"While there were definitely moments and days that were frustrating or sad or just really long, I would do the whole thing again in a heartbeat. I have learned so much about not only NGOs and development work, but also about myself and what I believe and value. I would encourage anyone thinking about applying to go for it as I think you can get so much out of it. This was definitely the "hardest quarter you will ever love." - Kathleen Kline, Class of 2007
January 16: After a two day layover in Senegal, we finally arrived in the Gambia late in the evening to the tiny airport outside of Banjul. I immediately got a hint of the flavor of this, one of the smallest countries in Africa, driving down the main single lane and rather potholed highway with grasses and mangroves towering over the car on either side of the road. I was struck by how intensely dark it was, and told by our driver that this was in part due to the electricity being off. The power here, as I learned later, is very erratic and goes off nearly every day, often several times and for extended periods. The headlights of our car provided the only light available to illuminate the outlines of the military guards that lined the road. Our driver also explained that the guards were only there because "the President was on the move," specifically he would be driving along that road later in the evening to catch a flight to Mecca to take part in the Hajj. At first I thought the guards were rather threatening, shining their flashlights into the car at the several checkpoints set up along that short stretch of road and addressing questions rapid fire to the driver in Wolof, but when the driver explained we were with "CRS," the man smiled and began asking excitedly if we knew his brother, who, coincidentally enough, once worked with the organization. This brought home an earlier statement by a former CRS Gambia employee that the organization here is a "big fish in a small pond."
Following our short amount of time in Dakar, the very cosmopolitan and strongly European influenced capital of Senegal, Banjul was quite a contrast. Though it is the capital of the Gambia, it is more like an overgrown African village, as one of my guidebooks put it, than a real city. An African village, however, where the homes are constructed of rusted metal sheets and recycled pieces of wood and plastic. I have been told that further upcountry there are more "traditional" African villages, which I will hopefully get an opportunity to visit at some point during the internship. I live in a middle class Catholic household, a minority twice over in the Gambia. More than 90% of the country is Muslim with a very small Catholic population largely located in the Western Division. By Gambian standards my host family is quite wealthy, as the majority of people in the country struggle to get by on less than a dollar a day. Because my house mother works closely with the Catholic church here, on my third night in the country I was invited to dinner at the Bishop of Banjul's house and got to listen to his stories about the Gambia and his native Ireland. He was a lovely man, but it was a bit of a surreal experience and I was still pretty jetlagged.
Living and working in another country is very different from the experience of being a tourist. I often find myself running into little cultural quirks that I had never thought about before. In the Gambia, for example, time is incredibly elastic and punctuality is of very little importance. A meeting that is scheduled to start at 9:00 may not actually begin until 9:30 or 10:00, or perhaps even be put off until the following day without anyone batting an eyelash. Coming from a culture that is so preoccupied with time and where being late is a major taboo, this takes a bit of getting used to and a lot of patience. Surviving as a vegetarian is also proving more difficult than I had anticipated. Finding fresh vegetables and even fruit can often be a challenge because, despite the tropical climate, many food goods are imported from neighboring countries, making them expensive and in short supply. Food expenditures are estimated to consume nearly a third of family income in poor households in the Gambia. Many items that could be easily grown here, such as certain fruits, vegetables, and grains are not because nearly all of the agricultural resources in the country are devoted to the cultivation of the Gambia's main export, groundnuts (peanuts). Ironically, despite the prevalence of the groundnut, the peanut butter I use in my sandwiches everyday is from Manchester England.
Being a former British colony wedged in the middle of a much larger former French one, English is the official language of the Gambia and although most Gambians who have attended school speak very British English, they also speak one or more of the local languages. Wolof is the most widely spoken of these languages in this area. Gambians often switch back and forth between English and Wolof in conversation which can be quite confusing, and I am struggling to pick up a few useful phrases. Speaking without American slang or contractions in order to be understood though I think is improving my vocabulary.
