23 February 2015

A day in the life on the Eastern Peninsula of Zanzibar

The colour alone of the waters of Zanzibar will quench thirsts in your soul that you never knew existed. You can’t open your eyes wide enough to absorb it- the limitations of the human senses do not allow you to merge with the feeling it invokes inside of you. The waters are striated with bands of dark blue, turquoise, greens and whites against sands that are the colour of simplicity and purity. When you walk barefoot on the wet sand, it is softer than the most imaginable velvet. You feel as if you are walking on a hidden treasure of mother earth’s skin. Never has it been exposed to any of the harsh elements of nature or cruelty of humanity. Perhaps because it was hidden away in the curves of her body waiting for you to experience this moment.

The dance of the of wispy waving coconut palm leaves which frame the scene are reminiscent of a young girl’s long hair streaming behind her- dancing like a kite tail while hurriedly riding her bicycle home during the endless summer nights of childhood. The tickle of the leaves by the wind result in music echoing soft rains.  Every part of your past, present and future seem to be here in the many moments of the sands of time.

You watch the rhythm of life so clearly dictated by the flow of the tides. To imagine that your day is not measured by the hands of the clock or the conventional cadence created by modern societies where we live “average” plus or minus standard deviations from “bed time”, “dinner time”, and “work time”. Rather, your day is dictated by the tender pull of the moon on the earth’s waters; how tightly the land hugs the sea after hours of dancing forward and backward into their final embrace.When the ocean is far away-flooding and feeding the currents of the world-the land shows the jewels of her tide pools. This is where the women of the eastern peninsula group together-their colourful hijabs and chocolate coloured skin a magnificent contrast to the white sand and turquoise waters. They carry with them buckets and sticks to hunt octopus as they silently chatter during their walk out to the tide pools. Once far on the horizon, they disperse like oil on water and spend their days coaxing the octopus out of their hiding places with the skill of any prey-predator relationship. Afterwards, the women come together to the shore with octopi dangling from their shoulders; the murmur of the sea and whispers of their laughs indistinguishable.
Behind them, the tides swell again filling the pools and bring the shallow waters warmed by the sun. The beauty of the reunion of the land and the sea cannot be explained. Like lovers destined to part and reunite by inexplicable forces much greater than themselves providing a beautiful backdrop for children to swim and destitute boats to come alive again; after all, a boat without water is merely a piece of wood.

These days the tides bring with them heavy winds called kaskasi in Swahili (“north winds”). The winds on the island are currently changing directions; the north winds asserting their dominance with an unmatched fury and force. The winds are shaking the trees and grasses to remind the land which was once complacent with this rhythm of life that nothing ever remains the same. Old palm leaves weighing down the trees are blown away while deeply rooted plants are given more life from the wind.

You long to peek under the ocean to catch a glimpse of its mysteries. While floating over massive reefs of pulsating coral-the heartbeat of the ocean-colourful fish swim by seemingly unaware of life above the water. You hold in your hand a bright red star fish and wonder if the gentle movement and suction on your fingers was from the velocity of the star falling from the sky and caught by the ocean. You savour the tentacles gently wrapping around your hand as you hold hands with the ocean. In the depths of the ocean, you see families of dolphins weaving through ocean and air with a rhythm and playfulness that invokes in you a new definition of freedom. Fisherman gracefully pull long nets from the waters as rainbow coloured fish flap in their last protest at being plucked from their homes. These images slowly fade away as the sun begins to descend and makes way for day’s grand finale.


