Tuesday, February 03, 2009

Honora is back in Africa

My friend, Dr. Honora Englander, is on assignment again in Uganda. She always has wonderful observations and has given me permission to share them with you. Here are excerpts.

Dear friends and family,

I am sitting on the veranda in front of the guesthouse where I am staying. Hibiscus flowers are blooming all around me, there are beautiful iridescent blue birds chattering and darting from tree to tree, and there are couplets of butterflies meandering from one long blade of grass to the next. The sun feels great on my pale skin, and I am so glad to be back in Africa.

Yesterday was quite a day – I couldn't have asked for a better introduction to Mbarara, or at least the mzungu part of life here. I woke early, still in Entebbe having just arrived the night prior. Despite being exhausted, I was unable to sleep much of the night; tossing and turning due to a whole mix of anticipation and excitement, jet lag, and lingering worries about parts of life at home that are starting to feel continents away.

I arrived in the lobby of my hotel to meet my ride that was slated to come at 8AM. Imagining that 8AM would be much closer to 9 (as it was), I was happy to start up a conversation with the bellhop, a man named Robert who I soon learned is 34 years old and used to work in animal conservation but lost his job; for the last year he has worked at the hotel several hours by bus west of his home. Our conversation started with small talk – family, work, geography – but ended up where many conversations with strangers here do, centering around the AIDS epidemic and people's thoughts on the matter.

Robert is from a small village outside of Jinja in Eastern Uganda and is one of twelve or thirteen children, however his father had two wives, he explained. He is married with two children. I asked if he plans on having more wives, and he explained that he only wants one. He explained that he prefers one wife because he doesn't want to create a situation of jealousy between two women, and he worries about costs of supporting two families. He also prefers to love just one woman – for now at least, unless his wife misbehaves, he explained. I asked if he thought that the AIDS epidemic has played in at all to what seems to be a cultural shift from largely polygamous families to a trend towards monogamous marriage.

On the airplane I started reading a book by Helen Epstein called The Invisible Cure that references work suggesting that the high prevalence of concurrent relationships (i.e., polygamy or multiple concurrent long-term partners) and not promiscuity or other high risk behaviors, may explain the rapid spread of HIV in East and Southern Africa compared with the rest of the world. I am intrigued by this idea, which is supported by epidemiological and mathematical models, and was curious to learn more about cultural shifts from my new friend.

Robert didn't have much to say about whether AIDS is affecting marriage practice; he said monogamy is praised in church, but didn't say much else. He was, however, emphatic about the progress being made around HIV, and expressed a sense that AIDS can be a chronic disease and how people can live for so many years. He told me about AIDS education in the schools, and that though people may be reluctant to be tested, he thinks that that they overcome their fear and are getting tested. He explained how several years ago, he convinced both of his parents to be tested for HIV. He did so somewhat strategically and cautiously, first approaching his mother during a visit to the village. He explained that since she had given him the luxury of an education, it was now his duty to share what he had learned with her and that she should be tested for HIV. He even brought her a home HIV test, though recommended that she go to a testing center where she could get HIV counseling and subsequent testing. His father, he explained, was even trickier to cajole, but he too accepted. Both were tested, and were negative.

There was a moment in my conversation with Robert where I was struck by what seemed in one breath astonishing, and another so obvious. Over his lifetime, AIDS has changed so dramatically – it went from being unrecognized to rampant and shockingly devastating. In the past I have been suspicious of the reported lower rates of incidence, but he seemed to think both prevalence and incidence are coming down. My conversation with Robert suggested that amongst some lay people, there is a sense that Uganda is gaining in efforts to curb devastation caused by AIDS and in efforts to educate and promote testing. I was also somewhat amazed by his sense that HIV is can be a chronic disease, not because I disagree but because I hadn't heard that expressed here in the same way before. In my conversations, mostly with East African medical students, and in my own exposure here, we are so biased by seeing AIDS mostly in the hospital, where people's chances of survival often seem so grim.

Minutes before 9, a near bus-sized van with Mbarara University of Science and Technology arrived. Inside was a driver and two of his friends, and we were off, heading west through bumpy roads rust colored, verdant countryside and heavy rainclouds.

I made a quick trip into town, but the remainder of the day consisted of long conversations that meandered between lighthearted and fun and thoughtful and reflective, sharing a glass of wine or two as the evening creeped on. Though I am just meeting people, my sense is that this is such a special group of people – there are clinicians, researchers, volunteers and spouses, and each persons work and interests range from clinical medicine and education to PhD work around issues of trust and disease prevalence, fee-for-service vs. capitation payment models in Uganda, and cell phone use for dissemination of health information. Thus far, I have been so impressed with the maturity, understanding, generosity and kindness of this crowd. I feel so lucky to have landed here and to be welcomed with such open arms.

So, it's been a great start and I am eager to start on the wards tomorrow.

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