My part in the project to which I have been assigned concerning HIV/AIDS is just now beginning to emerge. While West Africa in general has lower HIV/AIDS prevalence rates than those in South Africa, there has been a sharp increase in infection in the Gambia over recent years. CRS Gambia recognized that while there were a number of programs addressing prevention activities, care and support programs for the increasing number of people living with HIV/AIDS, or PLHAs in shorthand, was minimal and badly needed throughout the country. CRS, in collaboration with local groups, diagnosed the core problem relating to PLHA quality of life/programming care as being "poor community and family support and care for PLHAs, due to stigma and discrimination against individuals that contract the virus and misconceptions regarding the modes of transmission of HIV/AIDS." Due to a high level of stigma in the Gambia surrounding the disease many people do not want to know their HIV/AIDS status, or do not reveal their status to their partner and/or family for fear of being ostracized and isolated, unfortunately an all too common occurrence. CRS thus decided in partnership with several other existing organizations to implement a joint anti-stigma campaign and advocacy program for people living with HIV/AIDS, the goal being to not only reduce infection rates by creating the opportunity for greater understanding and education about the disease and modes of transmission, but also to improve the quality of life for those living with HIV/AIDS and their families. Care and support programs are especially needed here because Anti Retroviral drugs are not widely available for people living with HIV/AIDS in the Gambia, nor are there plans to make these drugs available or accessible in the immediate future.
This project is now just over a year old and is at a bit of a crossroads at the moment due to funding issues, which is incredibly frustrating given the need for the programs it is running. Just in the short week that I have been here I have already encountered this attitude of stigma and discrimination. Even in conversation with highly educated and widely traveled Gambians, when I described the project I would be working on, they questioned its "usefulness" and wondered at the long term benefits of assisting people considered "lost causes" by many. It is both difficult and heartbreaking to hear things like this, in part because I know so many others share this sentiment as well as because I know many PLHAs themselves feel this way and consider themselves "doomed," causing them not to disclose their status or to seek out support. Despite such disheartening attitudes and statistics, as well as an unimaginable lack of resources and supplies to work with, the people I have met here who will be my co-workers on the project have an incredible passion and dedication to their work that is truly inspiring, and I am very much looking forward to working with them in the coming weeks.
February 5: I can't believe the quarter is nearly half over already, just as I feel I am finally getting settled in at work. Though I go into the CRS office in Banjul weekly to check-in with my project supervisor, I spend most of my time working out of the office of the local NGO that is CRS' major implementing partner for the care and support project. The compound the partner office is housed in was originally and still is an auto-mechanic garage. A small brick-making factory is also housed in the compound and run by the NGO to produce inexpensive bricks to make money to pay for office expenses, a pretty ingenious idea I think. Despite the dedication of my co-workers, the frustrations of working in a small NGO with limited funding and resources become clearer to me everyday. On a positive note, the lack of paper and ink for printing has forced me to drastically curtail my former paper wasting ways and to be more succinct and to the point in my writing (excluding of course my rambling e-mails).
With the hope of improving my overall understanding of the project, and therefore being able to make more informed recommendations and better carry out my assigned tasks, I have spent the last few weeks visiting and interviewing the various groups and organizations involved in the implementation of the project and/or those who hope to benefit from it. One of the groups whose meetings I have been attending is the Santa Yalla Support Society. Santa Yalla, meaning "thank God" in Wolof, is a support group of about 500 people living with HIV/AIDS in the greater Banjul area. It was founded in 1997 to bring together people living with HIV/AIDS, in the words of the current president of the group "to know each other." The majority of the members are female. In addition to the fact that in most African countries, the Gambia being no exception, more women than men are infected with HIV/AIDS, women also seem to be more likely to go for testing and to seek support.
Despite the relatively high membership number, meetings usually consist of no more than about 30, as many who are registered with the society do not attend meetings regularly or at all. The president of the group along with several of the other members suggested this was because many were afraid to see someone they knew, or who knew them, at the meeting. I think the main reason I am being allowed to sit in on meetings, as well as why most of the members seem to feel fairly comfortable speaking openly in front of me and answering my annoying questions, is because I am such an outsider and have no knowledge of any of the members apart from the group context.