The sun sets on the opposite side of the peninsula reflecting subtle colours serving as a reminder of the beauty of phenomena happening nearby-thus solidifying the interconnectedness of people and places connected on earth by one sun. Muted golds and oranges tint the sky and soften the blues of the waters until darkness overcomes the peninsula. The stars emerge in the minutes of black sky before the moon makes her debut; dancing with the clouds which temporarily hide them. You long to bask in momentary glimpses of their brilliance. A large moon slowly rises from the sky. A deep red-orange orb coloured by her umbilicus to the earth. As she climbs, she draws within her the remaining light of the day until her brilliance outshines all but the brightest stars. Dwarfed by her beauty you are forced to gaze deeply at the secrets hidden in her shadows.
When the moon is big and bright, the reflection on the water is a narrow dancing line connecting you with the moon like the string of a lost balloon. Often there is an old boat in the moonlit path gently swaying to a lullaby in the sparkling streak revealing not more than a hint of the lines of the weathered wood from which it was born. As the moon rises higher the narrow stream widens like the slow smile of a shy child until the surface of the water is bathed in its reflection.

On the nights where the moon is small in her cycle of rejuvenation, she steps back allowing the most timid stars an opportunity to reveal their places in the interconnected universe. As you look up to make sense of the patterns they create, like millions of people who roamed the planet before us whose shadows we live amongst, clusters and colourful trails emerge. You, yourself, are reduced to a moment in time where you reflect the light within you to the light of the sky.

On the nights where the winds are resting and the sea invites the local fisherman. The horizon far off in the distance is dotted with dancing lanterns of the fishing boats. They sway in a rhythm only known to them but calmly familiar. Because the sea is higher on the horizon than the eye-level, it is difficult to distinguish the lights of the fishing boats on the horizon from the fireflies of the summer nights. Maybe it’s because the vision invokes the same type of amazement and wonder-the simplistic desire to chase after that which attracts and fascinates us-often deceptively within our grasps when in reality it is merely a moment in time mixed with memories we can only hope to record in that split second.

In the times when you awake in the middle of the night your eyes celebrate the state between sleep and awake by resting on subtle glimpses of bright shooting stars. The moon is now in its path to the other side of the sky as it disappears over the horizon just in time for the sun to rise.

The sun rise is not nearly as predictable as the sunsets here. Like an aspiring actress not yet able to execute the complexity of a scene with mixed emotions, it lives on the edges of the dramatic. Or maybe it is you who has witnessed a million times more sunsets than sunrises; unable to decipher the emotions within the sunrise. Similar to a child only able to colour a rainbow with a pack of six predetermined crayons when a more experienced artist knows not only the infinite power of colour and the subtle differences which lie within them, but also the emotions invoked when placed next to or mixed with each other.
When the sun rises it beams radiance in every direction and is coloured with purples, yellows and oranges of the spectrum. A few days ago, a storm came at the time the sun was rising and the birds were recklessly gliding in the changing directions of the wind-oscillating between panic and recreational bliss; similar to the first time you rode a rollercoaster and felt fear and hope in one moment-the vision of your own mortality and the surging tides of endorphins when you realize you’ve conquered death. Cautioned to tempt it again but recognizing the bliss in the revelry of laughing at death. This moment of a stormy sunrise expressed itself in magnificent violets and magentas-streaked with lunacy and recklessness.




And so begins the birth of another the day on the Eastern peninsula of Zanzibar.

31 March 2012

The beginning of field research..Bloemfontein, South Africa

Rainbow Nation

Some of you have been requesting a blog post (thank you for the reminder) and I've been quite busy laying down the foundation of my research here in Bloemfontein but wanted to shoot off a post or two to share some of my journey with you. For my first post of the trip, I'll start what I'm actually doing....... This post is more academic than my usual stories so scroll down to the bottom if you just want to know specifics..first I'll give you a little idea of the problem.


South Africa and HIV

South Africa has the highest HIV prevalence in the world-- and to top it off has the highest tuberculosis (TB) rate and a human resources for health crisis (I'll blog about this another time, not glamorous but important). The prevalence of HIV is on average is 18.5% in this province (which is the 3rd highest in the country) but in specific populations it is as high as over 30%; Meaning 1 in 3 people are infected. Those with immune systems which are already vulnerable from the HIV are therefore more susceptible to opportunistic infections like TB- so a functioning health system is key.

