The Ethics of Hope: Final Chapter

Tomorrow afternoon will find me sitting in a window seat of an Embraer RJ135 prop plane destined for OR Tambo International Airport in Johannesburg, South Africa. At 2:00 P.M., I will hit the rewind button on that psychotic journey which brought me to Swaziland in August of 2007, albeit with a derivation in the route of travel. How can I mentally prepare myself for 18 solid hours of recycled air and equally irritable souls flying from Johannesburg to New York City?

Three months of desperately awaiting this journey/escape is all the mental preparation I need. And considering the previous two parts of this three-part series, you might imagine me boarding that prop plane without a shred of hope for the project and the country I leave behind. In broad global and national terms, the donor/aid/relief/development industry seems defective in the most irrevocable sense. My honest present observation (and I say this devoid of emotional charge) is that the imminent failures and imperfections in global conditions overpower the minority of successful programs designed by a few committed organizations. On the individual level, I fear that even the most blameless members of society cannot escape the gruesome impact of HIV, poverty, and corrupted authorities.

So in that way, assumptions that my carry-on luggage would be stuffed with down-trodden defeatism are not far off the mark. I could whine about the misery and fury which was forced upon me this year, or complain that life is unfair and the world hurt me and so on and so forth. With some shrouded apprehension, I could even protest the injustice of this year’s brutality, claiming that I tried so hard, did all the right things, etc. and therefore did not deserve to be stripped of hope.

For quite some time I actually did wallow in those objections. Fortunately, by way of the “complex examination of hope” that I mentioned in Part 1, my outlook was revolutionized. It is as if I had spent 23 years walking through life and wearing the wrong prescription lenses, bumping into things indiscriminately, until Someone took note of my folly and granted me proper spectacles through which the world sharpened in focus. An explanation...

“As water wears away stones, and as torrents wash away the soil of the earth; so You destroy the hope of man.”

Job said that in a despondent, and likely infuriated, prayer to God. He was stripped of health, home, family, and all possessions instantaneously and unjustifiably. No doubt, his accumulated wealth afforded great hope for the future of his offspring and his own legacy. I imagine his hope was tied to the idea that a righteous cause and a righteous character beget justice and comfort. To lose everything so quickly probably pissed him off and I would bet his initial reaction to the tragedy made him wonder if God haphazardly dismissed the things which mattered most. He probably felt hopeless.

Horrible things happen in spite of righteousness: hopelessness is the logical fallout.

Just like Job’s hope that righteousness would precipitate justice, I held great hope in the world’s financial and occupational commitment to eradicate those afflictions so prevalent within developing communities. Is there any cause for justice more compelling than the 11-year old malnourished child forgoing his meal for the younger sister in his care, after both parents died of AIDS? Hundreds of stories like these should dramatically compel every global citizen toward righteousness. And yet, “As water wears away stones”, this year slowly broke down those expectations and made social justice seem like a pipe dream. Hoping for donor salvation now seems a preposterous solution to deeply complex problems like poverty and AIDS. Considering how many people expectantly depend on that fallible salvation, you might even argue that the promotion of such hope is unethical because it traps the creative minds of the poor within a system bound to fail them.

What I mean to emphasize is the difference between errant, misleading hope (or delusions of grandeur as some may define it) and natural, dependable hope. One is obviously preferable to the other, and following the experiences of this assignment, it occurs to me that the proliferation of dependable hope is a fundamental requisite for human life. Dead-end/misleading hope could feasibly kill the soul and leave a hollow human shell behind.

What then is the foundational form of dependable hope; the kind of hope that keeps us alive? Is there any commonality between the hope of an AIDS orphan, a cancer survivor, and Andy Dufrain? I suspect the remainder of my lifetime will be characterized by a profound examination of that question, so it would be unreasonable to suggest that I know the answer at this very moment or that I will know the answer when I board a prop plane on July 19. The scientific method of hypothesis testing may bring some clarity to the matter, and so I would like to propose a hypothetical answer regarding the source of dependable hope.

This theory materialized unexpectedly while reading the first installment in C.S. Lewis’ science fictional Space Trilogy, Out of the Silent Planet. Weston is a gifted physicist, and the primary antagonist, who lands on Mars to secure the future of humankind. He believes that human superiority justifies all ruthless intergalactic expansion and domination by his species. In short, Weston’s adoring veneration for the conceptualized brilliance of humanity compels him to ensure the future of his species beyond the point when Earth’s resources are exhausted.

Prior to his arrival, and during the several months he spends on the planet Mars, Weston commits murder, betrayal, and a host of other crimes in the name of something, “so fundamental as a man’s loyalty to humanity”. However, knowing that Weston was willing to betray and sacrifice the human protagonist in the story, the God-representative of the planet suggests to Weston that “what you really love is no completed creature, but the very seed itself.” Love for humanity is worthless if there is no love for another human.

I discovered some of Weston’s twisted ideology in my own story this year. Every time I was motivated by a generalized love for “poor people”, my motivation was shattered by exposure to poor people who rob, rape, and murder other poor people. Or it was shattered by exposure to organizations which care more about politics than starvation. When love was abstract and unspecific, I became hopeless.

On the other hand, if I was motivated by a focused and individualized love for friends or host family members or those at the NCPs, hope felt limitless. I had no trouble staying motivated in my job and always found a solution on the other side of darkness.