Even many of those who attend meetings regularly have not yet disclosed their status to anyone outside of the group, including family members and partners. The president of the society was a member of the group for two years before telling his family he was HIV positive, but is now the spokesman of the group and regularly attends public events concerning HIV/AIDS to advocate for the most vulnerable. He, along with about 8 others in the group, are currently taking anti retroviral drugs (ARVs) paid for by the government in a very limited trial. While this is a positive step in improving quality of life for people living with HIV/AIDS, in the course of talking with those currently on, or hoping to be soon on ARVs, there seemed to be a serious lack of information or understanding about what the drugs can and cannot do. Several people have mentioned hearing of individuals who consistently took their ARVs eventually testing negative, and voiced hope that if they too took the drugs regularly, and otherwise stayed healthy, they may also one day no longer be infected with the virus. Multiple times members have said that they do not want to die of AIDS, as someone put it, "people who die from AIDS are the ugliest corpses"- drawing laughs from most of those present.
Many in the group blame fear as the source of stigma surrounding the disease and people infected with the disease. One person mentioned that fear rather than education has been, and continues to be, used as a prevention technique keeping people silent and fostering stigma and ignorance. Consequently, HIV/AIDS is distinguished from other chronic illnesses as shameful and that those infected are to be isolated and avoided rather than cared for and supported. Health interventions that only target those living with HIV/AIDS, and make a special case of the AIDS patient without addressing issues of stigma in the community or society at large can actually make the situation worse for people living with HIV/AIDS in the long run.
Something I did not expect to encounter in speaking with an HIV/AIDS support group was the large degree of stigma regarding transmission that persists. Words like "innocent" and "guilty" are often used to refer to people who are infected or to how someone became infected. It was mentioned that many contract the virus and are "innocent," implying that somehow others who test positive are "guilty" of something and therefore deserve to be infected. More than the lack of information, I find this attitude troubling and much more difficult to address or deal with as it seems to be so ingrained in the attitudes of many, including some of those who work with and care for PLHAs.
I have also been attending the meetings of Gambia AIDS Services (GAS), a group of about 20 youths who volunteer their time to go into communities and provide information about HIV/AIDS, as well as sensitize them about stigma and discrimination and encourage people to go for voluntary counseling and testing. They conduct their sensitizations primarily through the presentation of dramas. At the last GAS meeting, I watched the members create a drama to present to a largely illiterate audience about the premise of voluntary counseling and testing and designed to encourage community members to "Know Your Status!" as the billboard on the highway into Banjul shouts at passing motorists. As they created the drama, I realized how difficult it is to present "knowing your status" as a positive and empowering thing when it could mean isolation from family and friends and the end of life as you know it. The finished skit featured a married man who had been cheating on his wife and lately had been feeling ill. He was convinced by a friend to get tested and he found he was HIV positive and told by the counselor that his wife could be infected as well. In the final scene of the drama the man who tested positive was speaking to the friend that had encouraged him to go for VCT in first place, blaming him for ruining his life and saying that he wished he had never found out. The friend replied that it is good to know your status so that you can begin to "live positively" and not infect others. The man agreed with the wisdom of this statement and went reluctantly to tell his wife she should go in for VCT. I realize of course this is a drama, but watching the final scene I couldn't help but think how hollow the words of friend sounded and how little comfort they will bring the man and his wife.
Despite some of the more difficult things, I am really enjoying my time here. Hopefully I will have the opportunity to do some trekking upriver to see more of the country, but for now I am content to explore the sprawling marketplaces of Serrekunda and Banjul, and wander through various neighborhoods taking pictures of the giant trees and the beautiful dresses the women wear. I take my camera everywhere, and I feel somehow braver and less conspicuous when I am taking photos (though I am sure it is probably the exact opposite).
Luckily, I have also been given plenty of work to do, through I worry that my contribution here will be a very short term one, and that the difference or impact I am having will not be, in development terms, "sustainable." I have been told that development work is often an agonizingly slow process and that unlike relief or emergency aid, it can be difficult to see the impact that you are or are not making, but it is still hard to come to terms with the fact that in my very short stay here I will almost certainly take much more out of this experience than I will contribute.