Over 80% of the population accesses the public healthcare system (versus private) which is a nurse-led  (read: too few doctors). In 2004 the prices of medication finally came down from an interesting global battle with patents and many players and treatment was finally relatively affordable. In South Africa in 2004 when the rollout of antiretroviral treatmeant (ART) for HIV patients began, it was done with separate clinics and staff specifically for HIV patients (called a vertical programme). The process was very cumbersome for the patients as they had to go to a separate clinics for HIV-related care  (often not conveniently located- meaning they needed money for transportation, time off work etc.)  and another clinic to get any other care. Patients were stigmatized when seen going to HIV clinics (since people then knew they were HIV positive then) and also there was criticism that the health system was focusing too much on HIV and neglecting other priority diseases, infections and health needs of the population. The photo below shows the steps 1-2-3-4 that patients had to go through previously.
The cumbersome process previously to access treatment for HIV patients

This is not only a problem here in South Africa, but also in many other countries in Sub-Saharan Africa, especially when larger global health initiatives (i.e. The Global Fund, Bill and Melinda Gates Foundation, PEPFAR etc.) came in with wonderfully ambitious goals to test and treat tons of people for HIV. They  created a separate health system which paralleled the crumbling public sector system and drew resources away from it. The critics started asking, why can't these funds actually strengthen the health system for some long term, sustainable improvements?

The Solution?

Hence---drumroll----the concept of integration was re-birthed. In South Africa, that meant every public sector primary health care clinic should be able to provide ARTs to HIV patients (a.k.a. integrating Primary Care and HIV care). The people will then have a "one stop shop" for all their health needs. The Free State started this in 2010 and have been slowly rolling out this concept to all the 222 public sector clinics. Currently, they have reached about half of the clinics.

However, when you add all these patients who were seen at another clinic to a primary care clinic which is already struggling to cope with the needs of the patients, what happens? In some cases you may be adding an extra 1200 patients a month to a clinic without giving them too much more support. HIV patients have special needs and sometimes complex treatment regimens and the clinics are already under-resourced and understaffed.  Specifically, what happens to how the clinic functions and primary care. Are there aspects of it which are strengthened and aspects which are weakened? This hasn't been answered yet and is the question I am looking at.

My Research

My project has 2 main components: First, I'll use the data the government has collected on a select number of health indicators to see how they have/will change as integration progresses for each of the 222 clinics. Since I came, I have been sitting down with provincial program managers, assistant managers and data collectors to identify which indicators will tell me what I want to know for each program. Examples of things I am looking at are immunization rates, number of patients they see, diabetes and hypertension, tuberculosis--just to name a few.  I've narrowed it down to about 12 indicators and now and will analyze these from 2008/9 to 2013 on a monthly basis to pull out some trends.
The former homeland of QwaQwa

The second part is selecting 4 very different clinics in the province (based on urban/rural/former homeland, size of the clinic and when they integrated). The photo above is from a former homeland area where people were forcibly moved during the apartheid. I'll do a separate post on this. This week I went out to the 4 clinics across the province and  pitched my research to them. The largest clinic has about 10 nurses seeing over 400 patients a day and the smallest had 3-4 nurses seeing about 100 patients a day. I will do interviews with the staff and focus groups (group discussions) as well as my research assistant will administer a survey to patients and caregivers (In Sotho, the local language) to see what they think of the services they have received. I will repeat this part in one year (March/April 2013) to see how things have changed and compare it to the data I find this year.

What I hope to find is information that can help with recommendations for policy and support to the clinics to enable them to cope with handling this many patients within this resource-constrained setting. The number of patients needing treatment will hopefully grow and will not compromise the other services. Eventually, I would like to see all health systems be able to handle the needs of those with infectious diseases (like HIV and TB) and chronic diseases (like diabetes, heart diseases etc) and  balance prevention and treatment. I hope other countries can also learn a bit from what is happening here since South Africa has the largest public sector ART program in the world. This will be the largest study on this topic spanning the longest time period.

