Saturday, March 27, 2010

239: What continent is this?

For the last three years, the World Council of Churches had been planning a regional meeting in Madagascar to support the efforts of local churches dealing with HIV and AIDS. Finally, it happened. Our small plane left Johannesburg, crossed over Mozambique and the Indian Ocean, and graced over rocky outcrops and luscious green rice fields until it landed in Antananarivo, Madagascar’s capital. Very few tourists have come to this island since last year’s military coup, so in February the country cancelled all visa fees and now gives every new visitor an informational booklet on the history of Madagascar’s lunar calendar (which is Arabic in origin). Does the government really think these gestures will persuade tourists to start coming again?

An international city – in a time warp

Unfortunately, I could only stay less than one week. But what an amazing experience! Antananarivo is one of very few historic capitals that lie neither on the ocean nor on a major river. Instead, it is located in the middle of the country, perched on hilly outcrops about a mile above sea level. There are 2 million inhabitants and not a single traffic light. Not one!

The traffic is terrible, as you can imagine. But I enjoyed looking at the proliferation of cars from the 1950s, which gives a feel of Old Havana – albeit with a French overlay. Most cars are rattling Renault 4s and 2-horsepower Citroens, which are used as taxis.

Old buildings line the streets, with sloping tiled roofs, tiny wood-shuttered windows and small balconies where people hang out their laundry to dry. None of the structures seemed quite straight, least of all the narrow outdoor staircases that lead one to the second floor or up the steep hillsides of the city. Looking at these scenes, I was reminded of old Moldova or parts of Eastern Europe fifty years ago. Yet the street signs are all in Malagasy and French. And, given Madagascar’s history as a former French Colony, our meals invariably included croissants every morning and French wines at night.

Perhaps because I knew so little about Madagascar, I never expected the city’s residential and business areas to be so crowded. People’s homes and shops are squeezed into tiny spaces in between flower-potted gardens, polluted canals and sour-smelling garbage heaps. Most surprisingly, however, the flat areas that surround the city’s hills consist mostly of rice paddies. In the middle of the city! Sadly, however, the paddies are becoming less productive every year, as an epidemic of hyacinths choke out the oxygen in the stagnant water. Seemingly, no one knows how to get rid of this invasive plant. (The same has happened in the Chesapeake River outside Washington, I understand.) A number of local farmers try to induce their cattle into the water to eat the hyacinths, but with little success.

These scenes and my interactions with the Malagasy people transported me even farther afield -- to Asia. Most people look Polynesian and they speak a local language that resembles a Papua New Guinea dialect. (The photo of me is with Rev. Vololona Randriamanantena – a descendent of Malagasy royalty and coordinator of the World Council of Churches’ efforts in the country.) What little you see of new construction is almost entirely financed by Chinese banks using Chinese labor, and in my Chinese hotel nobody even bothered to translate the instructions from Chinese on how to operate the TV or telephone. Over and over during this trip, I kept pinching my arm to remember what continent I was in.

The two sides of HIV in Madagascar

But of course, we came to focus on the HIV situation. Coming from other southern-African countries that have the highest HIV-prevalence rates in the world (for example, Namibia’s adult population is 18% HIV-positive ), once again Madagascar blew me away. The national prevalence rate in Madagascar is less than a half-a-percent – far less than in Washington D.C. (at 3%) or the United States as a whole (close to 1%).

What is Madagascar’s secret to success?

If you answered “its isolation” you are probably correct. But it’s not only that Madagascar is an island, far away from Africa’s mainland. Even within the country people don’t move around a lot due to the country’s miserable road network. So the normal patterns by which disease is spread don’t apply here.

Moreover, when people do travel, it often means that they are looking for work outside Madagascar and, because of language issues, that usually means going to Mauritius or France or West Africa where the HIV prevalence is much lower. Finally, you may be aware that male circumcision reduces the likelihood for HIV infection by 60%. And, despite the fact that Madagascar is mostly Christian, virtually all Malagasy boys get circumcised by the age of two. It’s not a foolproof solution (as Jewish and Muslim men with HIV can sadly testify), but it certainly helps.

