On being gross

I’ve been in Swaziland for more than four months now, and I’ve now been at site longer than I was at pre-service training. This I consider a milestone. Being at site feels much different from being at PST, where we saw other volunteers every day and had a structured schedule. The routine there was extremely rigid. Here, there isn’t much in the way of a routine. That’s fine with me. I keep thinking about how difficult it’s going to be to go back to a 9 to 5 world after this experience.

I’ve also been thinking recently about how Peace Corps changes the way we think about what’s “gross.” (In this way, I suspect it’s a tiny bit like having a kid.)

Examples:

1.     Peeing in a bucket inside. Not every volunteer does this. Some go to the pit latrine at night; guys of course have it easier in this regard as well. But for some of us, if we need to go when it’s dark, we use a bucket and dump it the next day. Chamber pots have existed for ages, but I don’t think most people in the Peace Corps have used them till now.

2.     Food that doesn’t look as delicious as you’d like. As PC tells you, you become a little less discerning about what’s a bit past its prime. I don’t eat rotten food, but I’ve probably eaten some uglier produce than I would back in the U.S. I have a fridge, so this is less of an issue for me.

3.     Bathing infrequently or less thoroughly. I take a bucket bath at least once a day and wash my hair at least every third day. Some volunteers go longer; one volunteer went two weeks without washing her hair. When washing your hair and bathing are a pain, your standards change.

4.     Washing your clothes. My host family is constantly doing laundry. I mean, every day, sometimes twice a day, the ladies are out hand-washing and hanging clothes. There are washing machines in Swaziland, but I haven’t seen one. I tend to let things go about three rounds before I wash them (unless they’re visibly dirty or it’s been really hot). Like my family, I change out of my work clothes and into crappier clothes when I come home every day. I can’t tell you how happy I am that I bought two comfortable cotton knee-length skirts from Old Navy, black and gray. I wear one every single day. Old Navy attire is part of the PCV uniform, which also includes Chacos, a Nalgene and a Leatherman. (Side note: Walker sent Leatherman a letter saying he liked their products and was using them in the PC, and they sent him a thank-you note, a carrying case for his Leatherman and a bunch of stickers. Nice guys, those. He hasn’t heard back from SmartWool or Celestial Seasonings.)

5.     Killing things. I haven’t seen any super scary bugs or pests, but other PCVs have, and they do not hesitate to kill them. I did see my previous host family kill a bat that found its way inside. It was dramatic. But PCVs kill snakes, giant spiders, scorpions, roaches, etc. I am not looking forward to this. But when it’s you or the snake, well, you gotta have priorities.

6.     Diarrhea. It’s not that PCVs love talking about this, it’s that everyone experiences and expects it. So we talk more openly about it than I’d dream of doing back home. I’ve already heard a few stories, man. Lemme tell ya. Before I left, I heard that PCVs said pooping your pants was a rite of passage in PC (this is not Swaziland specific). I’ll go ahead and tell you that I haven’t crossed that particular bridge. Chances are that you won’t hear about it in this forum if/when I do, so don’t get your hopes up. Feel free to ask me when I come back. I’m sure it’ll be a heck of a story if it goes down. In the meantime, I’d be OK with avoiding this.

Topic No. 6 does raise an issue they don’t talk much about before you come. Going to the bathroom when you’re not at home can be something of an issue. In the big cities, there are public bathrooms you can pay to use. In Manzini, the new fancy mall has wonderful free bathrooms. Restaurants don’t seem to be required to have restrooms for customers, as far as I can tell, though some do. But there are some towns that just don’t offer any options. You have to plan ahead, which is often tricky (if not impossible, in an emergency). I don’t love this. But it is, as they say, what it is.

Anyway, I just wanted to share some of the PC realities with y’all. I know some of you thought it was just money, fame, fast women and a life of leisure.  

More photos!

 Sunset over my backyard maize field.

 View of the hills behind my homestead.

 More hills! Plus the pit latrine, which I don't use because I use the flush toilet (holla).