Thanks for sticking around and making it to the end of the post! I promise the next ones will be less academic and more stories.




01 September 2010

Coffee in Ethiopia





So I've admittedly not actually had enough time or internet access to properly shoot some stories off but I'll try to catch up in the next few days before heading to Cape Town.

Addis Ababa, Ethiopia was a wonderful experience. It is the only sub-Saharan African country which has never been colonized (only occupied by the Italians for a few years) and so it leads one to wonder about the impacts of colonization when compared to some of its neighbors and other African counterparts. It is a landlocked country although it was once had many ports when Eritrea and Djibouti were part of Ethiopia. It is a multi-ethnic state with 200 distinct dialects and the principle language being Amharic (which is thought to be related to Arabic and Hebrew).

"Lucy", one of our oldest ancestors was discovered in Hadar linking human life in this country back 3.2 million years ago. Ethiopia is thought to be the origin of our species. The history is quite interesting with a dynasty that dates back before Christ.

Modern Addis Ababa is an interesting place...having many characteristics of a capital city (such as the hustle and bustle and housing the World Health Organization's African regional headquarters) it also resonates a strong feeling of the pastoral life of the rest of the country...with unaccompanied donkeys weaving in and out of traffic and people-- dutifully carrying bundles of fire wood to their destinations.

One of the most fascinating parts of the history is that the coffee bean originated from Ethiopia and the coffee was incredible-both in its history and in the ceremony around it. I actually had a chance to learn how to do the ceremony and roast the beans.

The history around the discovery of coffee is interesting. Kaldi is a shepherd who -as legend has it-tended to the goats that discovered coffee. He noticed his goats turned into "jumping goats" after eating these red berries in the highlands. He decided to collect a few. The stories I heard now diverge at this point.

One version says he brought the berries back to a monastery and the monk did not approve of this "drug". The monk therefore threw the berries into the fire and Kaldi went after them. He washed the ashes off with boiling water and this was the first cup of coffee (roasted and brewed).

The second version I heard was that he gave them to 3 monks and they made them into the coffee we know today. In the ancient and modern Ethiopian coffee ceremony the 3 monks are honored in the brewing of the coffee. The ground and roasted beans are brewed three times in a clay coffee vessel over hot coals. Between each round it is placed in a cloth holder at a bit of an angle to separate the coffee and the grounds. The first brew is called "Abol" after the 1st monk and is made for those you love and respect since this is the strongest and best brew of the grounds. The second brew is called "Nota" for the second monk and is for those you hate because it is often made for uninvited guests. Finally the third brew is called "Bereka" and is the weakest brew made for the travelers, merchants and students coming from afar and hence late.

When we went to a little coffee house that does the ceremony the coffee came with a small leaf which neutralized the bitterness (does anyone know what the leaf is? Stevia?).

Coffee in Ethiopia was a sheer and pure pleasure especially since it is now winter. The heat of the coffee complemented by the berbere (Ethiopian spice mix--their garam masala essentially) cut through the misty fog of the rains and warms you from the inside of your soul to the smile on your face.
--- more on South Africa when I get a chance :)

17 August 2010

Nairobi Kenya-Short but Sweet




Upon arriving early in the morning to Nairobi I began to learn about the variety of cultures and tribes in this country. There are 40 million people people here with 42 distinct languages and ethnic groups. Apparently the struggle for independence in 1963 was a bloody battle lead by the Kikuyu tribe which makes up 22% of the population. I was told that when the English originally came to Kenya they would go to the chiefs of the villages and offer rides on horses (which apparently were very rare at that time). When the horse became tired this would be one boundary of the land they would take to begin their agriculture. After a days rest, they were then taken on a ride in a perpendicular direction to determine the square land that would be taken. Even today large plots of land are still owned by the British.

With the new constitution passed last week there is rising hope for Kenya. First the constitution was amended so that land must be in Kenyan ownership within 99 years instead of the previous constitution which stated 999 years. Also there is health reform in place attempting to provide universal access to health care. The government plans on financing this by levying a tax that is a small percentage of the wages. Additionally many other reforms are taking place and Kenya is poised to become one of the powerhouses of East Africa.