“These three remain: faith, hope, and love. But the greatest of these is love.” Seems to me there is some good logic behind that statement. Faith and hope apparently originate from love.

Perhaps there is no reaction in life that precipitates an ethical or eternal form of hope without love as the acting catalyst. Maybe our failures in the developing world can be attributed to our rudimentary vocabulary that includes phrases like “the disenfranchised”, “the developing world”, “the child”, and “resource-limited populations”. If our programs and interventions seek to serve names and faces instead of disengaged concepts, would poverty disappear?

Becoming an epidemiologist will certainly improve my professional capacity to make a difference in any country around the globe. But I am useless to the poor, the rich, or any other group of people if I cannot learn to love.

Easier said than done.

The Ethics of Hope, Part 2

Faded letters G-S-H were scrawled in black permanent marker on the left chest pocket and the right thigh of a drab and tattered set of white linen clothing. “GSH”, or Good Shepherd Hospital, is located in Swaziland’s eastern sub-tropical hub of Siteki, a town surrounded by “Foot-and-mouth disease” check points set up to prevent the passage of any and all produce. The check points themselves are a mental jolt every time I visit the area. But I sat there at Good Shepherd without even the slightest thought of foot-and-mouth, trying and failing to converse with the skeletal frame draped by those rancid white linens with permanent marker.

This guy was the poster boy for the developing world’s ugliest ailments; malnutrition…AIDS… TB…you name it. Cheekbones stood abnormally pronounced on his face and his collarbones jutted upwards above his shoulders. Sharp boney fingers trembled and fumbled with an archaic mobile phone while he avoided eye contact and attempted to answer my stupid questions.

Conceptually, this scene would not have disturbed me in the least. I’ve spent enough time around similarly demolished bodies to build up “shock and awe barricades”. But this guy blew straight through the barricades for a very simple reason; he’s my friend.

Two weeks prior to that meeting, I discovered that Ganawam (name respectfully changed) was diagnosed with Tuberculosis and admitted to Good Shepherd Hospital. I felt bad for him but was not terribly worried because, as every bit of advocacy material reminds us, TB is curable. When a colleague responded to the news by flatly stating that he had TB once before, the dark possibility of drug resistance bore down on me.

Resistance is a simple concept. If you contract TB and the intensive 6-month course of antibiotics does not eradicate it completely (because the patient did not adhere to the treatment or the strain was unique), the bug could potentially transform into an undefeatable freak. Identifying drug resistance is a ridiculously slow process, so most patients begin treatment without confidence that the medication was correctly prescribed. The modified Franken-strain of bacteria takes the world stage with an acronym; MDR or XDR (multiple drug resistant or extensive drug resistant TB).

Visiting Ganawam was a priority because, next to my host brother, he’s my best friend in this country. We’ve worked together on the NCP project and he was far-and-away the most dedicated and effective field monitor. He is a double orphan caring for his younger siblings and living in the most drought-affected region of Swaziland. He speaks English quite well and holds great potential to become an agricultural expert. More importantly, in a world where you’ve got to fight for yours, he spends most of his time fighting to provide for his family and other orphaned kids in his community.

When I first saw him at the hospital, I did not recognize him. My visual memory of him was characterized by seemingly full health only one month earlier. Suddenly half his stature vanished leaving the bones that stood before me. After I pulled myself together and sat down to ask my stupid questions about soccer, the food in the hospital, and what he needs, I somehow remained totally blown away that TB could do this to someone; I had no idea he was that sick.

The visit was squeezed into a break in food distribution, and the schedule demanded that I get back on the road, so I said goodbye and promised to get him some much needed apples and oranges. Before leaving, I checked in with his nurse to ask about his treatment. I knew enough about TB drugs to recognize whether they were administering second-line treatment for a drug resistant strain. Sure enough, the nurse confirmed that his treatment was second-line, involving daily injections and enough pills to fill a small gumball machine. “It’s OK,” I thought, “maybe he can beat this and return to health in the future.” She assured me the drugs were free, I thanked her for taking care of a good friend, and said that I intended to cover whatever minimal fees were incurred by his 2-month stay at the hospital. With a slowly inflating sense of hope, I stood up to leave and was instantly shattered when she off-handedly mentioned, “he’s also on HAART”.

HAART: Highly Active Anti-Retroviral Therapy…as in treatment for HIV.

“What?” The question was not one of clarification, but rather a question of qualification. As a Zimbabwean clinician would later confirm in a casual conversation, the prognosis for someone with drug resistant TB undergoing aggressive treatment for HIV is not good. The nurse unwittingly burst my little bit of hope for his recovery. More than that, the injustice of it bears down on me. HIV and its opportunistic cronies never really forced their way into my private sphere. Sure, in an abstract and somewhat distant sense, this year connected me with the realities of HIV and its impact upon the world. But it can’t happen to friends, especially not Ganawam. His character is admirable…his moral convictions are flawless…this shouldn’t happen. Is this the colossal failure of justice? There must be some sort of mistake, right?

Pulling out of the hospital parking lot and driving down to Ganawam’s village to deliver boxes of vegetable blend, my work suddenly seemed quite futile. My sacrifices seemed so trivial. In a fit of cynicism I asked myself, “Did I accomplish anything this year?” Neighborhood care points are all about impact mitigation. Did I realistically “mitigate” an ounce of this epidemic’s impact? If TB and HIV can extend their life-draining reach to an extraordinary individual like Ganawam, what does that mean for the next generations to come? All these small interventions- the material distribution, the hygiene and sanitation training, income generation projects, building a sustainable future for NCPs- are they like trickles of water on a ferocious blaze?

