Women’s Day

March 8th, 2011 by Maeve Lalor

I was truly surprised by the men of Karakalpakstan today! Lunch time in our office is one of my favourite parts of the day for me here. At one pm our cook shouts “Abyet/Lunch” and everyone pours down into the lunch hall where we feast on delicious plov with Kim-Chi, accompanied by one of the best breads in the world, peanuts, chocolates and green tea. Half way through our lunch Asker, one of the logisticians stood up to make an announcement (not unusual here at lunch time). One of the translators also stood up to translate into English for those who don’t speak Russian. “Today, the men would like to wish all the women a happy Women’s day.” Suddenly, into the room came several men bearing gifts and each woman was given a beautiful red carnation (very rare in the desert!) and two nicely presented glass vases for chocolates or sweets. We were all made to feel special and wished “Sprasnikom”.

In Uzbekistan, women’s day is a public holiday, and as it falls on a Tuesday we have a four day weekend. I have just understood why, having just returned from the market which is bustling more than usual with people selling flowers, teddy bears, cakes, and many delicious foods. I noticed a lot of women buying the food and rushing about. Here’s hoping that at home it’s the men who will cook up the feast today!

For me, I would swap pancake day for women’s day every year if I had the choice.

The Highs and Lows

February 26th, 2011 by Maeve Lalor

The last few weeks have been very up and down. I’ve gone from feeling extremely frustrated to excited and motivated. I find it amazing how quickly the mood of the project can change.

A series of frustrations crept up on me lately- it can be extremely difficult to find out what is happening here. It’s easy to see the resulting problem- but it’s so much more difficult to understand the reasons and complexities to why the resulting problem occurs, and one of the most frustrating things for me is how long it takes to get to the bottom of it. A recent example-in a high DR-TB area, all TB suspects should have culture and drug sensitivity testing (DST) as well as smear to begin treatment- yet many were not being tested. To figure out why they were not being tested took weeks of questions, discussions, confusion and misunderstandings. Were the doctors and nurses aware they could get these tests, what lab was producing the smear results, why were the samples not being sent to the central DST lab? Finally, we got to the bottom of the problem-the incorrect form was being sent with the samples. Yipee, finally understanding the problem should result in a solution! But no, the sheer number of samples that would need the additional tests would overwhelm the lab as there are not enough staff to cope with the work. So a decision was made to focus on expanding our activities to the new areas, and getting it right in the new areas. We can’t do everything at once, a priority has to be set. But it doesn’t make it any easier when you see a way to make something better, and then can’t fix it-frustration sets in!

But I started this by saying I’m now feeling motivated and empowered. The long-time MSFers often accuse “first missioners”, (people who are new to MSF like myself), of not being realistic about what one can achieve. They are so right, I came here hoping to make things better and want to do it all at once… but then the longer you are here the more one begins to settle into a frame of mind where you believe things can’t just be changed that quickly and some things might even have to be accepted….

It was just at this point that I was sent on a management training course along with a handful of the other international staff and a dozen of the national staff managers. I have to admit, I wasn’t all that excited about the course until I went on it! As well as learning a ton of useful tactics to be a better manager, communication, negotiation, planning etc. our team went through a transformation and came out feeling more empowered and motivated to bring about positive change. I’m hoping this feeling lasts!

Sabrina (MD) Mitchell (MD) and me on top of fort Chilpik. You can see the salt (not snow) on the ground in the background.

24 Degrees

January 20th, 2011 by Maeve Lalor

January has been a marathon month of never ending data requests, summarising the project we just handed over to the Ministry of Health, summarising the last year of work, estimating how many patients we will have for the next four years, estimating how many samples the lab is going to have to process from now until the end of 2014. It’s easy to get lost in all the numbers, so I’ve tried to put them into pretty graphs and created a new project noticeboard with epidemiological updates to get people talking about the data a bit more.  This month we did an assessment of the four new districts that MSF plans to extend “Comprehensive TB care” to.  A couple of the districts had surprisingly few TB patients, while the others have many TB patients including some who have already been diagnosed with DR TB. These DR TB patients  are currently mixed in a ward with sensitive TB patients, they are now waiting for MSF to begin operations so they can be treated correctly.