Unfortunately, the downside to this low prevalence rate is that for those Malagasy citizens who do happen to be HIV positive, the stigma and discrimination issues are awful and overwhelming. Most people living with HIV are afraid to tell their employers or even their family members that they carry the HIV virus for fear that they will be thrown of their jobs and homes. Clinics and support organizations for HIV-positive people are few and far between, and also very difficult to find. (The desire for anonymity keeps them hidden, without any public outreach.) The churches have a big role to play in breaking down stigma and discrimination, and from what we could see many are trying their best.

We visited a number of HIV/AIDS clinics and support groups. Interestingly most of the people living with HIV whom we met were men, while worldwide the disease predominantly affects women. Is this because of the relatively more-accepted practice of men-having-sex-with-men in Madagascar? I can only guess. So much on this island remains a mystery – and not only to me.

Lemurs are best!

Of course, no trip to Madagascar is complete without taking in some other unique aspects – specifically, some of the country’s 16 surviving species of lemur. Our natural history guide was named “Good-smelling,” which I thought bode well for our adventure.

Lemurs are the world’s earliest prehensile mammals, maternal in their social structure, and generally living in groups. They are primarily vegetarian and females always eat first. A night, lemurs sleep in a circle, with the males forming a protective ring around the females. They are naturally curious creatures, their round eyes staring at you intensely like Namibian bush-babies. Tragically, a loss of habitat has endangered many lemur species (15 are already extinct). We saw them in the zoo, in an open reserve. I would have loved to visit their natural habitat. Yet even here, I could have watched them for hours.

Madagascar is not on our world-trip itinerary but I hope I can come back one day. To end, here is a wonderful local proverb that I learned during my stay:


Let your love be like the misty rain,

coming softly but flooding the river.

...............(Madagascar)




Saturday, March 6, 2010

238: The constancy of change

Three years ago I first visited MWEDO, The Maasai Women’s Development Organization in Tanzania. Leaving Arusha in Northern Tanzania, we spent an entire day driving over rough tracks to reach a group of Traditional Birth Attendants who had received training in basic health, hygiene and HIV/AIDS, thanks to support from the Stephen Lewis Foundation. At the time, my efforts were rewarded with a warm welcome by my age-mates (women of similar years) who dressed me as a local Maasai and told me – through translation – how much their training increased their knowledge and the respect they receive from other villagers. (To my left in the photograph is the mother of MWEDO’s founding director, Ndinini Kimesera Sikar, who was taken out of the village as a young child to receive an education, and is now a world-famous champion for women’s rights.)

On this trip, I learned that MWEDO (www.maasaiwomentanzania.org) has expanded its work in six districts, where it now empowers thousands of women through various income generating activities, advocacy over land-rights, and follow-up training with the Traditional Birth Attendants. They also involve young men as peer-educators, as these men often travel to the towns and cities looking for work and are therefore most-at-risk for bringing the HIV-virus back home to the rural areas. I visited three villages to ask about these experiences and find out what the participants had learned.







The work has been extraordinary, but some questions still remain. As Ndinini and I sat under a tree, one young man challenged me: “We learned how to
use condoms, but were told you could still get infected (with the HIV virus). So why should we bother with them?” Ndinini had already warned me against speaking directly about sex in this culture, but I sensed this question was a test. How I answered could determine the way this community continues to accept training by the Stephen Lewis Foundation. I thought carefully before responding, and then looked up at the new road that was under construction about two hundred meters from where we were sitting.

“You know, if you cross that road, the danger always exists that you could get hit by a truck,” I said. “In order to avoid that danger altogether completely, you have to stay on this side of the road. But if you want to cross the road, then you should reduce the chance of getting hit by a truck as much as you can. So you must look both ways to make sure it is safe and then you walk across very quickly. Well, it’s the same with the condom. There are things you can do to avoid getting hit as much as possible.”