Maybe. All I can say retrospectively is that HIV suddenly felt personal and unbeatable.

The Ethics of Hope, Part 1

During the last week of May, we finished a second round of food distribution. Hooray. It’s a grueling task on its own, but that week surpassed the normal threshold of exhaustion for reasons unexpected and independent of the logistical crunch involved in any distribution. The experience dragged me through a complex examination of hope. Generally speaking, my thoughts move quickly and jumble themselves to become indecipherable creations; sort of like abstract art. I have done my best to refine those thoughts and write them down because I think they provide an interesting summarization of this year, as I see it upon departure. Such is the purpose of the following two stories and three parts.

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Bomake Bembuso in Zombodze makes for an easy material delivery point. Without any interruptions the care point is always working, and even after the children head home, I can always find at least one caregiver cleaning the classroom or talking with neighbors. Sure enough, a whole crowd of women stood inside the cinder block building on Wednesday, May 28, praying for the future of their care point.

They are beginning to feel some excitement about the overall improvements in the project of late (water supplies received, hygiene training completed, food delivered, whispers of money for permanent structures, etc.). Consider that my arrival with a truck bed chock-full-o-food puts Publisher’s Clearing House sweepstakes to shame, and now you have a picture of the happy greeting.

After the brief ‘how are you’ and ‘I’m fine’ routine, I moved on to business. “So today, I will leave eight boxes with you,” I said through a smile while piecing English and siSwati together. Both women understand English well enough, but local language efforts make a world of difference. During our pleasant chat they did not see me scratch out the number “6” next to “Bomake Bembuso” and boost it to an “8”. Sometimes I like to cheat the rationing in favor of the care points with the most severe needs and the most committed caregivers- Bomake Bembuso is one of those care points. What little food supply Church Forum does receive is so minimal that it must be rationed at 70 calories per child, per day to reach every care point; a shocking underestimate of any growing child’s recommended caloric intake. A few extra boxes cover a few extra days for children who cannot collect food from any other source, and because some care points are covered by ample World Food Programme supplies, it doesn’t hurt to shift the rations a little.

Clasping their hands together with a sense of urgency, both women said frankly, “Oh, it helps us so much when you bring the food! We do not have the money to go and pick it up in town.”

This is the part I was not looking forward to, the part that drove me to virtual madness in the last week of May. “Yeah, about that ma…” [fading smiles and a new look of concern ] “…this might be the last time Church Forum can deliver food for a while. The big NCP donor in Swaziland is not willing to pay for distribution.” I went on to explain why the complicated political web spun by a couple enormous multinational donors prevents funding for an essential activity like food distribution. The politics infuriate me, and yet I knew they would find it more ridiculous than I do.

Both women listened intently but appeared physically weakened by the news. When I finished, one of them gripped the rail of the truck bed on the verge of tears as her bottom lip quivered and her whole facial expression asked, “How can any rules or any political issues be more important than our kids’ lives?” Audibly, all she could manage to say was “Oh…I see.”

Gracious donations from a church and friends in California made the first two rounds of distribution possible. By NO means do I blame them for the terminal quality of food distribution; such donations are not sustainable without any way to 1) verify the success of such distribution in the future and 2) gauge the interest of future NCP-related staff to continue the work of distribution. They filled an important funding gap while we expectantly waited for more lasting support from the primary project donor. After months of waiting and apparent approval of the activity, we were shocked to learn that support was not coming.

The case of food distribution is merely an indicator light for bigger problems in the Development & Relief engine block. Effective projects require in-country agencies to fund the activities, monitor, and verify their success. Such projects also require in-country staff to implement successfully and make adjustments. And before anything else, they need full initiative and commitment on the part of their recipient communities.

Any and all of these working parts fail as frequently as a 1993 Ford Explorer. The community could lose interest over time, or the community leaders could squander and misuse resources. In-country staff might not adequately connect with the community in the first place, become sloth on the job, or squander and misuse resources. And big funding agencies are whipped by their own donors, who establish universal rules and regulations for their money which may inadvertently cause that same money to be misdirected, leaving realistic community needs ignored.

On my side, the big funding agencies held massive celebrity appeal. If humanitarian relief is a game (and sometimes it seems to be just that), those big names are enshrined with the god-like status of any super-athlete and bolstered by their frequent publicity in The Economist and BBC programming. One too many years of reading about big donor exploits and dreaming of humanitarian glory got me all starry-eyed.

When August of 2007 dropped me in Swaziland I held a great deal of hope in the world’s ability to fix the world. Of all things, that hope died hardest. I immediately jumped onto the merry-go-round of relief and aid. I attended meetings with quality food, raced to beat deadlines for proposals and reports, answered every question patiently and attentively, and did all of that while fully committed to distant, dusty field work. Spinning in circles was fun for a while, until it messed with my equilibrium, forced me to stumble off the merry-go-round, and puke.

Standing back from the madness a little, I feel beat by the failures of the working parts. Most of all I see the relief and development community clinging to the merry-go-round while needy people stand on the sidelines. Aimless meetings are convened, government fails to address corruption and prod civil servants to be servants, money is wasted, and there is a general lack of commitment to the “extra mile”.