Historically speaking the country is well known for the link to some of the oldest relatives of our current species with fossil remains found that date back 1.7 to 1.8 million years ago and along with Tanzania the home of what is thought to be the first "homo" genus.

While in Nairobi I visited the Maasai market with Alice and Sunil. There we could see a little bit of the handiwork and culture of the Maasai people. Their beadwork was incredible with bright colors and patterns.

The women are heavily adorned with beads. They are traditionally nomadic tribes people whose way of life had been originally discouraged but now has been accepted due to the ecological conditions of their lands. Their wealth is measured in cows and children. The Massai boys go through a circumcision ceremony at puberty in preparation to become the famous Maasai warriors (upon which killing a lion they earn the title of warrior—some say this is still practiced but the declining lion population is of concern).

There is a lot of controversy over not only circumcision of this tribe but over the increased circumcision practices in the bush. In addition to the traditional demand for adolescent male circumcision, many people are seeking out the practice because current research supports a reduced risk of HIV with the practice. In a country with an adult prevalence 10th highest in the world with 6.7% infected reduced transmission with circumcision could be both a blessing and a curse. Unfortunately 40% of those procedures done in the bush on adolescent boys end up in public health centres with organ damage and infections and there is growing concern over the use of non-sterilized equipment and the spread of HIV. With public health campaigns encouraging people to visit clinics for circumcision a market has popped up for unqualified circumcision clinics done by “quack doctors” (reportedly lab technicians or anyone affiliated with healthcare) that offer the procedure for low cost (200 Shillings which is about 3 USD) and are complicating the issue. Many of these patients also end up in the public health centres with complications and the government is cracking down on these clinics. There is an underlying cultural issue with boys/families preferring to have the procedure in the bush because it is seen as more “macho”. Obviously tackling this kind of cultural shift will be a long road but I hope it does not lead to increased HIV transmission in the meanwhile. I’m curious if any organizations/agencies are looking at training traditional leaders in completing the practice in a sterile environment and if so what the sustainability of having supplies, etc is.

The main purpose of my stay in Nairobi was to see my dear friend Alice who was my flatmate while I was living in Bangkok in 2008 and her delightful Sunil. Although my stay was short my mission was accomplished and I spent a heartwarming time with them-- dancing, laughing and talking. Thanks guys! Photos to come once I end up at a computer where I can upload them :)

16 July 2009

Djenne Mali



I arrived in Djenne which is the one of the cultural and intellectual capitals of Mali. Founded in 800 AD it was a huge trading center for gold, ivory, lead, wool, kola nuts etc from the south where the goods then went north to Timbuktu and Northern Africa and Europe. There has been activity reported here since before Christ although archaeologists do not know why the empire fell apart.

One of the highlights is the weekly market (photo) and another Grande Mosque that has been declared a World Heritage Site by UNESCO.

Mopti Mali






After returning from Dogon I spent some time in Mopti Mali where the Bani river and Niger river meet. The city is formed by 3 islands and is known as the Venice of Mali. It was great to be around water again and I spent some time cruising the waterways during sunset on the wooden local boats. The river plays a large role in the livelihood of the community for transport and fishing. As I walked through to the docks it was a surreal experience to see the baskets of dried fish commingling with cut up fish heads, scraps of cassava and fumes from the passing diesel trucks. The town had a greyish tinge to it and it was amazing to see the contrast of the brightly colored merchandise on the boats with the dark murky water.

The old mosque is famous here and is the backdrop of the old town. I inquired about a bus to Timbuktu from here since it is only a days journey. The situation in the region is very shaky right now due to Tuareg rebellions and Al Qaeda having a strong foothold in the region. They have been known to kidnap tourists and even a few months ago a British man was kidnapped and executed. So, alas my trip to Timbuktu was off and I headed to Dejenne.