Peace Corps responses to HIV/AIDS from within

Hi all,
I am back from a long blogging hiatus with a piece that I wrote for Peace Corps' 50th Anniversary. Enjoy!

Peace Corps responses to HIV/AIDS from within

What does the response to the HIV/AIDS epidemic look like nearly three decades into this ravaging disease’s tenure? How can we come from abroad armed only with knowledge of the epidemic and the will to make a difference and translate that into action which leaves a positive impact? These are difficult questions to answer. We have learned from years of experience that there are many development strategies that do not work and some that even become counterproductive, creating dependency on aid or destabilizing local economies. However, we have also seen development programs that give us hope, that originate from within communities and respond to the root causes of our woes. That we all have the ability to make change may be true, but good intentions alone will not suffice. Just as with other development programs, an effective response to HIV/AIDS is hard won and comes from within.

In my brief experience in Malawi working with the Department of Health and Social Services at the Zomba City Council the key to eliciting the answer from within lay in finding those willing to critically assess their role in responding to the epidemic and supporting their efforts. Thinking holistically, my counterpart and I took a closer look at how the department ensures for the delivery of all of its health services. Our first step was to better understand the health and wellbeing of the city’s residents. Moving from anecdotal observations to systematically collected information, we shaped a clearer picture of the health of Zomba City, acknowledging the heterogeneity of the city. From such a perspective, we are able to prioritize improvements in key health services in critical areas of the city and have united with all of Malawi’s urban councils to seek structural changes in local governance, allowing motivated Malawians the opportunity to better serve those in need.

Just as HIV/AIDS destroys the body’s ability to fight off infection and heal, mismanaged and underfunded health systems take away the government’s ability to prevent disease and provide treatment and care for those suffering. Improving health systems is like prescribing ARTs, as it enables the country to regain control and heal itself. In development jargon it is called health systems strengthening. It is the slow and strategic process of realigning the country’s public health services to respond to the HIV/AIDS epidemic and other health challenges. It is not a quick fix, but consistently pursued it is a crucial part of the HIV/AIDS response as well as an important step toward improving the overall wellbeing of Malawians.

I consider it a privilege to have been a small part of this important process in Malawi and it is my sincere hope that Peace Corps Malawi will continue to play its important role, in villages and cities, to promote sound development from within.

Mike Dalious
Peace Corps Response Volunteer 2010-11

World AIDS Day

Today I co-facilitated a community dialogue with the faith community of Zomba City. We had Catholics, Baptists, Seventh Day Adventists, Muslims, Protestants and several other small denominations all in the same room to discuss the response to the HIV/AIDS epidemic. After introducing them to the concept of a community dialogue, we asked them to share their beliefs with the group related to human rights and HIV prevention, treatment, care & support and impact mitigation.

Allowing them to express their beliefs in an informative way, rather than a preachy way, we were able to go around the room and hear from everyone. With attention paid to the differences, but emphasis placed on the similarities, we were able to come out with an action plan that includes teaching religious tolerance, accepting people living with HIV/AIDS and continuing the dialogue by inviting additional denominations to the discussions. And that was just my morning…

After returning to the office to write some emails and prepare for my sessions with the new volunteers, I was called upon to teach an employee how to properly use a condom. This is not really within my scope of work, however our AIDS Coordinator was still out at her community dialogue session and I learned from my colleague that the gentleman was HIV positive and his wife was not. He came into the main office today, World AIDS Day, because his CD4 count was falling and he was afraid that his wife would become infected. Since his diagnosis nearly three years ago they have been practicing partial abstinence, but his failing health forced him to consider using condoms and to request food supplements from the city to help him recover.

As I taught this young guy how to put on a condom, I was struck by how unfair life can be. Here is a guy younger than I contemplating his actions and his death. I could see it in his eyes. He was scared and I was scared for him. As my colleague translated what I was saying, I had brief moments to reflect on my own life, on my own worries. Me, concerned about finding someone to love, versus him, concerned that his love will die because of him. I am telling you I could see this in his eyes, in how he held himself. It is a moment that I will not forget and one that will serve to humble me.

Those who do more than endure

Yesterday I spent the day out in the community. The National Association of People Living with HIV/AIDS in Malawi (NAPHAM) was in town with their drama group and they performed at two community-based organizations that provide HIV/AIDS services. It was a long day for me as the events were conducted in Chichewa making it difficult for me to follow along. However, it gave me ample opportunity to think about what I should write about next.

On the way out to the first community we passed by a funeral, seen from the branches laid across the road to alert those passing so they can slow down and show respect for the dead. The driver of the bus slowed accordingly and softened the radio, which temporally dampened the joyous mood of the actors on board. Once we passed over the second strip of branches the music was revived and the volume of conversation quickly rose.