The NCP project proposal was approved as a shadow of its former glory. Any creative ideas for addressing the root causes of poverty and child suffering were left out because we were not given the chance to defend those ideas. We were forced to settle for an agreement that fits nicely with international donor expectations. The same agreement is a rather awkward misfit with the realities on the ground. Women at the Bomake Bembuso care point are obviously confused by the politics. They work at a furious pace on the sidelines, and their own contribution is not matched by the authorities.

My hope in “the world’s ability to fix the world” was misplaced at the beginning, and the death of that errant hope was the elephant in the room throughout food distribution. So I stood there, balancing a box of vegetable blend on the railing of the truck, trying to convince them (and myself) that good things are still to come; trying to pull hope from a hat.

Traditional Healers and HIV

Because HIV is so prevalent and occupies such a prominent place in the Swazi conscience, the palpable desperation for a cure manifests itself through some very unique media. For one, you can’t throw a cat in this country without it smacking into a sign that advertises traditional herbal cures for HIV and AIDS. There’s a good explanation for the lure of herbal cures. There is also a good explanation for throwing cats but that’s beyond the scope of this topic.

Swaziland holds ‘culture’ in rather high esteem. Most of that which resembles Swazi tradition and lore is sacred, prioritized, and sometimes worthy of a “Get Out of Jail Free” card. For culture, the King shows up to diplomatic audiences half naked with a sheet wrapped around him and no one thinks twice about it. For culture, tens of thousands of three-quarters naked girls parade for the royal family every spring at a festival known as Umhlanga (Reed Dance). And for culture, traditional healers and their medicine receive implicit trust and support from the Swazi community. Centuries of promoting traditional remedies in rural villages naturally creates a lasting bond between a people-group and their own understanding of health.

In the present context of AIDS, however, this could pose a problem. Seeing so many advertisements for “HIV cures” sparked a great deal of skepticism when I first dropped in on this kingdom. The confusion only multiplied. When someone begins hawking an herbal cure for HIV, the Western medical community responds with dismissal by saying “Oh, those crazy traditional healers” and the Ministry of Health responds with the exact same dismissal and a friendly chuckle. That apathetic acknowledgment is a huge mistake in my opinion. If someone really does have a cure for HIV, then the whole world better damn well know about it! And if someone is selling a fraudulent placebo, everyone better damn well know about it before the sick and poor get robbed blind and viral infection continues to spread! By simple logic, lethargic disregard allows these ‘cures’ to remain untested, unproven, and a large population suffers either way.

A Nigerian pharmacologist at the University of Swaziland added some complexity to the problem with a historic explanation. Many of the current drugs used to treat illnesses or chronic conditions are derived from plant life. Nigerians are particularly aware of this fact because there was a time when their traditional healers taught pharmaceutical pioneers about the healing properties of their local flora. Pharmaceutical companies thought this was pretty cool and so they took samples home, found ways of identifying and isolating the chemical agents with healing power, repackaged those chemicals, patented them, and sold them back to Nigerian hospitals for unspeakable windfall profits. I am not trying to paint Big Pharma as a group of maladjusted kleptomaniacs, but I can see how this would create some distrust between the masters of eco-medicine and the masters of laboratory medicine (even if they are technically on the same team).

So what’s the situation in Swaziland? Traditional healers obviously hold extraordinary sway in rural communities and their constituency is far greater than that of Western medical facilities. Are they confusing the population purposefully for the sake of a profit? Do they really hold the key to a cure for HIV?

In the name of informed reporting and all that, I decided to interview a representative from the Swaziland Organization of Traditional Healers (Letiko Letinyanga). When I announced to coworkers that I would be visiting the office of Dr. Nhlavana Maseko, they were shocked and advised me to take a weekend and clean out the evil spirits. Not that I was really worried, but the collective creepy fear of Letiko Letinyanga prepared me for just about anything.

My arrival was without fanfare. No disheveled women chucking dry human bones at me. No mysteriously clothed old men lurking in smoke and incense with bowls of goat’s blood. Actually it was completely civil. Their “offices” are mostly just rooms on a homestead transformed to accommodate work. Mrs. Simoyane, the mother of the homestead if I can call her that, was extremely kind and welcomed my questions. Here’s an abbreviated reconstruction of the hour-long interview.

Trevor: Could you give some definition to the current relationship between traditional healers and Western medicine?

Mrs. Simoyane: We do not have much of a working relationship. But not by our choice; those using traditional medicine want to work together. We are involved with hospitals and linked to doctors at clinics. But they don’t have much interest in working with us. There is no sense that traditional medicine can compliment Western medicine.

T: Are there any medical cases which you feel go beyond the scope of traditional medicine?

Mrs. S: Of course. Like cases of malaria must be sent to the hospital. But traditional healers can cure some things.

T: HIV is the biggest health topic in Swaziland now. What is the position of traditional healers regarding HIV and how should they respond to the disease?

Mrs. S: The truth is that traditional healers really don’t know HIV. What we know are the symptoms. We can deal with things like vomiting and diarrhea. But we cannot say that we can cure HIV because we do not have the machines or knowledge needed to understand HIV. The problem is that traditional healers want to say they are capable of curing AIDS because so many people have it. There is great demand for a cure. But we, as the organization, do not want them to say that because we know it’s not true.

T: If traditional medicine cannot cure HIV, and your organization acknowledges that, why are so many people still drawn to traditional healers?