 This is the krall, where the cows hang out when they're at home.

 Hills! And the pit latrine again. And the neighbors' pit latrine. All the good stuff, friends. Nothing but the best for you.

More hills in the distance. It was just so nice and sunny today, I had to take some photos. "Kushuta" is the Swazi word meaning to take photos.

On a lighter note

I can’t remember how much I’ve told you about food. Stop me if I have. HA! You can't. Anyway, if I haven’t been over it, you probably want to know what I eat. That’s a common PCV (and life) question.

Swazis eat a lot of liphalishi, or pap, a corn porridge. Most meals include some manifestation of this. For breakfast, it can be a “sour” version or a soft porridge. Think grits. For the lunch/dinner version, think grits, but firmer. I like it fine, but I don’t cook it for myself.

Most days I start with oatmeal with honey, milk and a banana. This is a pretty normal American food, though never one I’d eat in the U.S. I don’t know why I like it so much here. I think it’s because it fills me up, and I don’t have a toaster. I could toast bread in a pan, but why turn on the gas stove? I make my oatmeal using water I’ve boiled in my electric kettle. Of course, coffee is always a part of this event. You guys did an amazing job of keeping me supplied; I think I have six bags of deliciousness now.

I often do PB&J for lunch, the No. 1 food of PCVs everywhere. You can get those items here easily, and tuna also is available. For dinner, I’ll do a veggie and egg scramble with rice, rice and beans/veggies or pasta. Avocado will be a part of this if I have it around. I don’t cook meat for myself, though I have been eating it. I’ve always been the kind of person to buy a bunch of what I know I like and stick to it. I don’t mind cooking; food experimentation is just not high on my list of priority activities. If I find a rotation I like, I tend to stick with it. Sometimes I make beets, but it takes a while and eats up a lot of gas, so I don’t do it too often.

One thing I buy here that I didn’t buy in the U.S.: long-life milk. This comes in a paper 1-liter carton, and it lasts for up to a year. Once you open it, you have to drink it within a few days. Mine usually lasts a week in the fridge. This is particularly necessary here because many people have to get on a long bus ride home with their groceries. It’s a lot easier if you don’t have to worry about keeping things cold.

I’m not sure what process allows the milk to last for so long. I try not to think about it.

My two favorite Swazi food treats are chicken dust and emafeti, or fat cakes. I think I’ve mentioned the latter. Have I told you about chicken dust?? It’s grilled chicken served with liphalishi (or rice) and salad of some kind. The “dust” is because it’s sold on the roadside. So yes, you’re probably eating a little bit o’ dust. I like it best when it comes with shredded beetroot salad. I had some today from the car wash in my village, and it was DELIGHTFUL. It came with cole slaw and spicy baked beans. What I didn’t eat (bones and skin, mostly) went to the very pregnant dog on the homestead.

I hope, btw, that we’ll get some puppy photos soon.

Fat cakes are balls of dough cooked in grease. What’s not to like? I try to avoid buying them too often, with varying success.

That, amigos, is basically my diet. Trips to town usually involve treats like soft-serve ice cream or pastries (American-style doughnuts!) from this lovely place called Baker’s Corner. Sometimes I buy Toppers, chocolate sandwich cookies with chocolate cream inside. Those are dangerously delicious.

This is all supplemented with whatever you send me, too. Everything is MUCH appreciated. I even share. The fam seems to like the Tootsie Rolls and Tootsie Roll Pops.

Fixing a gutter — with attitude

 Kids hard at work cutting blocks to attach the gutter.

 Walker doing the thing.

 This kid loved my sunglasses. Who could blame him?

His pose was so good, I decided to copy it for my own photo.

A whole bunch of public health stuff

Sanibonani, all!

Today I don’t know what I’ll do. Perhaps I’ll mosey over to the primary school to see what they typically do during life skills class. I’m not sure. These are the sort of funny days, where I could sit around and read and do crosswords but will spend at least part of the day getting out and about. PLUS it’s overcast, which means it’ll be nice and cool. Definitely something to take advantage of.