As we were watching the first performance, I was struck by a small boy with a distended belly and blondish hair–familiar signs of malnutrition–who through hazy eyes knelt down near me, placed his forearms on the ground for his head to rest on and quickly fell asleep.

Both of these stories partially describe my experience here. They serve to illustrate the depth of poverty which embraces much of Malawi. However, these stories in isolation do not do justice to the people that endure them on a daily basis. For they are strong enough to bare the constant loss and the pains of hunger without losing their startling ability to warm your heart with a glowing smile and kind eyes. The bus rolled on to a vibrant performance and the small boy got up to go off and play with his little friends.

This strength of character did not escape the drama group. With their play, they walked down the path of HIV infection and the saddening stigma experienced by so many. And with tears in their eyes and frowns covering their faces, they would explode into radiant smiles with the tears still running down their faces to a wave of laughter and applause from the audience. Quickly as it came the smile would disappear into a look of confusion and fear as the actor lashed out at his wife or neighbor. The dramas were roller coasters of emotion that cleverly illuminated the lives of their audience in a way that encouraged acceptance and coexistence. For me they were a reminder to write of more than the ugly and strange face of poverty, to acknowledge those who do more than endure.

And then there was one.

I arrived to Malawi with two fellow volunteers. We actually met in the Johannesburg Airport boarding our flight to Malawi. Mike O. was coming from Albania where he had served in the Peace Corps and then worked for several years with World Vision International. Richard was coming from a freshly completed Peace Corps service in Botswana, where he was working as a district AIDS coordinator. We spent two and a half weeks in and around Lilongwe for an orientation then were sworn in as Peace Corps Response volunteers by the US ambassador. Richard and I headed south to our sites in Blantyre and Zomba. Mike O. headed to the west for his site in Mchinji.

Backing up a bit in the story, I was recruited by the Peace Corps to serve as a response volunteer in Malawi, a job I was happy to take because I wanted work experience in Africa on health systems strengthening projects. Peace Corps was recruiting for 10 response volunteers that they planned to spread out over Malawi in an attempt to support the response to the HIV/AIDS epidemic. They only got three. I chalk it up to a limited pool of qualified candidates and well let’s say life. If you have finished the Peace Corps and have a graduate degree, you are no spring chicken. What you are is in that middle ground between running around and settling down. Mike O. and Richard were already married and a few years older than me. It was clear that we were all looking for something.

Well, a week into our service, Richard flew back to the States for his home leave. Having come straight from Botswana, the Peace Corps gave him a month to go back and catch up with his family and friends before returning to work. After a little delay, we heard that he was not coming back. So then there were two.

Mike O. and I got along great. He is a light-hearted guy that is quick with a joke (that’s what she said, Mike) but who also has a serious hardworking side too. We were the two response volunteers in country, Mchinji Mike and Zomba Mike. We hung out a few times when we were both in Lilongwe for work or a wedding, and we sent text messages, emails and called back and forth a few times.

Unfortunately Mike’s counterpart was a dud and it was difficult for him to get anything moving. The first time around in Peace Corps this would be considered a very normal occurrence and a process of growth for the volunteer as they experienced how things can come to a halt despite our best efforts. As former Peace Corps volunteers, Mike had experienced this already and was not up for a repeat performance. I can’t blame him. As Peace Corps Response volunteers, we expect tangible work assignments and the resources to accomplish them. I got lucky, as in Zomba I found a motivated counterpart and quickly got funding. Mike made the best of his situation for a while, but then made the decision to go home, a decision that I fully support, though I am saddened to see him go.

And then there was one. As the sole survivor of Peace Corps Response Malawi, I have to ask myself what it is that I am doing here. I laugh to think about the old Army commercial’s slogan, An Army of One. In development work, nothing seems more ridiculous than a sole person—especially a foreigner—trying to move seemingly inert government employees and policies and improve the lives of so many. Development is a collaborative process beset with trials and errors. It is a learning process that thrives on communication and good will. And it is a process that needs to reach a critical mass or it will simply stop. As one volunteer, I have to face the fact that it is unlikely that my efforts alone will have a lasting impact on the health and well-being of Malawians.

I need not only to finish my work here in Zomba; I have also to ensure that it is scaled up across the other cities in Malawi. I have to make the case that the urban population’s growth is bringing with it new health and social challenges, and if the government of Malawi continues to neglect the health of its urban residents by supporting a poorly implemented decentralization of the Ministry of Health that favors rural service delivery, urban residents will suffer. My counterpart sees this and is working to change the current structure of health within the government. Peace Corps Malawi is also supporting my efforts to establish an urban M&E system for health, so that the cities can have a better understanding of the health of their residents. And of course we are lucky as there are only four major cities in Malawi, and there is a potential for placing new response volunteers in the other cities in an attempt to roll out the M&E system countrywide.

