I learn that Christina has delivered from David the Lay Counsellor, who calls me to tell me so. The line is bad, and although I establish that she delivered at Ipusukilo rural health centre on 3rd June, that the baby is a boy and both he and Christina are doing fine, I cannot confirm for certain that the infant received Nevirapine at birth. It is during delivery that a baby born to an HIV positive mother is most vulnerable to infection, therefore it is crucial that Nevirapine syrup (anti-retroviral prophylaxis) is administered as soon as possible to minimize the risk of transmission. By now I know where Christina lives, so on Sunday 5th June I journey out to see her, in the company of Anthony, the Clinical Officer who has been attending to Christina since she was enrolled on the PMTCT programme.
The arrival of a vehicle, particularly one with a musungu (white person) inside, attracts curious children, dusty and barefoot. They seem to appear out of the bushes, from all directions, their clothes hanging off them in scraps. The family is not expecting us, but welcomes us enthusiastically, particularly Christina’s mother Joyce, who claps her hands and clasps me in a bone-crunching embrace. Christina emerges from the house, wearing the same batik dress she was wearing on the first day I met her. It is a huge relief to see her up and smiling.
She quickly leads me into a room inside the family’s thatched hut, and introduces me to a bundle of blankets and pink and white knitwear – Patrick. Newborns are packed in so many layers here in Zambia, it’s hard to make out their actual size. On arrival at the maternity ward at Luwingu District Hospital, it’s not clear which are the babies and which are piles of blankets. Invariably, what looks like a pile of blankets is usually a baby – approach a bed and the mother will fold back the blanket to reveal a tiny wrinkled face. The women’s fear of the baby getting cold clearly outweighs that of the baby suffocating. Patrick is lucky enough not to have his face covered, but he is wearing a pink hat – Christina had made no secret of the fact she was hoping for a baby girl.
He has been named after a brother of Christina’s who died in April last year, aged only 40. Christina is the fourth of eight children, and all three of her older siblings have died in adulthood, in the same order that they were born. When I first met Joyce back in March, she lamented that Christina was next. When I had asked her how her children had died, the answer was simply ‘ubuloshi’ – witchcraft. As my relationship with the family has developed, I have been able to delve a little deeper. The first, I learn, had ‘malaria and hiccups’. The second had the misfortune to lose his wife to his younger brother, an affair which brought him bad luck and eventual death. The implication, I later learn from Legzai, the Counsellor who translated the conversation, is that the younger brother put a spell on the second-born, so he could continue the relationship with his wife. Indeed, when he was out of the way, the couple later married. Patrick, the third to pass away, had something moving in his stomach which couldn’t be seen by medical professionals. Since modern medicine couldn’t provide any answers, the family took him to see a ‘ng’anga’, a traditional healer. The ng’anga informed the family that Patrick had received magic as a child, which had caused this stomach problem later in life.
Fortunately, Christina does not believe that ubuloshi can cause HIV/AIDS. HIV/AIDS is not considered an African disease in Zambia, and most ng’angas do not claim to be able to treat it. But many people do not want to learn their HIV status in the first place, or do not readily accept that they are positive, which is hardly surprising considering the stigma and discrimination that continue to surround the virus. Such people may prefer to consult a ng’anga to get an explanation for their aches and pains; they may even prefer to learn that their neighbour has cast a spell on them, rather than that they are HIV positive. A ng’anga will not perform an HIV test, and an unscrupulous ng’anga will prescribe traditional medicine even if they suspect their client is HIV positive. In Zambia, ng’angas practicing centuries-old African medicine are present in almost every village, compared to sparsely distributed health facilities, often lacking staff, medicine and equipment. In this context, Christina’s determination to stick to her treatment, to ensure that Samuel takes his treatment, and to walk several kilometres in the dark, whilst in labour, in order to deliver her baby in a health facility, is highly impressive.
Impressive still is the fact that not only did Patrick receive his Nevirapine, but that it was Christina who reminded the staff assisting the delivery that he needed it. Just as for the births of her previous three children, there were no qualified health personnel in attendance, just one CDE – ‘Classified Daily Employee’ – Theresa. In fact, if you leaf through the delivery register at Ipusukilo rural health centre, you will see that most of the deliveries that take place at night are attended to by Theresa. And this is despite the fact that Ipusukilo is luckier than the more remote facilities in the district, in that the Ministry of Health has assigned two qualified health staff there, a Clinical Officer, Martin, and a Nurse, Memory. But Martin and Memory are not always available to deliver babies at night; they may have been on duty all day, they may be on leave, or at a workshop, they may have malaria, and besides – Theresa had been delivering babies for years before Martin and Memory showed up, so what’s the problem? This is one of the many contradictions MSF has to grapple with every day at field level – the Ministry of Health does not officially endorse CDEs to conduct deliveries, however CDEs like Theresa are doing deliveries, night after night, day after day. There are simply not enough qualified medical staff in Zambia. Even if MSF wanted to staff the rural health facilities ourselves, 24/7, it is highly unlikely that we would be able to hire enough trained health staff willing to live and work in such remote areas, far away from their family and friends.
So on we go, trying our best to work within a far-from-perfect system and figure out the most constructive ways to support it. It didn’t take me long to realize that this is a far bigger challenge for MSF than if we were able to just take control and do everything ourselves. In this setting, the rewards come more slowly, some imperceptibly. At this delivery, Christina knew what she had to ask for – and although that may not be quite the way we want things to work – this reward will sustain me for a good while yet.