February 21: Happy Gambian Independence Day! On Saturday the 18th of February, The Gambia celebrated the 41st anniversary of becoming independent from Great Britain. I'm not sure what I was expecting, but it seemed to be more of a celebration of the current president and the "independence" the country has enjoyed since he took over. Several people I've spoken to say that since the coup in 1994, more emphasis is placed on "Military Takeover Day" (yes, that is actually what it is called) on July 22nd in remembrance of the day the military, led by Lieutenant Jammeh who overthrew the only Gambian president since independence. In preparation for this Independence Day, the military as well as civilians were busy all week cleaning the areas along the main roads that visiting dignitaries would travel down from the airport to the state house in Banjul. The trash that litters the roadways is one of the many differences between the touristy areas and "real" Gambia. Next to the major hotels there are small attractive streets full of vendors selling "local" souvenirs, kind of like Gambia Disney. I think many tourists who visit the country never venture beyond these paved and relatively clean streets. While I definitely enjoy visiting the lovely hotels and relaxing next to the pool (as we did when Janet visited) it is more difficult to relax and be a tourist knowing how much more there is to the country, and I know after this when I travel I will be much more aware than I have been in the past about what I am not seeing.
The President stopped by to observe the cleaning efforts on the street in front of my compound earlier this week and I was lucky enough to snap several photos of him. As he is a bit on the short side and was surrounded by military guards and private bodyguards, at first I could only see his white hat from where I was standing. Suddenly though, he ordered the 50 or so young army guys in front of me to drop and do pushups and I was able to take a full-length shot of him. In a bout of Gambian hospitality, the scary looking automatic gun wielding guards were extremely helpful in getting me as close as I dared, and in physically preventing anyone from getting in front of me until I assured them that I had taken as many photos as I wanted to. I was a bit nervous to take any photos at first because the weekend before I got in trouble for allegedly taking a photo of the US embassy, I didn't, but as one of the only young white girls in the area, when some other young white girl was seen taking photos, two guards showed up at my compound I suppose to "confiscate the film" and to generally freak me out.
One of the dignitaries who visited for Independence, and in whose honor President Jammeh declared Monday a public holiday (and so no work), was the young King of Morocco. As I was enjoying my holiday by taking a walk I ran into a crowd of about 200 school children, traditional dance groups and several hundred other interested spectators, for what I didn't know at first, but I waited for nearly an hour in the blazing hot sun with a crowd of students figuring whatever we were all waiting for would be worth it. After buying one of the deliciously tart local green oranges from a little girl who should have been in the second grade and not selling fruit, the Moroccan King passed by in his black stretch SUV and waved.
President Jammeh has been in power now for nearly 12 years. When I asked some of my co-workers about what they thought of him several said that he had not done much and that little has changed since he took over, but that they should "give him more time," kind of the opposite sentiment most Americans would have. Despite elections coming up quickly this next October, the only evidence that there is going to be an election soon are the campaign signs for the current President Jammeh. Even if they do not really like him, most people I have spoken to are fairly certain he will win, though many are not planning on voting for a variety of reasons. Given the violent history of many neighboring countries, perhaps the fact that not much has changed over the last 12 years is not such a bad thing. A Memorandum of Understanding between the president and the other political parties was signed last week under the auspices of the visiting Nigerian President. Hopefully this will ease tensions a bit between the ruling party and the opposition, which have been strained to say the least since the President had some of the opposition leaders imprisoned in late December.
Following the national news here can be very difficult as it is challenging to find an unbiased news source, not that that is an easy thing to find anywhere, but there are drastically fewer sources to choose from here. The only TV broadcasting station in the country is owned by the government and primarily covers the President and his "good deeds." The small independent papers seem to fall into two camps, either they are fervently in favor of the president and praise all his decisions or are clearly against the current regime and criticize all his actions. Most papers fall into the former, as criticizing the government can be tricky, despite official statements concerning press freedoms.