Mrs. S: Well, as I said, there is great demand and some healers still claim to have the cure. Naturally, people want to believe that. But there is another issue that is very important. Hospitals can be horrible. The attitude is horrible, and there is no explanation for treatment, no one speaking about the reasons for these pills. At [some hospitals], the staff just vanishes at 1:00 in the afternoon for lunch, but people are still there dying on the floors during lunch hour!

T: There’s no personal attention.

Mrs. S: Yes! That’s exactly right. That is why people prefer to go see traditional healers. They sit down with you, establish a relationship, and really take a look at what is going on with the person. There is a personal connection.

T: You believe that traditional medicine can really compliment Western medicine, and there is this added benefit of the personal attention given by traditional healers. What then is the greatest barrier to working with Western medical institutions?

Mrs. S: Finance. Everything is done by finance. We do not have the money to even approach them and ask for cooperation or mutual understanding. And they certainly do not approach us…maybe because they are afraid of us. The problem for traditional healers is that we are not armed with funding because we work where poverty is around every corner.

T: You obviously have a desire to fight against AIDS and the terrible impact it has on your community. If you could make one request of Western medicine in order to successfully fight AIDS, what would that be?

Mrs. S: Train us to use the machines and testing equipment that are important to understanding HIV. Traditional healers can be trained in this, they want that training. Traditional medicine has something to offer the patient. We are not saying it offers everything, but it offers something. So there is no need for conflict between the two fields. We must help each other to care first and foremost for the patient. Conflict just suggests that the patient is not the most important priority in the field of health.

In the last post I wrote that a group of individuals holds enormous potential to positively or negatively impact the fight against HIV and AIDS depending upon how the rest of the world chooses to treat them. If you have not figured it out by now, that group is traditional healers. Mrs. Simoyane emphasized an essential point in HIV care when discussing the difference between personal attention from a traditional healer and impersonal medicine at a hospital or clinic. More than that, traditional healers do have something to offer a patient beyond just a listening ear.

Mainstream funding for HIV-related causes should watch their next step with traditional healers very carefully. Letiko Letinyanga exemplifies an organization with level-headed, patient-centric principles that is eager to work in cooperation with doctors and nurses at any hospital. Traditional healers already own the trust of many Swazi citizens and can make a positive difference in the context of their established personal relationships. But if the larger medical institutions continue to give them the brush-off, Letiko Letinyanaga will find it increasingly difficult to stem the tide of false cures and misinformation.

Information and HIV

EuropAid, the European Commission’s relief and development arm, announced the availability of a large sum of project money several weeks ago. After that announcement a few of us in the office sat around discussing the most immediate needs for project-related funds. Like he was revealing a well kept secret, Gideon Fakudze, the Church Forum’s amicable Finance Officer, slowly said, “You know what I am thinking…We should try to bring mobile VCT [Voluntary Counselling and Testing] units to churches.”

“Genius. If pastors would agree to a public HIV test following a Sunday service, or something like that, most of the congregation would be encouraged and follow his example…” I excitedly responded. Sensing some hesitance in the room, I finished that response by pleading “…Right?”

“Yeah, maybe,” he said, “but I just don’t know how many pastors would agree to that. Too much stigma. People would watch and say, ‘Ah-ha! This person stayed after to be tested. She must have HIV!’ They do that because they are scared and don’t know how to fight the virus.”

I was both frustrated and not surprised by his comment. For all the information distributed, the campaigns on television and radio, and the billions of dollars spent to teach people about HIV, the majority of Swaziland still shows signs of misunderstanding the virus. Even if a person is perfectly educated, the virus still scares that person enough to avoid thinking about it or taking action. Reflecting on that enigma, I connected the dots by supposing that, “Everyone knows they’re going to die. It’s just that most people can afford to ignore that reality for another 50 years. When you find yourself HIV positive, it probably feels like death is staring you in the face.”

“That’s it,” Fakudze echoed emphatically.

“But what about treatment? There are so many success stories about antiretrovirals [ARVs] and--“

“--No one hears those stories,” Fakudze interrupted. “There is still so much doubt, and people do not trust because they know someone who died anyway.” At that, Fakudze leaned forward motioning the onset of a relevant story. “You know, my sister, she came to me one day and was very sick. So we took her to the hospital, and they told us this and that about TB, and she has HIV, but she can’t take the ARVs because she is too sick. So they gave her a lot of these…what are they…immune boosters. And she took them.”

“What about the TB?” I asked, not willing to let that detail go uncovered.

“Oh, she took all the drugs for six months. The doctors said that she must finish treating the TB and then start with ARVs. But you know, she had a CD4 of something like 50!” He emphasized the shock of the number.

Thinking back to my time at the Baylor Clinic, I remembered discussing this very topic with one doctor who agreed that most medical professionals prefer to run a patient through the full antibiotic course and address the opportunistic Tuberculosis before starting the patient on ARVs. However, there are cases in which the TB is severely advanced, and a patient’s CD4 count is so frighteningly low, that the patient’s body surrenders to the irreparable damage done by both infections after they start taking ARVs. Cases like these breed rumors that ARVs kill people. In truth, the drugs did not cause death; the diseases were simply addressed to late. With that in mind, I asked Fakudze, “So did she start taking ARVs?”

“Yes, she was still not well, but they decided to give her the drugs anyway.”

“When was this Fakudze?” I inquired.