It feels like I’ve been here for years, but I am almost exactly half way through my years contract. I’ve developed a pomegranate juice addiction- I find the whole process of picking out the pieces from the fruit very relaxing and the resulting small volume of juice generated (at least half an hour later) is both delicious and moreish. Interesting weather fact – one morning this week it was -14C when I got to work, but by mid afternoon it was +10C, a change of 24 degrees in one day.

My road in the cold.

Back to Surreality

January 10th, 2011 by Maeve Lalor

Tonight, I walked home from work in arctic conditions (-15C), clad in my balaclava it was difficult to breath. At first through my nose, but it felt like the contents were freezing…then through my mouth and my teeth began to hurt like I was eating ice cream. It’s a different kind of cold than I’ve felt before as it’s so dry here. The ground is sandy and dry, so it doesn’t freeze, you can still kick the soil and there’s very little ice- only where a pipe has burst. I arrived on my road, and hundreds of crows were swooping overhead, making a tonne of noise. They occasionally land in the trees, but then all through the night they take to flight, it must be too cold for them to stay still. Why they choose to stay in Nukus with these conditions is a mystery!

Birds flying to keep warm outside my house!

I’m trying to learn Russian- I love it! It’s much harder than any language I’ve ever come across before. It took me weeks to master the alphabet, and although I now understand more and more, I haven’t got enough confidence to speak it very much yet. The complexity, particularly the grammar can take over completely and that’s not too fun. My new project is to translate “The Little Prince” in the next seven months I have here.  90 pages, a page every second day…. Feasible I thought. Tonight it took me an hour to read three quarters of a page with the help of my teacher! But at least I now know the word for a Boa snake. Watch this space.

Home for Christmas

January 8th, 2011 by Maeve Lalor

The excitement built up towards the end of December as I went home for Christmas! I couldn’t wait to see my family and friends, eat a Christmas goose and relax with all the home comforts. It was touch and go whether I would get home at all, Dublin airport teetering between open and closed with all the snow. But I made it home despite my flight being re-directed to Manchester, and then the plane getting struck by lightning on the eventual landing in icy Dublin airport (didn’t do my fear of flying any favours!).

Coming back to Uzbekistan after Christmas , I felt much less nervous than I had when I first arrived. I knew what I was going back to and I was eager to get my teeth back into the mountain of work I knew would await my return. The contrast between the green grass, wild seas and extremely chatty Irish people with life in Nukus is even more noticeable than it was before.

Winterisation

December 3rd, 2010 by Maeve Lalor

This may be a good time to stop, think and reflect. This past month has been a very difficult one for our project both on a personal and professional level. One of our dear colleagues passed away most unexpectedly after a heart attack. He worked as part of the team for the last ten years, and in the short time I worked closely with him it was clear he was unique: positive, funny, skilled, dedicated and experienced. We miss him and the epi team is reminded of what an asset he was everyday when our database experiences another hiccough.

Our project has an ambitious vision to provide comprehensive TB care for all in Karakalpakstan and as a result we are in transition. All at the same time we are handing over some of our operations to the Ministry of Health, changing our targeted population to include sensitive TB as well as drug resistant patients, changing our model of care to treat patients in ambulatory care from day 1, rather than in hospital and finally, planning our further expansion to new districts. It’s a lot of changes all at once- not surprisingly an air of confusion descended on our project this month!

The epi team’s current challenge is to implement the new data system. The epi dream team consists of 5 people. The fabulous Data Manager-Sholpan who has been here since the beginning and knows all the interesting and complex patients by number. Gaukhar- the very dedicated assistant data manager who collects the data from the clinics and without whom there would be no data. Azat- proving to be an excellent detective, collecting data in our new districts and figuring out the sensitive patient system. And Ulyana, the Lab Database manager who meticulously enters and reports the many, many laboratory results produced each month.

