GHC Video

All of the footage for this video was taken during our training at Stanford. That seems ages ago now though it was only about 3 months now. The folks from Seedwell did a fantastic job on this. Big thanks to them for their time and energy putting this together.

The Global Health Corps from Seedwell on Vimeo.

A Few Pictures!

Here are Angie and Ameet, the two other American Global Health Corps fellows in Tanzania. Ameet is based on a tropical island called Zanzibar just off the coast of Dar es Salaam and Angie is a bit east of Dar in a town called Morogoro that's located at the foot of a gorgeous mountain range.

This picture was taken way back in our first week in Tanzania in August.


Here's a picture from Zanzibar I took when I was visiting Ameet for the Muslim celebration of the end of Ramadan called Eid. For those of you who don't know, Ramadan lasts about a month and Muslims don't eat during daylight hours for the entire time. As you can imagine, Eid is a huge celebration where families cook and have family and friends over for parties. The holiday lasts for 5 days but we only took part for 2. Even without the celebration, Zanzibar has by far the best food in Tanzania so far. This sunset was icing on the cake of a great weekend.


Here's a picture of the whole A-Team (Andrew, Ameet, Angie) from Tanzania. We were on the inside of an old fort in Zanzibar watching a concert of local singers and dancers as a part of the Eid celebration.

Meeting Time

Here's another quick example of work life in TZ.

Without naming names, here's an example of an attempt to meet with a TZ official.

A local official is upset we're not meeting with him to explain our plans and ask him for permission to meet with other officials and health workers. We have tried to meet with him in the past but he doesn’t pick up our phone calls, doesn’t have voice mail (no one in TZ does), is rarely in his office, and doesn’t respond to our text messages.

We call him to apologize and request a meeting.

He miraculously picks up and is happy to hear from us but can't meet today.

Him: How about Friday?
Me: OK, 10am work for you?
Him: Sounds good.
Me: OK, I'll call at 9:30am to confirm. (I’ve learned to do this ☺ )

Friday...

Call at 9:30am.

Him: Hello who is this?
Me: It's Andrew Peterson calling from CHAI (I've explained who I am and that I'm from CHAI on no less than 5 other occasions).
Him: Oh yes, hello.
Me: Good morning. I was just calling to confirm this was still a good time for you.
Him: What?
Me: I just wanted to confirm that you’re still available for a meeting now.
Him: Meeting?
Me: Yes, we had scheduled a meeting this morning at 10am. I was calling to confirm that time works for you.
Him: Oh… right… I’m busy right now. Can you come at 12pm?
Me: OK, I’ll call to confirm at 11:30am.

Call at 11:30am.

Him: Hello who is this?
Me: It's Andrew Peterson calling from CHAI (#6). I wanted to confirm this time works for you for our meeting.
Him: Ahh, yes I’m actually still busy. Can you come at 2pm?
Me: OK I’ll call at 1:30pm to confirm.

Call at 1:30pm.

Him: Hello who is this?
Me: It's Andrew Peterson calling from CHAI (#7). I wanted to make sure you’re still available now for our meeting?
Him: Umm not right now.
Me: OK, we’re eager to meet and share our work plans with you. When is a good time? Would you like to call us when you’re ready to meet today?
Him: OK, I’ll call you soon.

He never calls.

Currently, we’re waiting for another meeting that was scheduled initially for yesterday mid day.

At 5pm last night we were still waiting and the person we had been waiting to meet with goes home because he’s had a long day.

We scheduled to meet with him at 8am. It’s now 10:30am and we’re still waiting.

At least I have some internet connection to keep me busy.

Wives, Girlfriends, and Lovers

A few background facts first:

Tanzania has a long history of polygamous relationships with tribal men’s wealth and power being connected to the number of wives and children they have.

Tribalism was abolished in 1961 when Tanzania gained independence from England.

Current Tanzanian law on polygamy changes depending on what religion you claim to be:

· It’s against the law for Christians (~45% of population) to have more than one wife.

· It’s legal for Muslims (~35% of population) to have up to 4 wives.

· If you ascribe to a tribal religion, there is no legal limit to the number of wives you can take.

Of all the cultural differences between the US and Tanzania, I have had the hardest time understanding the dynamics of sexual and romantic relationships here. Though sexism and differences in gender equality are huge issues that have been hard to face and deal with as well, because of the implications that relationships and sex have on HIV/AIDS, I’ve been particularly keen to understand that aspect of the culture.

Here’s a conversation I had with a friend a few weeks ago.

Me: So do people here go on out on dates?

Friend: Dates? What is that?

