I will call her Christina. We are almost the same age – she’s 31 and I’m 32. Beyond that, we don’t have much in common. Christina completed 7 years of schooling and is now a married woman with three children and another on the way; her family grows cassava, beans and groundnuts and rears chickens. Occasionally there is surplus to sell, otherwise the family survives at subsistence level. I have a Masters degree and am single and childless. I quite like cooking, but if I had to grow my own food I would definitely be in trouble. This is my fourth mission with MSF in as many years.
I meet Christina for the first time on Wednesday 2nd March, at the rural health centre in Ipusukilo, Luwingu District, northern Zambia. She has come on foot about 1.5 kilometres for her first antenatal consultation, six months into her pregnancy. The distance she has travelled is undoubtedly small compared to many of the other women who crowd the benches, waiting to be seen. Christina is an attractive woman, with a well-proportioned figure; she is formally dressed in a matching skirt and blouse of embroidered batik material in rust orange and purple brown. Her shoes are black and sensible.
On arrival at the health centre, Christina sits alongside the other antenatal mothers and listens to a health talk delivered by one of MSF’s counsellors, Legzai. Addressing the women in Bemba, the most commonly spoken language in this region of Zambia, Legzai explains what they should expect of the day, telling them about the different people who will consult them, and describing the tests that will be performed, including HIV. He tells the women that they have the option to ‘opt out’ of the HIV test if they wish, however I later learn that very few women do so. Unfortunately, this is not because the women understand that in this era of treatment, HIV is no longer a death sentence. It is rather that knowledge around HIV/AIDS in this region of Zambia is so limited that testing positive does not carry with it the same associations as it so often does in other parts of the country – notably fear and stigma. In a country with an estimated 15% HIV prevalence amongst the adult population, it is surprising that in any part of the country there can still be ignorance about an illness that Unicef estimates has left 20% of children without one or more parents. However, in just three weeks in Luwingu District, I have heard time and again that women here who learn of a positive HIV status react with what appears to amount to nonchalance.
This is partly due to a comparatively low HIV prevalence in this region of Zambia. Women of childbearing age in Luwingu District have an estimated prevalence of 7%. Living in sparsely populated rural areas means that while 7% is by no means low, the impact of illness and death may not be as visible as in tightly packed urban spaces. Furthermore, there is a chronic lack of qualified medical staff in the rural health centres and health posts that are scattered across Luwingu District, meaning that the population is understandably not in the habit of visiting them. Therefore when people get sick or die, it is unlikely that they or their families know which illness has afflicted them.
MSF is trying to address the poor health indicators in Luwingu District in several ways, with a specific focus on reducing maternal and neonatal mortality, including reducing HIV transmission from mother to child. Which brings me back to Christina. After listening to the health talk, Christina undergoes the various lab tests. It is at this point that Dr Jeanie Yoon, an American Doctor on her first mission with MSF, approaches me. We had been discussing the previous evening how it would be interesting for me to follow an HIV positive pregnant woman through MSF’s PMTCT (prevention of mother to child transmission) programme, and to write about her experience and hopefully the successful outcome for her baby. Christina’s HIV test has come back positive, and Jeanie asks if I want to meet her.
First of all I consult David Mapulanga, a ‘Lay Counsellor’, who will be the one to talk through the results with Christina. MSF sponsored David through a short training in basic counselling skills in 2010, and now gives him a monthly incentive (approximately 25 Euros) to assist Legzai on the days when MSF comes to Ipusukilo. David comes from the community himself, so he knows many of the women who attend the health centre (including Christina), however he is well-versed on the importance of respecting clients’ confidentiality. When he understands my intentions, David asks Christina if she would mind me joining their counselling session, and she tells him that she doesn’t. I have never sat in a room with someone who is learning that they are HIV positive before, and I imagine how I would feel if it were me. I know that the news would be a devastating blow both to me and my family and friends back home. I know that I would self-stigmatize and that I would be stigmatized by others, who would make assumptions about my private life and through ignorance may even be afraid to touch or hug me. Thinking these things, and sitting across the room from Christina, I want to walk over and hold her hand or hug her. However I decide against it, she doesn’t even know me yet; I hope instead that over the coming weeks and months she will learn to trust me.
Christina accepts the news quietly and without shedding a tear. I cannot follow the conversation, which is in Bemba, however David does tell me that she is worried about her 3-year old, who is not in good health. David tells her it is important that she brings him to her next consultation, which will be in two weeks, so that he can also be tested. When David asks about her husband, she explains that he is in the Copperbelt Province, that he went there for a visit, and she had been expecting him back in December. She says this matter-of-factly, as if December was just yesterday.
When David has finished the counselling session, he accompanies Christina to see Jeanie, and translates the consultation. Jeanie explains that it’s possible to be HIV positive and to feel fine, but eventually the body weakens and becomes vulnerable to infections, and that’s when it’s necessary to start treatment. Christina has her head down and only nods to indicate that she understands the translation, while fiddling with the handles of her handbag, the colours of which match her outfit. Jeanie goes on to explain that babies born with HIV will normally die before they are two years old, however fortunately there is treatment available which can significantly reduce the likelihood of the baby contracting HIV in the first place. She says that to find out which treatment Christina should take, she must send a sample of her blood to the laboratory and wait two weeks. Jeanie then asks Christina to think carefully about who could assist her as a ‘treatment supporter’ – perhaps her husband or her mother? She says if possible, Christina should try to identify a treatment supporter and this person should accompany her on her next visit. Crucially, Jeanie also asks precise directions to Christina’s house, in case she doesn’t turn up for her next appointment. This is where David’s local knowledge comes in very handy – since he already knows Christina, he also knows where she lives; in all the health facilities where we are currently working in Luwingu, we are using Lay Counsellors such as David to carry out ‘defaulter tracing’, to visit the homes of women who have missed an appointment and to convince them to come back.
Finally Jeanie asks how Christina is feeling, and if she has lost any weight. Christina says that sometimes she coughs and feels feverish, however she doesn’t think she has lost weight. Before leaving, Christina has an antenatal consultation with the MSF Midwife on duty, Zodwa. Zodwa registers her, takes a basic history and performs a palpation (to gauge the gestational age and hear the foetal heartbeat). Christina is clear that she has been fully vaccinated against Tetanus. Zodwa gives her ferrous sulphate with iron to elevate her haemoglobin, a deworming tablet which Christina must chew there and then, Fansidar to prevent Malaria, a mosquito net and multivitamins. She is now free to go, and we all hope that we will see her again in two weeks’ time.