Will it work? I don’t know, but I am certain that I cannot do it alone. Peace Corps Malawi and the Government of Malawi will need to make substantial investments over the coming years to see this project to fruition. I only hope that I can set them rolling in the right direction.

Labor Intensive Development

There is a crew of men painting a center line down the main road that runs from Lilongwe down through Zomba and on to Blantyre. They have one pick-up truck with a large barrel of paint, some orange cones, paint brushes in varying states of wear, a length of string to make straight lines and small paint buckets made from an assortment of plastic containers. I have seen these same guys working for over a month now painting this one line—sometimes solid and sometimes dotted for passing zones—that stretches on for over 300km. When you see something like this it stands out in your mind and you think about how it is done back home. I think of a high-tech truck that can drive down the road cleaning the area with pressured air and then paint it with a spray-paint gun mounted on the back of the truck. This truck would have some flashing lights and drive at about 10 miles per hour, meaning that two or three guys could accomplish the work of 40 or so in two or three days instead of several months.

There are a lot of us that think sending a truck like this to Malawi would be a good development project. I can see the proposal now—roads painted faster and more accurately, more efficient use of paint, better paint retention time, less traffic obstruction, less risk for road workers, etc… All it would take is the one truck and we would send back reports each month on how many miles of roads have fresh lines to keep the drivers of Malawi safe. Until of course the truck needs maintenance or the spray-paint gun breaks and there are no parts for it in country. The cost of the truck, the shipping costs, the maintenance costs are negligible costs in terms of foreign aid, though combined they could probably pay the current crews wages for the next year. Employing Malawians to paint provides a steady income for the men who would otherwise be unemployed. All of their supplies are available locally and they can adjust their work schedule to the amount of funding annually available for road painting, unlike the high-tech truck which has high upfront costs.

So Malawians should say no to the high-tech paint truck right? Thank the donors for their good intentions but politely decline the assistance. Well, it doesn’t often work this way. Aid is political and often the beneficiaries in the proposal are not the only beneficiaries of the project. Government officials are inclined to keep saying ‘yes’ to aid projects, as those who decline are seen as difficult to work with and may miss the next round of handouts. And though the high-tech truck might not be a good development for the workers, modern equipment is seen as a sign of progress, a sign that the current political party is working for the people. To further complicate the issue, we might discover that the road workers, who were hired out of the capital city and have been living away from their families for months at a time, have a higher likelihood of contracting HIV and spreading it along the length of the main road—Lilongwe to Blantyre.

So do we like a high-tech solution or a labor intensive solution to paint lines? These are the often seemingly simple yet convolutedly complex decisions of development work. As for me, I say stick with the labor intensive method, but hire the men locally and spend a little more on training and safety. All of that to decide how to paint a line on a road, now let’s stop an HIV/AIDS epidemic…

Monday Morning

Monday morning rolls around. I wake up with two cups of coffee and head into the office. What to do this week? I have made my annual plan, my monthly plans, and each week I come up with a list of things to do. These plans help to keep me heading in one direction, but they are by no means day-to-day plans. You can’t force things here. It is a game of patience and diligence to accomplish anything. To know the right people, to approach them in the right way, to do so at the right time, and it often seems, to have a bit of luck; this is what it takes to check off each item on the list.

In a resource-starved environment often with under qualified though thoroughly networked staff, round about ways of accomplishing tasks develop that while being foreign to an outsider get the job done. When I get locked out of my office, there is not one person to go to. Instead I ask around until I find someone who happens to have the spare key to the room where the spare key to my office is located. When I am trying to obtain a copy of the reporting forms for health centers, I visit the health centers that refer me to the District Health Office then to the Zonal Health Office then to the central ministry and pick up an additional form or two at each place I visit.

Complicating things, at every step of the way there are three additional tasks that could be taken on. I am working to improve the coordination of the HIV/AIDS response in Zomba City by creating a monitoring and evaluation system that will collect key pieces of information from health providers in the city, which will be later used to make informed health programming decisions. However, right now we are not able to properly administer our bursary funds for orphan and vulnerable children meaning that there are children out there who could be in school but aren’t. We are not providing food supplements to city employees living with HIV which help them take their medications and retain their jobs. And sadly, I have just been informed that one of our secretaries, who has been cooking lunch for me since I arrived, has died from rabies after being bit by a dog this weekend. Apparently we need to revisit our rabies vaccination efforts as well.