Peace Corps tells us about the continuum of adjustment over our two years (that’s not the name of it, but I don’t feel like finding the appropriate manual). It includes phases such as the “honeymoon period” and “culture shock.” Word on the street is that the chart is pretty accurate. I’m not sure. It’s hard for me to know from day to day how I feel about what I’m doing here. Integration is all about getting to know the community and making friends. I think I’m doing that, so I suppose I’m doing what I’m supposed to do. I’m also working on a community assessment to help figure out the assets, needs and desires of the people in my area. It’s interesting stuff, and I enjoy it.

I think I’m technically in the period when I should be experiencing culture shock. That’s when you realize that you’re here for the long haul and that the cultural differences you experience aren’t going anywhere. The biggest challenge is probably the marriage proposals/people who want your number. I had a guy run up to the khumbi at a station the other day and start trying to get my number through the window. There was an awkward 30-second period where the driver let us have our conversation (I said no several times) before we moved on on. It’s tricky. Sometimes you just want to be left alone, but we’re in a fish bowl here. A lot of the time I don’t mind.

I have an awesome language tutor, and we spent some time discussing HIV yesterday. She was surprised when I told her that I see a fair number of children on ARVs at the clinic.

“I mean, I know there are children with HIV, but I just didn’t think of them taking ARVs,” she said.

She asked if they looked sick. I told her that some of them do. Some of the children seem smaller than they should be for their age, but others seem to be doing OK. It’s also hard to say whether stunted growth/being underweight is related to their HIV or some other factor such as malnutrition (or a combination of factors).

She also noted the availability of medication to prevent mother-to-child transmission (MTCT) of HIV, wondering why children were still getting infected if there are means to avoid transmission.

It’s true that MTCT rates have dramatically decreased in the SWZ. Most HIV transmitted from mom to infant is passed on during birth rather than pregnancy — fluid exchange being inevitable during the journey through the birth canal — though HIV also can be transmitted to a baby through breast milk. This latter point has caused additional challenges in resource-limited settings (listen to my public health jargon!). The problem is that women breastfeed in most places, and breast milk is by far the healthiest option available for the infant. Consider: if you don’t have access to a stable and clean water source, how can you provide safe formula to your baby? How can you pay for it? Also there are the other benefits of breastfeeding, such as nutrients, antibodies, etc. The World Health Organization recommends that women with HIV exclusively breastfeed babies for the first six months of life unless formula feeding is acceptable, feasible, affordable, sustainable and safe. (I just went through four lectures from my JHSPH HIV class to find the specific terminology WHO uses. You’re welcome.) Interestingly, some studies have suggested that mixed breastfeeding, where other foods are introduced as well, is more likely to result in HIV transmission than exclusive breastfeeding.

There is evidence of reduced transmission during breastfeeding if the woman is on antiretroviral medications (ARVs). OK, so you give ARVs to all the new mothers, right? This part is tricky because there are specific indications for when a person should be started on ARVs. HIV attacks CD4 cells in the immune system. When deciding whether a person’s immune system is weak enough to start him or her on HIVs, medical staff members (usually nurses, here) look at the CD4 count. If the count is below a predetermined threshold, the person gets ARVs. If it’s not, the person is usually given an antibiotic to ward off infection and sent on his or her way. You don’t want to start treating people with ARVs before you must because ARVs are expensive, they have some negative side effects, and once you’re on them, you’re on them for the rest of your life. Additionally, HIV is a troublesome adversary. It mutates frequently, and that means people develop resistance to certain types of medication if they don’t strictly follow their pill regimen.

At this point, you might think, “But those pills will save their lives. Why wouldn’t they strictly follow their regimen?” Then think of all the times you’ve been prescribed pills. Did you take the FULL course of antibiotics even though you started feeling better after three days? Do you ALWAYS take your birth control at 7 p.m.? Yes? Now imagine taking five pills a day (two at 7 a.m., three at 7 p.m., maybe) every single day for the rest of your life. Imagine doing that if you don’t feel or look sick. Imagine doing that if you know you might be around friends or family members who don’t know you have HIV.