I held my breath and looked at Ndinini who smiled. The young man said he understood and was satisfied. Then the women followed with stories and questions of their own, mostly related to and about HIV-testing and care. Before the Training, they said, it used to be their custom to share razors when shaving each other’s heads (a traditional sign of beauty). But now they realize this habit could spread the HIV infection. So they are teaching each woman to keep her own razor. As Traditional Birth Attendants, these women also know that if a pregnant woman is infected with HIV, she should go to the doctor to get certain drugs that can reduce the transmission of HIV from mother to child. As further protection, the pregnant woman should give birth in a health clinic, rather than in the bush. But Maasai women are used to giving birth in a squatting position, these women explained, while the clinics require you to lie down on your back. Could we do something to change that?

The truth is, I’m not sure how much can be done but I wish all organizations would pose challenges like this one. By contrast, I found out that another organization I had waxed eloquent about in 2006 (that was founded by two volunteer-doctors) has gone down the tubes. Fortunately it was the exception: Ruined by external funding and the lack of administrative know-how, though very little money was lost.







Where to next? I have a meeting next week in Madagascar, followed by consulting work for Family Health International. I’ll be back in time for Passover and an Easter-weekend trip with Bernd to see elephants, and then I head to Malawi for more work. Meanwhile, however, our “to-do” list for the Big Trip seems to be growing longer rather than shorter.

We’ve started to figure out what we should pack and what we should leave behind. I’m reminded of a jewellery-bedecked saleswoman I met in January at Chico’s (one of my favorite stores in the U.S.) when I was looking for a wrinkle-free blouse that I could use as an all-purpose “dress-up” outfit on the trip. The poor woman’s eyes popped out when I told her why I was being so fussy about what to buy. “How do you pack for a whole year?” she sputtered. Now, I’m beginning to wonder myself.

Nevertheless, we are making progress. This past week, Bernd and I went to hear a local speaker who had travelled around the world for fourteen months, albeit mostly as a beach bum -- not our style. He re-enforced two very important concepts, however: First, that in order to be truly open to new experiences, you have to detach yourself from the parts of your life that don’t matter so much. Second, don’t try to plan everything ahead of time because that doesn’t work anyway. (As an inveterate planner, this last bit of advice hit home. I have promised myself to try to hang loose on some of the details, for example waiting until we get settled in one country in order to decide what to do in the next.)

We still hope we’ll get to see Sergio before we leave in June, but aren’t sure. He remains in Okinawa and has turned his body into a canvass for the tattoos he designs. This latest photo includes one of his beloved guitars. (Appreciating this artiness is also a test – we’re okay with the picture but wonder what it will be like in-person.) Elsita’s future is also unclear at the moment: she didn’t get into the graduate schools she wanted and now wonders: Should she stay in Africa longer, move back to the USA with her friends and look for a job, or apply to Ben Gurion University in Israel for a Master’s Degree in Desert Ecology? (All three options have pros and cons. See her below at work in the laboratory - www.gobabebtrc.org.)

Bernd is teaching a course in Cryptography for the first time and really enjoying it. After six weeks of agony and applications to every tertiary-level course we could find, Sofiana (the Angolan refugee who lives with us) got into a 2-year diploma course in Accounting at the University of Namibia and is thrilled. She hopes for on-campus accommodation next term, but will continue commuting from our home in the interim.









(The photo of President Bush was taken during his visit to MWEDO in 2008, kissing a tall Maasai woman. I think it’s a hoot!) As a final note, yesterday I was interviewed by Namibia’s Anti-Corruption Commission based on some non-profit work I am doing (where the director was being investigated), but happily it was all a false alarm – motivated by party-politics and another Board member’s vindictive nature. I wish all disputes could be ironed out this easily!