This last week a press meeting with leading journalists was held where the Secretary of Communications announced that Gambian journalists should not "hide" behind so-called "freedom of the press," or criticize just to criticize, and requested journalists not jeopardize development efforts by basically making the country look bad. The Secretary also criticized countries like the US that claim to have freedom of the press but yet would imprison a journalist, a "female" journalist it was emphasized, for not revealing her sources, something the Secretary of Communications assured those present The Gambia would never do. According to Reporters Without Borders, however, press freedoms are in danger in the country. Last year a prominent editor of an outspoken opposition paper was murdered. An investigation conducted by Reporters Without Borders pointed to military forces for the murder and for ongoing attacks against journalists though no charges have been made. Several radio stations were also recently shut down when the President accused them of creating tensions or "bad feelings" between The Gambia and Senegal. In the wake of the recent outrage over the cartoons of the Prophet Muhammad, the President spoke out against "sensational journalism" and said that human life and political turmoil are the potential costs of press freedoms.
I attended two community sensitizations last week with Gambia AIDS Services. The first was with a youth group that already knew quite a bit about HIV/AIDS and Voluntary Counseling and Testing Services, and the second with a primarily older married audience that did not have quite as much information. Both sensitizations were conducted in Wolof so that everyone could participate, but it was easier than I at first thought it would be to follow the discussions. With the older married audience there was a lively debate about who is more likely to "stray" in the marriage and to put the married partner at risk. One man dared to suggest that women were more likely to have affairs outside of marriage, a bad move considering he was outnumbered nearly 2 to 1 by the women in the group who most definitely objected to this characterization and provided multiple examples to the contrary. Both sensitizations seemed to go really well as all of the participants invited the group to return for further discussions and several people asked where VCT services could be accessed, though many others also expressed completely understandable fear about being tested. I have been working out of the CRS office this week on the Annual Project Summary of Activities for 2005, but am hoping before the end of the month to go upriver on trek to visit the other project site in Basse.
March 7: I have noticed lately that "development" seems to be the word of the day here. Every other article in the papers, or news story on the national television station is centered around the theme of "development" and events or actions influencing the development of the country for better or worse. Every elected official, or would be politician, talks about what their party is doing, or plans to do to further the "development" of the nation. The word is used to exhaustion, like when you repeat a word over and over again until it becomes just sound and syllables and has no real meaning any more. I think the problem is one of definition. For many, "development" means simply something new and more complex, a new technology, new building, new public policy-all are described as "development." I think most working in the development field would take a far more nuanced stance on what they understand "development" to be. Development does not necessarily mean something new, it can often times mean a return to an older system or custom that has been lost but is resurrected to address a current issue or problem. I think CRS' "Kabilo" peer counseling project here is a good example of what I mean. Basically, the project aims to improve sanitary conditions and hygienic practices in rural communities in order to improve the overall health of the community and specifically the health of young children who are most vulnerable to the effects of contaminated wells and lack of clean running water. The project makes use of the traditional "kabilo" or clan structure to disseminate information and to organize activities and to address behavioral change and has been quite successful.
While I would not hesitate to describe that as "development," to label the huge shiny new bank that has been under construction on the corner near my street since I arrived as "development" just does not seem to fit. Witnessing the final touches being put on the building I could only think how at odds it looked with the rest of the very small and much more modest looking buildings on the street, and how the building literally casts a shadow on the women and children selling small bundles of firewood along the road nearby. In addition to the fact that there is another bank just a little further down the road, the new building seems grossly oversized as very few Gambians have any kind of savings account or keep any money in a bank. If this is "development" as it has been labeled, development to what I wonder. There are all too many examples of so-called "development" in the country that has not necessarily improved the well being of anyone, and some that have actually negatively impacted quality of life. The structural adjustment program the country underwent in the late 80's and early 90's to participate in the new "global" economy led to a staggering increase in poverty. The removal of agricultural subsidies resulted in expensive agricultural products that could not compete in the world market, and thereby directly worsened the welfare of an estimated 70% of the population that depends on agriculture for its livelihood. In the aftermath of liberalization, coupled with rapid population growth, poverty increased from 33% of the population living below the national poverty line in 1992/1993 to 69% of the population in 1998. Furthermore, despite the numerous "developments" that the current regime has implemented in recent years, the United Nations Human Development index rating for The Gambia has dropped from 149 out of 177 in 2001 to 155 in 2005. But then again, it is often easier to see the negative than the positive. There have been a number of positive developments in recent years as well, especially in education. According to recent reports The Gambia is well on its way to meeting Millennium Goals in terms of overall student enrollment, and the country has taken many steps to increase the number of girls attending school.