The epi team

Here in Nukus, the process of winterisation has begun. The gas pressure has been increased, the vines have been buried in the ground to hibernate until next year, and the windows are being covered with plastic sheeting. Outside, during the day it is bright, sunny and crisp, while inside it is dark, hot and airless! I’m sure then when it finally reaches -30C I will understand why “winterisation” is needed!

I’m hoping for easier times to come, but I suspect this mission is going to be complex all the way through…

Focus

October 19th, 2010 by Maeve Lalor

“You’re going where?”

“Uzbekistan”, I repeat.

“Pakistan”

“No, not Pakistan, Uzbekistan.”

“Where is that, and why mumblemumbleStan- what are you going to do? Do you have to go there?”

For the few weeks I had in Dublin to get ready for my mission in Uzbekistan, this was the recurring conversation. Having worked for the past 7 years between London and Africa (and fitting in a PhD part time), I had decided I needed some time off. I planned to take a year off, go travelling, relax, spend time with my friends and family, figure out my next life/career move. To stay in Academia? To resist my desire for Africa? To move home to Dublin/ settle down (unlikely)? So, I set off on a cycle trip along the West coast of Ireland in search of answers. Instead I found beauty, adventure, and a reinvigorated Maeve ready for more.

I admit it, I knew almost nothing about Uzbekistan- but after seeing my ideal job advertised in Uzbekistan (MSF, MDR-TB, epidemiology and not in Africa), I set out to find out more…. Bordered by Kazakhstan, Turkmenistan, Tajikistan, Kyrgyzstan and Afghanistan I would be heading for the middle of the Stans- Central Asia.

Now that, I’ve been here a couple of months it’s hard to remember what it was like not to know Karakalpakstan- the autonomous region of Uzbekistan- the centre of my world for now. Forgotten Central Asia? Not even mentioned in the weather forecast on “world” news channels!

Talk about TB: HIV and Africa is at the foremost of most people’s minds. While, many new drugs have come onto the market for HIV recently, TB remains out of focus- there is a desperate need for new drugs to combat TB. I had thought of MSF as a medical charity that provides emergency aid in conflict zones. But what MSF does is respond to medical emergencies in at risk populations. This project is a bit different from many of MSFs programmes- there’s no conflict here and it’s a much longer running program than most. But MSF is here because there is an emergency: an MDR epidemic and at present the government of Uzbekistan is not able to cope alone with one of the highest rates of MDR-TB in the world.

So while most focus elsewhere, I will focus on Karakalpakstan.

It’s not easy to focus though. I’ve been here two months now, at first a very steep learning curve. As the epidemiologist in charge of the project’s data, I had to try to get a general understanding of all aspects of the project: the disease, the treatment, the lab, the psychosocial support, the epi data collection system, and the management and reporting of the data. I came here knowing what my focus should be- analysis and dissemination of the projects wealth of data-our data should help us learn what works and what doesn’t and it may help us to bring more attention to this part of the world about the MDR epidemic.

Last week, I lost focus- something changed. I suddenly knew enough to see the 101 things that could be improved. For a few hours, I felt overwhelmed, unsure what to do.

Karakalpakstan is back in focus. I can see clearly again. It’s a challenge- but that’s why we are here!

Changing seasons

October 9th, 2010 by Maeve Lalor

Last weekend, we baked in the sun within the inner walls of the city of Khiva- an ancient city on the silk route. On our return journey, bumping along the road through the desert, the wind picked up, the sky darkened and the season changed.

It’s the season of visitors for the Nukus project. As the longest and largest running MDR project within MSF, some come to learn, others come to advise and new expats arrive to embark on their mission. It’s been a week of debate about the future of this project: how to expand into other areas while leaving our current location -the central referral point for TB patients. Next week is annual planning week, and there are many decisions to be made.

It’s been a busy time for the epi team. Last week was reporting time, by Monday our database was fully up to date- details of newly admitted patients, changes in treatment regimens of existing patients, doses of each observed drug, and all laboratory results were entered. There were three reports to be prepared; the monthly report for MSF, a report for the ministry of health and the third for the ministry of justice. Since 2003, 1395 patients with drug resistant tuberculosis have started treatment in this project, with 440 still on treatment. The aim is to provide comprehensive TB care for the whole of Karakalpakstan by 2014, so these numbers are set to increase substantially in the near future. The epi department’s challenge will be to keep track of all these patients’ vital details in order to monitor the program.