Me: Hmm, dates, you know like taking a girl to dinner or the movies?

Friend (Gives me a puzzled look): …

Me (to my work mate, Goodluck, sitting close by): Hey what is the Swahili word for date, like to take a girl on a date?

Goodluck (looking puzzled): Umm, we just call it ‘date’. There is no word for it. (friend understands now)

Me: You don’t have a word for date in Swahili? I’m assuming that doesn’t happen much then?

Friend and Goodluck: Nope

Granted, I have friends here in the younger generation that are starting to date more, but, they are typically dating Westerners so that doesn’t really count to me. When I explain to other friends the idea of going on dates and, particularly, having multiple past dating relationships, their take on it is that by dating women and not marrying them I’m tainting them.

They say, “What man would want to marry someone you’ve dated for a year?”

Ironically, I’ve read that in parts of Africa, and heard this to be true for rural Tanzania, a woman with one child is more desirable to marry than a woman with no children as she’s proven she is fertile. It’s this juxtaposition of seemingly conservative views about dating and marriage and more liberal attitudes about sex that has had me continually confused.

Men and women don’t date here. They get married. Most families don’t allow children to have boyfriends and girlfriends because they’re only allowed to have one. The process, as I understand it, of finding the right marriage partner has more to do with family and money and practicality than it does with love. Parents have the ability to veto any potential partner, husbands pay dowries to their wife’s family and husbands sometimes even take less attractive wives to reduce the chances that she cheats on him.

I know relationships differ greatly but, on the whole, husbands and wives aren’t companions. They don’t hang out or go on dates. Wives spend time with the children and husbands spend time at work or with friends. Women make babies and men finance it.

That brings me to sex.

Here’s an excerpt from Stephanie Nolan’s 28: Stories of AIDS in Africa:

AIDS in Africa is often understood as a disease of poverty – of hungry young women who sell sex for food, slum dwellers who can’t afford condoms, and subsistence farmers who can’t pay for medial treatment. And this is accurate. But that picture is not the full one: AIDS is also a disease of wealth. Population survey’s across East Africa have found that rates of HIV infection are more than three times higher for people living in the best-off households than for those in the poorest. Why? People who have a bit of disposable cash can afford to pay for the services of commercial sex workers, or maintain a girlfriend in the city as well as a wife back in the village, or have sex with an occasional partner and in return pay her school fees or buy her a cell phone.

Years of research have made clear that Africans do not, in the course of their lives, have a greater number of sexual partners than North Americans or Europeans. But where people in the West follow patterns of serial monogamy, moving from one partner to the next in relationships of varying length with limited overlap, many sub-Saharan Africans have the same number of partners in what are called concurrent sexual networks, where some or all of the partners overlap. Because of the way HIV works, those networks greatly increase the odds of infection. An estimated 40 percent of HIV transmission occurs when the people transmitting the virus are in the initial six weeks of infection-when their blood teems with the virus, before their bodies muster an immune response and push the level of HIV back down for several years. Say the civil-servant husband gets HIV from his girlfriend in the city. A few weeks later, as the presence of the virus peaks in his system, he goes home and has sex with his wife. She gets infected. Then when her husband goes back to the city, and while she has the peak level of virus in her system, she has sex with her local boyfriend-who is then at much higher risk of infection. And so are the boyfriend’s other partners.

This explanation has helped me understand the higher risk that culturally common sexual practices here mean for AIDS transmission. But, what Mrs. Nolen’s book didn’t explain is how common a practice taking concurrent sexual relationships actually is.

Again, though there are exceptions, if you have the money and you’re a man, you pay for sex or you pay for things for a girlfriend in exchange for a sexual relationship. If you’re a woman and you want extra money or want some financial independence from your husband, you get paid for sex or get an extra boyfriend to pay for things you want.

Here’s how another conversation went with a friend while a group of us we were at a bar:

Friend (looking around the bar): So who do you want?

Me: Like women? Uhh, I’m good just hanging out with the group.

Friend (looks a little incredulous): You mean you don’t want to have sex with someone tonight?

Me (while thinking through the many reasons I didn’t want that including not wanting to risk contracting AIDS): No, I’m good. You got your eye on one?

Friend (ignoring my efforts to change the subject and even more incredulous): You know you could have anyone of them, right?

Me: Wait, they’re all prostitutes?

Friend: Not exactly, but if you bought a girl and her friends their drinks all night you could definitely have sex with her.

Me (puzzled): So which ones are the prostitutes and which ones are not?

Friend: Umm, I don’t know.

Me: That could get dicey. So what’s the going rate for a prostitute?