In other news, I went to a naming ceremony (or more accurately a naming ceremony reception as the actual naming was done in the early morning) with a co-worker of mine last week. As the only one with a camera, I became the official photographer of the gathering and took shots of all the guests and the first photos of the 8-day-old guest of honor, that I was happy to later present to the lovely couple as a gift. While sitting outside in the compound listening to the guests around me joking and arguing in Wolof and Manjago with some English sprinkled in for good measure, I suddenly became aware of a group of about 6 young boys standing under a small tree next to my chair watching me. I had not realized they were there immediately because it was so pitch dark as the power was out (per usual in the evenings) and there were no lanterns or candles to be wasted outside. (I think my night vision must not be as developed as Gambians or something as I have to rely on my mini flashlight to descend a dark flight of stairs that they nimbly run down without the aid of any kind of light.) The other guests asked the boys what they wanted and laughed at their reply and then translated for my benefit. The boys said that they had seen a white person in the compound and that white tourists have money so they came in. The guests tried halfheartedly to shoo the boys away but they returned soon after and everyone was too busy talking to bother again so the children were ignored. I tried to do the same, but it was difficult to pretend not to see a group of now 10 little boys begging for money, except they were not begging or even talking to me despite my rather lame attempts at conversation starters (most likely the boys did not speak any English which would make sense if they were not going to school). The boys continued to stare at me for a while longer as I tried to understand how none of the other guests seemed to be disturbed by the situation. It is not as though any of the guests were bad people, I think they were all just used to a situation that is really unfair and horrible but has existed for so long people have become somewhat desensitized to it. I am sure most Gambians would agree that yes, poverty is horrible, and yes, all children should be able to go to school and not be selling things or begging on the street, but that is not how things are.
I am continually surprised by the number of things that still surprise me here. I still find it mind boggling how many people lack basic information about HIV/AIDS considering the amount of information that would seem to be out there. In addition to the billboards, nearly every evening on the government owned local Gambian television channel there in a mini drama shown about HIV/AIDS in Wolof or Mandinka. At the last Gambia AIDS Services community sensitization though, in answer to the question of "what would you do if you found out your spouse was HIV-positive?" posed by one of the group members, a man in the audience responded that he would take his wife to the hospital to get her medicine to cure her.
It still surprises me and makes my fingers itch to grab my camera like an excited tourist when I see goats and huge chickens and even cows wandering across a busy street, or a horse drawn cart rushing down the road next to dented yellow cabs and overcrowded bush taxis. It still surprises me how excited people, especially children get at having their pictures taken. Jessica and I visited the largest mosque in the country in Banjul last weekend and were immediately mobbed by children anxious to have their pictures taken and fascinated by their images captured on our digital cameras.
In addition to taking photos, I have become obsessed with the fabrics here. There seems to be a fabric stall or small open-air shop on every street selling the beautiful and exuberant wax prints, batiks, tie-dyes, and every other kind of beautiful fabric you can imagine. As the selection of imported ready-made clothing is sparse and expensive (and of pretty poor quality) most Gambians have their clothes hand made, or sew them themselves. Unfortunately, the bright bold prints don't suit me as well as they do the Gambian men and women who wear them with such confidence, but that hasn't stopped me from perusing the stalls and buying several yards of different fabrics.
It is difficult to believe I will be going home in two weeks. I feel like I am finally getting settled into a routine and carving out a place for myself here. The taxi drivers remember me (though I think very few white girls take my route, its still nice to be greeted like an old friend), and I am a regular in the local market where I buy my water. The time has gone by so quickly up to now, and I feel torn between wanting to go home so much I can practically smell the rain, and feeling like there are so many more things I still want to see and do here and that I am not yet ready to go.
March 16: Time is a funny thing. While it feels impossible that I have been here for 10 weeks and for the most part they have flown by at an incredible speed, at the same time, thinking back to the day I boarded the plane at Sea-Tac that day feels like it was a lifetime ago.