So back to ARVs and breastfeeding women. If a woman doesn’t need ARVs for her own clinical purposes, is it wise to give them to her only for the duration of the baby’s breastfeeding? It’s not an easy question to answer, and many a brilliant public health mind is working on that. I’m sure a lot of questions will be answered by the time I leave the SWZ.

It’s my understanding that most HIV-positive Swazi women who deliver in a clinic have access to single-dose nevirapine to prevent transmission. Nurses give women the drug during labor, and they give the drug to the baby within its first 72 hours of life. This fairly simple protocol does a pretty good job of reducing MTCT at birth.

I don’t know what the percentage is of MTCT of HIV here. I do know that in the U.S. it’s less than 2 percent. Some studies have looked at the possibility of getting that number to zero, but to my knowledge it hasn’t budged. Women in America more often have access to elective cesarean section, which greatly reduces MTCT, as well as ARVs. Elective c-section is all but nonexistent here.

I suppose what I’m trying to express with all this stuff (public health people, did I miss anything crucial? Did I screw any of it up?) is that HIV is an extraordinarily complex problem. Another element of it that my tutor and I discussed is the idea that the presence of ARVs decreases the public’s fear of HIV. Women and men say, “Yes, I could be infected, but then I’ll just take some pills.” That, of course, is a whole other issue. ARVs in SWZ are provided largely through global donor funding. If that dries up — which is a real possibility — a whole lot of people could be in serious danger of dying. And a whole lot of those people would leave behind HIV-positive and HIV-negative children with no one to pay their school fees.

OK, so there you have it: one piece of the HIV puzzle in Swaziland. Sorry to be a downer, friends. To compensate, I'm going to upload another post with some photos from Walker and my recent day spent fixing the gutter at a local primary school. He did most of the fixing and supervising of the kids. I did a lot of ladder holding and chatting.

Ohh, and thanks to O for a lovely letter and to Debi for the excellent package! I had to exercise restraint to avoid a breakfast of peanut butter M&Ms. They’re so very delicious.

Photos!

 Giant chessboard at the hotel at Pigg's Peak. Pretty sweet!

 The view from our mini hike was nice. This was what we did instead of swimming, which was OK by me. You can probably tell that the weather wasn't that great. I'm definitely enjoying the rainy season. So much water! It's nice that my family doesn't have to go to the river for now. They've harvested so much rain, it's great. This, of course, makes me realize how difficult it is for much of the world to obtain the basics. Never thought much about water security in the U.S.

 From left: Rob, me, Abdul, Walker. PCV friends, yo.

This is another view from the top of the waterfall. Pretty nice, eh? I hope to get more photos up and around soon. The dongle continues to make my life easier, but I pay by the MB, so it requires some forethought. So many new things to think about.

I spent the evening with a bunch of PCVs at a game park called Mlilwane. It has a great hostel, and we enjoyed pool time. I ate wild boar. It was delicious! The rest of the crew went to a dubstep show at a music venue called House on Fire. I don't dig that particular genre (though apparently this was more like reggae), so I went to bed at 10 instead. I felt awesome this morning, which was a bit of a contrast to most other folks. Still, they had a good time.

Salani kahle, all!

Two requests

Hi, all. Two easy things you may be able to help me with.

1. For the JHSPH kids (or anyone else with access), I'd love to continue to read public health articles these two years. If you come across good ones or boring ones on interesting material, please send them along. I want to remember what a p-value is in two years' time. Anything and everything: email it my way (to gmail, please)!

2. Do any of you know teachers whose classrooms might want a Peace Corps pen pal? I'd be happy to write letters and send photos of life here. I love me some letter writing. Or if YOU want a letter, just send me your address. I've got spare time, folks.

Thanks!

xo