“Oh,” he pasued and looked upward, reaching back into his memory to identify a date, “maybe 2003.”

“And how is she now?”

“She died.”

That’s it, right there. That’s the point where I don’t know what to say. Combine the sadness with the encrypted Swazi code for managing grief, and I always end up silently waiting for them to carry on the conversation or change the subject; those two options seem to make people more comfortable. Although I’ve had plenty of practice dealing with that moment, it still feels awkward.

After a thoughtful pause, Fakudze suggested that accurate information and knowledge of HIV treatment probably would have saved her. “But, you know, these people…they get all confused by this herbal medicine, or this healer who says he can cure AIDS, or Government telling stories, or this pastor who tells his church that they should not take ARVs because you only need to pray to God or repent from sin. Even I still get confused by everyone shouting their own message.”

Those examples of confusion are not fabricated in the slightest. Church pastors actually do host “revival conferences” encouraging the committed faithful Christians of Swaziland and greater Africa to “Come and experience divine healing, where the excellent Pastor _____ will exercise the work of God’s power!” The revival advertisements are fraught with these clips of the pastor practically putting his palm through the forehead of some elderly woman who falls backward dramatically, causing people to scream “Oh my God! She’s healed!!”. Of course, God’s power is only available to the sick and needy for the price of admission. And of course, God’s power bought a 2008 BMW X5 for Pastor ____, which is parked just outside the “revival tent”.

I could go on, but cynicism has limited appeal. There are some twisted entrepreneurs in this world who discovered that HIV turns a handsome profit. Not all church pastors are fomenting confusion about HIV to get their hands on expensive luxury; quite a few are busy proclaiming a credible message of hope and care for everyone affected by HIV. But the reasonable men and women are always drowned by the fanatics.

Governments and NGOs also hold a significant share in the discontinuity of information. One group wants to promote condoms, another group wants to promote abstinence, and still another group believes HIV and AIDS are elaborate conspiracy theories (see: South African President Thabo Mbeki). The unfortunate truth that much of the population affected by HIV lives below the poverty line and did not receive an education at the high school level exacerbates the miscommunication. If such people can barely read English, they may also struggle to decipher all those “He Said She Said” newspaper articles about HIV. That’s if they can spare 30 cents to buy a newspaper.

But all is not lost. What I find especially fascinating is the power and promise held by those who work at eye level with the people. Doctors who fluently speak the tribal language achieve more in one day than most governments achieve in one year, and they do it in the face of a glorious private practice income. The same doctors, alongside nurses, counselors, teachers, and community organizers commit themselves to living and working where it matters most while sacrificing unfathomable wealth and publicity. People like these are capable of making a continuous positive impact on the health of so many community members. Part of me is surprised to find that the most compelling world-changers are only heard in whispers.

There is, however, another subtle presence on the ground; a particular group of individuals which holds eyebrow-raising influence in rural communities. In the battle for clear and cohesive HIV information, this group could become a priceless ally or a staunch opponent depending on how funding and advocacy bodies treat them. We will take a brief look at their position in the next post.

Top 10, v2.0

Before the Red Sox became 2007 World Series Champions and the global economy found itself up a certain creek without paddles, I listed the top 10 surprises of my first few weeks on assignment. You should know that Swaziland, just like every other country, is full of surprises. To prove my point, I put together another top 10 list of things that surprise me now, even toward the end of this long, slow year.

10. Swaziland gets cold! After endless months of heat and sweat I almost refuse to believe the temperatures. Now, in chemical terms, there is no such thing as cold; there is only the absence of heat (Just a second…I’m adjusting my pocket protector….There we go). So is it really cold, or did I become accustomed to the heat? Am I a temperate sissy? Probably.

9. Although it would be difficult to technically quantify, there is good evidence to suggest that Swaziland’s recurring years of drought are more the result of human error/incompetence than nature’s unfavorable turn. Inequitable water management, poor agricultural planning, the dismal state of farming assets, and weak efforts to encourage household food production are a few of the prime catalysts behind Swaziland’s food shortage. Higher authorities in governmental and non-governmental organizations know this and openly admit it; meanwhile everyone on the ground just thinks they’re starving because of a rainfall shortage.

8. Chickens are not awesome. They crap everywhere, errant feathers swish their way into every corner, hens are absurdly and unnecessarily protective of their young, and they hold no respect for sleeping hours. When my chicken whipped out the largest stock of baby chicks, I felt no pride; only disgust with the menacing fur balls.

7. Snakes are generally awesome. Their appetite for rats (inherent disease vectors) earns them valuable recognition in the health field. Black mambas, however, are the physical manifestation of evil on Earth. They stand up on their tail to six feet in height with intention to strike their prey in the face. Inside the safety of a vehicle, I have seen this. According to my host brother, they also make a sound reminiscent of a barking-yet-choking bull mastiff. Freaks me out.

6. You simply CANNOT underestimate the positive impact of Barack Obama’s nomination on Africa. Communities all over the continent are adopting him as their own leader of sorts. I know, I know, we should consider his anticipated policies and whether he can adequately manage the responsibilities and challenges of the U.S. presidency. But let me say this: perception is often a festering cause of interpersonal and international conflict. Obama’s selection for “the knockout round” changes the perception of America dramatically. When I walk down the streets of Manzini or climb into a crowded van-bus, I am no longer “some arrogant colonial white kid” (yes, that accusation frequently hits me without warrant). These days, I am “some kid who probably supports an African brother”. The dissipation of an unfortunate stereotype changes everything, and if you are living in a foreign country, you probably understand what I’m talking about. Congratulations Mr. Obama; you’ve achieved your lauded concept of “change” before the general election even takes place.