My persistence and nagging finally paid off this last week when I able to go upriver on trek to Basse with a colleague from the local NGO I have been working with and a CRS co-worker. Most of the road along the way was in such horrible condition that I am surprised we only experienced three flat tires (one on the way and two on the return journey), but despite that I really enjoyed the trip. It is good to see the "real Gambia," as most of the country outside of the greater Banjul area is very rural and most Gambians live by farming and fishing in the countryside and along the river. Gas is quite expensive and few people travel long distances very frequently. On our trip we rarely passed another vehicle along the 8+ hour journey apart from a few crowded bush taxis or battered freight trucks (a number of which were broken down along the side of the road).
Basse is the largest town in the eastern part of the country, and owes its existence to the highway running north-south through The Gambia that is used mostly by the semi-trucks passing through to and from central and western Africa and northern regions. While the truck drivers who pass through are bringing much needed business to the area, they are also contributing to the increase in the number of brothels and the number of prostitutes in Basse. In recent sentinel surveys, the HIV/AIDS prevalence rate, and that of other STDs, in Basse was discovered to be well above the country's average. In light of this and the serious lack of health care facilities in the division as a whole, CRS and its partners decided to base a VCT (voluntary counseling and testing) center in Basse, and begin providing home-based care services out of the same office.
Even during my brief visit it was clear that the staff is completely overwhelmed in terms of needing more funds, more training, and simply more staff in order to continue to visit all of the registered clients (and the new clients coming in each week) on schedule. Staying in the city I had thought HBC (home-based care) was a more confidential option than requiring patients to visit a public clinic each week, but after a day of lumbering through tiny neighborhood dirt streets in our large white jeep, with the NGO logo on the door, past the many people sitting outside their compounds I realized why so many patients resist being visited by the home based team for as long as they possibly can (i.e. until they are physically unable to go into the clinic to pick up their food rations and medicines for opportunistic infections). In an attempt to reduce stigma and discrimination as much as possible the team also provides HBC services to a few chronically ill patients such as those who are paralyzed or otherwise unable to get into the clinic.
Driving house to house with the HBC team I was also informed that their biggest problem is that patients are dying too quickly. Down every street the staff pointed out houses they used to visit, and tried to remember the names of the patients they had lost most recently. By the time many come for testing they are already very ill, and there is all too little the HBC team can provide for even those who are tested when they are still relatively healthy.
Only one of the nearly 100 patients the small team visits are taking ARVs. The HBC team, and me, have difficulty explaining why the drugs are being dolled out so slowly and why more are not made available by the government. To register someone to receive ARVs itself is an excruciatingly slow process. Two patients the team had recently lined up to begin receiving the drugs, which entails among other things, physically bringing the patient on the exhausting journey to the Brikama health center to have their CD4 counts taken (there is no CD4 count machine in Basse), having the patient reveal their status to at least one other person apart from a nurse or doctor (a requirement that is being challenged by some as it has been cited by many as a major deterrent to people wanting to begin the registration process, but the organization responsible for distributing the ARVs maintains it is critical to ensuring the patient takes the drugs correctly), having the patient's situation reviewed by a board of individuals, and then more waiting to find out whether or not they are going to receive the drugs. In recent months, two patients the team had lined up to begin receiving the drugs became seriously ill and died before they ever received the promised ARVs.
The first woman we visited lived with the 3 youngest of her 5 children in her brother's compound as her husband died a long time ago before either was tested for HIV. The woman had not been receiving home-based care for very long and while she answered most of my questions, she stared at the dirt floor of her small single room home almost the entire time we were there. One of the pieces of information I was trying to gather was on whether the HBC clients would be receptive to the creation of a support group in the Basse area similar to the Santa Yalla Society in Banjul. I asked the woman if she knew of anyone else who was HIV-positive and she quickly said no. I asked her if she would be interested in joining a support group for other people living with HIV/AIDS, if there were such a group near her home, and she almost as quickly said no and that she did not want to be seen or to see others like her. The nurse who was translating for me added that she felt ashamed. I felt overwhelmed by how isolated she must feel. I strongly believe that meeting other people living with HIV/AIDS and knowing she is not alone would do so much to improving her quality of life, but cannot be forced to do things they are not ready for. Not two minutes away from her compound we stopped at another house to visit another HIV-positive HBC client.