Friend: Depends. Maybe 15$, maybe more, maybe less.

Me (silently dumbfounded thinking that was the price of our taxi to the bar tonight): … interesting… no, I’m good.

Friend (mutters something about me being homosexual, collects himself and gives me a polite): OK.

This is just an example of one conversation but I’ve had many like it. From my experiences, exchanges of sex for money are inexpensive and, consequently, pervasive regardless of your relationships status, rate of AIDS prevalence, or age. The major factor is money. And because I have it, people expect me to pay for sex.

There are many more intricacies to the romantic and sexual relationships of Tanzanians that I’ve learned and have yet to learn. I’ve been trying hard to be honestly inquisitive and not judgmental because, at the end of the day, it’s just different than what I’m used to, not better or worse. We [Westerners] undoubtedly have our own ironies and downsides to our romantic/sexual relationship institutions.

Unfortunately for East Africa, the consequences of the current cultural practices are devastatingly high rates of HIV/AIDS transmission.

Recent statistics estimate 23 million people in sub-Saharan Africa are infected with HIV. In late 2007 only 2 million people from that group were taking antiretrovirals.

Speaking of …

Goodluck and I arrived back in Kilwa recently after a planning period in Dar with our management team to map out our work plan for the following year. Having a detailed Excel sheet with our strategy relaxed my type-A tendencies a bit as I started being able to visualize the road we have ahead of us.

Hitting the water for an otherwise boring morning swim, I started processing our main next steps. “We have to speak with doctors in each health field to prioritize the data we are collecting. We have to speak with the dentist at the district hospital to see if we can get a complete map of the health facilities in Kilwa. We have to speak to contacts at the health facilities we’re working with this month to plan when to consolidate their data from the previous month. We have to speak…” Get the pattern yet?

I keep assuming there has to be other less formal, less time-consuming ways to get information here, especially for professional organizations and critical health/hospital information. But then I think again and realize that’s exactly why I’m here in the first place (to work on health information systems). I need to remember to shake the Internet age off me every morning before tackling our work, but it’s hard to do.

Information in Tanzania exists in people and is disseminated orally. It is 500 years after the advent of the printing press yet, particularly for rural Tanzania, it’s like that never reached its way down here. Information is locally based and it is shaped by each human who passes it on. The details and accuracy are then the product of the person who owns the information and are virtually impossible to objectively validate or verify outside the community of people one knows.

I’ve been reading Stephanie Nolen’s 28: Stories of AIDS in Africa. In story number one, Siphiwe Hlophe remembers when doctors informed her that her sister was infected with AIDS. Stephanie writes, “Siphiwe kept the information from her sister. She was afraid to touch her, wondering if the rumors were true if she could catch the disease by bathing or feeding her. Three days after the test her sister died. ‘If only I’d had information about HIV, maybe she’d be alive.’ Siphiwe said. But it would be years before she learned any more. ‘The page of HIV was closed to me until I discovered my own status.’ But even then, five years later, people didn’t know any better.”

And how could they know any better? Who were they going to ask? Who even wanted to ask?

At least for our project, Goodluck and I know who we need to talk to and trust that they’ll have the information we’re looking for. Even if we don’t completely trust them, for really important data we know we can verify it with specialists or even via the Internet. Our biggest challenge is time, not quality information or the means to get it.

During one of our visits to a rural health center, Goodluck was approached by a man desperately seeking information and advice on an apparent STI (sexually transmitted infection). He couldn’t physically walk to the hospital that was 20 miles away and couldn’t afford treatment even if he made it. That, and the treatment he would get would likely be from, at best, a nurse with limited training (especially for non critical illnesses). I couldn’t understand what the man was talking to Goodluck about but I could tell it was more than just asking for money. He was terrified.

I came to Global Health Corps and the Clinton Foundation from Google; the virtual epicenter for all information. Many (including myself) have seen the internet as the ultimate liberator of information to the world. However, considering again that western society has had many important technological advances and the oral tradition continues to remain so strong here, it’s unlikely that technology alone (Google or otherwise) will ever solve the information problems facing the East Africa.

Solutions aside, when I think about what it would be like to need information and not know how to get it, I feel terrified too. And though it’s hard to foresee being in a real situation where I don’t know how to get accurate data, I more clearly see the value of working on health information systems in a place where non-existent, poor quality, or false data seem common.

GHC in WSJ

So I've been in Dar es Salaam at a number of meetings with our national team here and haven't had time to blog but more will be going up soon when I'm back in lively Kilwa :)

In the meantime, our fellowship program made the Wall Street Journal (article) and I got a shout out!