5. There is no such thing as a “tree-ripened” avocado. At least not in Swaziland. Our avocado trees allow the rock hard fruit to loiter on the branch for months, and within a half-day flash, they rot. If you want to eat the avocado, you must pick it and wait for two weeks until it softens to a spread-able state. Maybe these trees carry a peculiar genetic defect that prevents tree-ripening. Or the supermarkets lie. One of the two.

4. If I were to give a percentage estimate comparing intestinal regularity to intestinal irregularity over my entire time in Swaziland, it would look something like this: 20% regular and 80% irregular. See, this blog is worth every penny you pay to read it.

3. The World Health Organization declared last week that there is little-to-no risk of a global heterosexual AIDS epidemic (as reported by The Independent here). I found this shocking because after all the frail dying bodies and emaciated children I’ve seen this year, I was pretty sure that AIDS is more than just a threat. But wait, there is one clarification. They did not lie about sub-Saharan Africa where HIV and AIDS are just as ruthless as they thought. Thanks for reminding me that this nightmare is real.

Quite a few journalists jumped onto the bandwagon and began chanting "See! HIV is only for high-risk groups like prostitutes, homosexual men, and injecting drug users!" Whether their motivations for attacking the dispersal of misinformation are honorable (advocating for more effective use of the limited available funds) or dishonorable (using an epidemiological report to foster a moral agenda), the media frenzy proves that much of the world still does not understand HIV or the theological grounds for humanitarian work.

If one child dies because his mother was raped by an HIV positive vagrant, and she was unable to access life-saving drugs years down the road to prevent transmission of the virus, that is one child too many. If one teenager gets sucked into hard core drug use and thereby contracts HIV, that is one teenager too many. If one poverty-stricken man is desperate for financial scraps and travels to the mines where he sleeps with an equally poverty-stricken prostitute, that is one man too many. And if one homosexual male in an upper class neighborhood is slowly dying of AIDS-related infections, that is one homosexual male too many. Who gives a damn about numbers!? Shame on the larger funding agencies if they used numbers or doomsday predictions to draw donations. Shame on the implementing organizations for wasting that money on low-impact, ineffective programs. And shame on anyone who cares about how many people are suffering, or where someone is suffering, or what type of person is suffering. "He who is without sin, let him cast the first stone" suggests that AIDS is gravely important to all of us no matter who is affected.

2. Poor rural communities are not the oasis of morality and happiness people imagine (i.e. the ever-popular “poor people are happier because they are not corrupted by wealth and they don’t emit as many greenhouse gases” theory). For example, because the community leadership covets my host family’s property, they fabricated stories that my host great-grandfather never paid a cow when he settled. Somehow his bovine default justified brief mob destruction of my host family’s fence a mere two months before I arrived in Swaziland. Fortunately, they were stopped from advancing by a combination of seething canines and a few reasonable people. The community is now using outlandish legal means and relief agency projects to push the family out. The powers also decided to limit my host family’s only supply of water (a community tap) to the following: 150 liters per day to be shared among ten people for cooking, bathing, washing, etc., and absolutely no water on Wednesday or Friday. But fear not, for there is a silver lining. I am now capable of bucket-showering with 7 liters of water!

1. God shows up. Right now, the Pharisaical readers are tossing their heads back and scoffing, “That should not be a surprise, O ye of little faith!” Atheistic readers toss their heads back and scoff, “Religion is the opiate of the masses!” And many others are likely wondering why I would make such an outlandish claim following some of the previous surprises. Honestly, I have no clear answers for that question. My faith is weak, and religion does often appear to be the opiate of the masses.

Ultimately, any explanation for this final surprise (whether written on a blog or discussed in person) will be of no use to you. Faith and experience should not be group-think. They should be deeply and unshakably personal. I would also add that you do not need to run through the same volunteer assignment to explore this issue. Terrifying challenges and difficult questions will force their way upon you whether you like it or not. When they do, jump in. You will likely discover a few surprises of your own.

What It Feels Like...

Billabong, one of the surf industry magnates, used to run these brilliant advertisements in a number of surfing magazines. Always a one- or two-page spread, the ad was set up by an awe-inspiring photo of any given pro leaning into a bottom turn, stretched out in a death-drop beneath a breaking wave lip, or tucked smartly into a glassy tropical barrel. And the phrase in the corner was perfect: Only a surfer knows the feeling.

Call it endorphins or stoke or whatever, but riding a wave produces some incommunicable sensation that makes life perfect, if only for an hour or so. After all the waves I’ve ridden it is still impossible to identify what exactly about the whole ordeal is so spectacular, considering most waves finish within two or three blinks (unless you’re surfing one of those Chilean lefts, in which case you could read a book before getting out to the shoulder).

