Would you tell your family and your partner?"
Girl: "Yes."
Ricardo: "Are you sure? You wouldn't go home and commit suicide or anything, would you?"
Girl: "No."
Ricardo: (Sighing heavily) "Can you read this piece of paper for me?" (slides over her test results, written in sloppy handwriting on a piece of scrap paper)
Girl: "I…can't read the handwriting."
Ricardo: "R-E-A-C-T-I-V-E. What does that spell?
Girl: "Reactive."
Ricardo: "Do you know what reactive means?"
Girl: "No."
Ricardo: "What does non-reactive mean?"
Girl: "I don't know."
Ricardo: "Okay….. It means that when someone takes a test for an illness, like malaria or HIV, they either come back with the results reactive or non-reactive. In your case, it looks like you came back positive for malaria and…HIV."
Girl: (no reaction) "Okay."
(Vivienne, with the sudden urge to hold the girl's hand, watches a white gecko stalk a spider across the cement walls of the hut.)
Ricardo: "So… here is your prescription. You can take this to other hospitals in Xai Xai as well. You don't have to come to this hospital if you don't want to."
Girl: "It's fine. I'll just come here."
Ricardo: "Are you sure? You're going to tell your partner, right?"
Girl: "Yes."

About 20 minutes after the girl leaves, her boyfriend pops in to the hut with her prescription of pills. He is… much older than she is. He asks Ricardo to repeat instructions on how to take them, and Ricardo explains. As the man turns to leave, Ricardo says, "Has she talked to you yet?" The guy shakes his head. "I don't think she'll tell me what's wrong." "Oh she will," Ricardo says mysteriously, "She promised she would. She has a lot to talk to you about."

For me, the whole experience was astounding, no less because when the girl found out she had HIV, she didn't physically react at all. Although she must have been freaking out inside, her expression didn't change. Whereas I'm sure that most American patients would immediately collapse in tears, or panic, or immediately call somebody up on the phone and break down. The Mozambican girl, a secondary school student!, got up and left with the same quiet dignity that she came in with. It really hit me then… the reality of HIV in Africa. Working at a hospital in Mozambique is going to bring me a number of new perspectives and experiences in the upcoming weeks.