Also difficult to grasp was finding out that virtually none of the children of families where one or both patients are HIV-positive and receiving HBC have been tested for the virus. The team explained to me that the children are too young to consent to testing or to fully grasp the implications of the disease, and that unless the parent specifically requests their child is tested, something the nurse I spoke to cannot ever remember having happened, they are not. He went on to explain that the school age child of the first woman we visited is enrolled in the OVC (orphans and vulnerable children) program that UNICEF funds to provide nutritional support and to ensure they attend school and have school books and uniforms, but all I could focus on was the likelihood that all three of the children who helped their mother cook dinner and sell firewood with their uncle to support the family were possibly HIV-positive, and I wondered how much more prepared they will be to grasp their situation when they are orphaned. I have always believed that knowledge is power and so to me it seems that hiding or ignoring the truth only makes children like this more vulnerable, but I know the situation is more complicated than that. Before leaving the first house I asked the woman if she would like any photos of her children and she said no, but when I expressed to her how beautiful they were, she jokingly (?) said I could take one of them with me if I wanted.
I was also able to visit the one patient receiving ARVs. The man is well over 6 feet tall, very rare in this country, and lives with his second wife, who is also HIV-positive and recently gave birth to a son who has not contracted the disease thanks to her being tested before she became pregnant and enrolled in a program with another NGO in the area to receive medications to prevent parent to child transmission. During the interview, the man sat below a picture of his third wife who had been the initial contact and patient the HBC team visited in the family before she died last year. The man has 5 older children all together, none of whom have been tested, but all of whom are enrolled in the OVC program. He was a model success story for ARVs. In the photos he showed me of himself at his son's naming ceremony a month ago, just after he began receiving the treatment, he looked frail and gaunt, his head too large for his body and he said he had no appetite and thought he would die soon. Now he looks much healthier and says he feels strong and well. Though ARVs are not a "cure all" as the HBC team is careful to say, they do have the potential to dramatically improve the quality of life for thousands in The Gambia and millions throughout Africa and other "developing countries" where they are still unavailable to those who are most in need.
Another woman we visited, and who I was informed before hand "did not speak," was in a very advanced stage of the disease and the HBC team do not expect her to live much longer. She looked impossibly thin and seemed completely unaware of what was going on around her as the HBC nurse performed a brief physical exam. Her teenaged daughter was sick with a fever and diagnosed on the spot by the HBC nurse with malaria and given an injection of chloroquine.
Later we crossed the river to the north bank, only a stones through away, on a tiny and very old ferry boat as there are no bridges across the river at any part and very few ferry crossings, most people cross in wooden fishing boats or rafts. We traveled to a small village where the team had arranged for one the HIV-positive HBC patients to speak at a community sensitization. It was quite a complicated affair as our presentation was in Wolof and Mandinka and then translated into Jolla for the community. I was also very long with all of the introductions and back and forth and the heat made it really difficult to stay alert. But the community was very welcoming and receptive to us, emptying the cows out of an open barn to use as a meeting area.
I interviewed the man who spoke after the presentation. This was his first time speaking in public about being HIV-positive and he repeated over and over again to me how important it is that he speaks out to inform others, and that "you cannot hide." He told me that he would be willing to go to any village to speak about living with HIV/AIDS, except, he added, to his own village where he lives with his wife, who is also HIV-positive, and their three young daughters. He said he thought if he made his status public he could no longer live in his village, and that his wife and daughters would suffer and so he must "pretend." The HBC team is currently working to get him registered for ARV's, but they are concerned he will not have the necessary support at home and may not be willing to come into the clinic on a regular basis to collect the medicine, or be willing to allow the HBC team to visit him at home so often.
We fly out tomorrow morning to Dakar. After saying all of my goodbyes today, I can honestly say that I am really ready to go home. While there were definitely moments and days that were frustrating or sad or just really long, I would do the whole thing again in a heartbeat. I have learned so much about not only NGOs and development work, but also about myself and what I believe and value. So thank you for reading about my experiences and I would encourage anyone thinking about applying to go for it as I think you can get so much out of it. This was definitely the "hardest quarter you will ever love," or however Janet put it in the syllabus.