Most waves are remembered for the segments that stand out; dropping down the face and quickly turning down the line, slicing your fins through the lip and hearing the splattered spray on the backside of the wave, getting punched in the head when the wave closes out, etc. It all happens so fast. But you always ride over the shoulder at the end, drop to your chest, paddle back into the lineup, and find yourself unbeatably blissful. Without seriously studying that phenomenon or dissecting the mechanics of that feeling, I would say that I surf exclusively for the fleeting contentment. The potluck that is my lifetime is peppered with a reasonably serious investment in a variety of action sports; snowboarding, mountain biking, road cycling, skateboarding, wakeboarding, kayaking, and others. Every one of those sports makes me pretty happy. But surfing…well…only a surfer knows the feeling.

I am not telling you this to make you jealous or to enlist myself in some exclusive club with a special password that you don’t know. All this gushing is a reminiscent explanation of how surfing saved my year to a small degree. After eight months of frustration with donor politics, multiplying orphans and vulnerable children to whom we can’t even provide the simplest amenities, and the ballooning concern that Swaziland is entering a phase of intractable anguish, it was nice to feel stoked again. Throwing some spray on a cutback, and even taking a wave on the head, was pretty satisfying and relieved a lot of pressure that I never even acknowledged until it was released.

So you will be surprised when I say that, as much as I enjoyed the magic of ocean energy and soggy wetsuits, surfing only played a role in April’s refreshing weeks off. On April 13, my parents arrived in Johannesburg and spent the next week following me around on the job, five straight days of “Take-Mom-and-Dad-To-Work Day”. While delivering supplies funded by generous contributions from friends at home, and a few funded by UNICEF, I tested a nutritional survey with the caregivers and gave my parents time to absorb the environment and interact with the children. Inwardly, and now outwardly because I’m putting this on a blog, I was beyond impressed with my parents ability to soak up what they witnessed in Swaziland. During every NCP visit, they showed sincere interest in the caregivers, the children, and the lives each of them lead. Never once did they complain of heat or fatigue or discomfort, but always made an effort to connect with the complex working parts of every care point. For this, you should applaud my parents.

(Note: You don’t really need to clap. I always despised forced clapping; like when the actors in a “Peter Pan” production force the audience to clap for Tinker Bell. As if a fairy really needs a bunch of no-names to clap so she can continue indiscriminately sprinkling dust everywhere. Give me a break. It’s just a way of saying that my parents are rad.)

After the working week in Swaziland, a special flying machine called an “airplane” took us to Cape Town. We stayed in a beachfront apartment for the week at a ridiculously cheap price, enabling me to go for a surf in the morning and my parents to walk for a while on the beach. Even at our leisurely pace, we explored all the best of that city; hiking over and around the Cape of Good Hope, walking and swimming with penguins at Boulders Beach, climbing up and down Table Mountain, exploring the winelands of Stellenbosch, and generally reveling in a stunning corner of the world. Going out for dinner was easy because we were guaranteed a win-win experience (winning on taste and winning on price comparable to a similar experience in California).

Before turning this into a travel guide, I should drive to the two important thoughts/feelings rendered by that week.

1) Cape Town feels ignorantly dropped into South Africa’s politically contentious context; a place where enormously complex racial lines bisect the dichotomy of rich and poor. After reading stacks of material about South Africa, I could have exhausted myself in further examination of that dichotomy and nudged myself toward the mirage that is solidarity. But I didn’t want to spend the week like that, and worse, I couldn’t work myself up to give a damn. Maybe I was justified in my escapism. Maybe spending so many consecutive weeks on the edge of disease and poverty earned me two weeks in Neverland.

But extended exposure to the truth about HIV and TB and drought is supposed to turn me into a radical, right? Shouldn’t I be well on my way to Paul Farmer-ism and a totally righteous commitment to the daily battles of social justice? What exactly is putting out my fire? Or maybe my vision is shifting focus and my sense of purpose in all this mess is becoming toned. Whatever the answers to this confusing problem, I am only thinking retrospectively; such thoughts did not really harass me during the two weeks of vacation.

2) “Isolated” is a somewhat accurate description of this year, although the isolation is different than you might imagine. I’m not spending 10 days at a time in the bush, hunting for food and chatting with a volleyball about the latest movement of elephant herds. But much of this year forces me to “go it alone” even though that’s not what I want. The simple presence of people who know me (like my parents with whom I can speak honestly about the events of the year and the subtle nuances of character change) made an astounding difference in the way I see my life this year. I especially noticed the impact of my parents during their week in Swaziland. Truthfully, it was a relaxed week in comparison with those of the past and present. But instead of seeing something traumatic at a care point and talking to myself about it at the end of the day in my back-breaking-bed, I had friends around to listen and encourage and advise.

Cape Town was an amplified version of this pick-me-up. Simple things like showers, toilets, washing machines, and a kitchen with all the works made me pretty happy. Throw in Magnum bars, good breakfast meals, seafood or steaks for diner, and I’m ecstatic. Top it off with incredible people like my parents, the joy of exploration, and generally good times with good laughs, and then we’re talking about something else entirely. Taking a step back to examine my life this year during the week in Cape Town was, just like surfing, an incommunicable feeling.

Mom and Dad left for the States after that week, while I moved on for my second week off in Jeffrey’s Bay. For those who don’t know the place, it is an iconic surfing destination with a long right point break over volcanic reef and a smattering of other peaks in town. So it figures that I surfed myself to exhaustion that week, or at least as much as wind conditions would permit. Physically exhausted but mentally renewed, I returned to Swaziland with lighter hair and the smell of salt water stuck in my nose. This year is quickly winding down, and to be honest, I’m looking forward to the coming days of friends, family, and of course, surfing.