In the face of it all, it is easy to understand how people can become demoralized. Some blows can take away your breath while others seem to deprive you of the air around you. However, day by day we make incremental steps towards a healthier Zomba City: by teaching an environmental health office how to use a GPS unit; by encouraging our data entry clerk to submit timely reports even to government agencies that are not cooperative with us; by incorporating rabies control efforts into our M&E system. Though they often do not appear in work plans and are difficult to measure and appreciate, they may be the most lasting efforts we make. They quite literally are the blood, sweat and tears of development.

HIV/AIDS technical advisor

The position in subtle variations is so ubiquitous across this region of Africa that my coming blends in with the seemingly endless flow of HIV/AIDS programs and personnel. I have an office in the city government and liaise with the City AIDS Coordinator amongst many others. My principle assignment is basically to grasp the current extent of the HIV/AIDS response in the city, provide key indicators of its performance to the city government, and assist them in improving their coordination of the response.

An estimated 88,000 individuals reside within Zomba city, with a daytime population easily surpassing 100,000. 15 health facilities operate within the city boundaries, including a regional hospital, a mental hospital, and institutional hospitals and health centers at the police, prison and military campuses. 53 community based organizations are registered with the city government with mandates to provide social services, including HIV prevention, care and support, to city residents. The National AIDS Commission and countless NGOs have been implementing HIV/AIDS programming here for over a decade.

The national prevalence of HIV/AIDS is currently estimated to be 12%. Though the prevalence is thought to be even higher in the south of the country, where Zomba is located, with urban areas even more affected. Here prevalence rates are estimated as high as 18%, translating to nearly 1 in every 5 individuals living with HIV. The epidemic is generalized, affecting all groups, with women experiencing higher prevalence rates due to biological and socioeconomic determinants that increase their risk of acquiring HIV. There is no one here who has not been directly affected by the epidemic; the loss of loved ones, the risks of pregnancy, childhood and adolescents, the economic instability of a diminishing workforce. HIV/AIDS is omnipresent, an oppressive plight within the warm heart of Africa.

That said HIV/AIDS is an elusive evil, one that lies beneath the surface of the social fabric. It is a virus that suppresses the immune system of those infected; increasing susceptibility to opportunistic infections that can quickly erode quality of life, if left untreated. As such its outward expression is of a host of infections that lead to skin lesions, persistent coughing and wasting. Its acquisition is marred by the social taboo of discussing sexual practices that are tightly intertwined in the cultural and socioeconomic reality of those affected. In a society that values high parity and sees being overweight as a sign of success, HIV/AIDS brings shame on a family. Thus in difference to those infected and affected, HIV status is handled with discretion.

The burden is carried silently as those affected toil in the fields and markets. Nor is it the only hardship that must be endured. It is the latest and arguable the most deadly in a long line of diseases that compromise the health of African society. HIV/AIDS is also an addition to every other hardship that comes with living an impoverished life; the grueling physical labor, the uncertainty, the parade of material objects that are out of reach.

If poverty is an oppressive lack of information and options, HIV/AIDS exacerbates the situation; pushing the dreams of the young couple out of reach, robbing the old of their children and burdening them with more grandchildren then they are capable of caring for. In this context, it seems reasonable that the pain caused be gently hidden from view and a focus be given to family and more immediate challenges.

As treatment and care programs are being scaled up, people are living longer and speaking out. Gains are being made and Africans are learning to adapt in ways that not only ease the dangers of the current epidemic but also prepare them for future challenges. But the scars have been left on a generation of children that see the suffering and continuous funerals as the norm in a childhood devoid of choice and opportunity.

What does it all mean for an HIV/AIDS technical advisor? It means that daily I stare into the invisible eye of an injustice that is crippling those selling me bananas or kind enough to ask me how I am doing. Such a reality is enough to take your breath away. It is also a dilemma so large in its totality and complex in its composition that it can thwart the efforts of thousands of motivated and good intentioned individuals. On the best of days, it is an immense beach slowing being eroded by a tide that makes uneven passes at its miles of dense sand. At worst, it is completely out of reach, something visible but untouchable floating through space and time claiming those around you, frustrating your best efforts in strangling it before it can claim another life.

The land of acronyms

I am swimming in Peace Corps alphabet soup. Here is a quiz for everybody...
PST
IRC
PCRV
EAP
And some global health soup too...
PMTCT
PLWHA
OVC
MCP

ANSWERS
Preservice Training
Internal Resource Center
Peace Corps Response Volunteer
Emergency Action Plan

Prevention of Mother to Child Transmission (of HIV/AIDS)
People Living with HIV/AIDS
Orphans and Volunarable Children
Multiple Concurrent Partners

And that is just the beginning...