With the sudden arrival of the cold weather, the short sleeves were replaced overnight with wooly jumpers and coats. There was a noticeable drop in gas pressure at home, as many people at home have now switched on their heating systems. At work everywhere in Uzbekistan, everyone eagerly awaits the magic date: 15th October. It is on this date we are officially allowed to turn on the heating systems. Even the gas company will be instructed to turn up the gas pressure and winter will start!

Just breathe normally

September 17th, 2010 by Maeve Lalor

This morning I joined one of the doctors at the MDR-TB hospital, which is set on the outskirts of Nukus on the edge of the desert. We arrived at the hospital, met the other doctors, and set off to do the rounds. Standing outside the hospital, I fitted a mask to filter the air I would breathe to prevent me from inhaling any mycobacteria. Looking into the hospital from outside, I could see patients walking up the stairs, cleaners mopping the floor and staff passing- all wearing masks. We entered the hospital, and walked past the drugs table in the reception area where patients go once a day to take their medicines. Each person receives one little, round plastic filled with colourful pills.

We rushed along, and entered the first room. Three men, each sitting on the edge of their bed, awaiting to be questioned by the doctor. How are you feeling? Why did you not take your medicine everyday? I hear you ran away on Saturday, why did you leave and not take your medicine? I stood at the back of the group of doctors in their white coats and yellow masks, listening to my whispering translator and deeply aware of every breath of air that I breathed in. It’s impossible to think about breathing in a normal way when you enter an MDR hospital. Every one of the patients in the hospital has multi-drug resistant tuberculosis. That means that the TB they have is resistant to the strongest TB drugs that are available. MDR patients have to take up to 20 pills a day for at least two years. MDR TB is not something that you want to breathe in. But while I stood protected by my mask, I imagined what it must be like for the patient sitting on his bed looking up at the four white coated doctors whose masks inflate and deflate with every breath. He would never see the doctor’s mouth, see if it smiles or laughs. He must spend the next 2 years talking to masks, and explaining why he couldn’t swallow the drugs yesterday because they made him vomit, or they made him deaf, or he wanted to see his wife so he ran away for a day…..

We went to each room, and asked all the patients how they were. Some were feeling better, smiled and were happy they would be going home soon –home, but not yet fully cured: most of them will need another 1.5 years of ambulatory treatment. Others complained of deafness, gastrointestinal problems, headaches, all side effects of the drugs. There was an XDR (extensively drug resistant TB) patient who had been an inpatient for two years and seemed close to giving up on the treatment. Apparently, none of the available drugs are able to cure him. A young girl who had TB two years ago, was now back with MDR TB, and her mother had died of TB. The pictures you see on TV or in books of people who are just skin and bones became reality for me today. While many patients were thin, there were a few that were so thin- it’s hard to imagine that they are alive and breathing. You want to cry, but you can’t cry- this is their reality and you have to hope the drugs will work and they will get better.

We finished the rounds, and stepped outside into the sunshine, and stripped off our masks and inhaled the fresh air. It was just another day for the doctors on duty, and we walked to their office for a meeting. Being in a meeting where you have to be translated is so difficult! Someone speaks, but instead of being able to understand what is being said, you strain to listen to the whisper of your translator desperately trying to summarise and translate the gist of the conversation. You miss, or misunderstand about 50% of what’s going on…

My afternoon was a little more normal for me as I was in front of my computer drowning in numbers, looking at the patients’ weight over the course of their treatment. The numbers were more powerful this afternoon though as those light patients now had a face.

Translated into vodka

August 21st, 2010 by Maeve Lalor

My first weekend in Nukus all the expats that work for MSF were invited to the TB hospital’s Chief doctor’s birthday party. We arrived at midday, and sat down around a huge dining room table laden with fish, salads, cold meat, fruit and nuts. We each had a small porcelain bowl which was filled up with vodka. The birthday boy made the first toast, welcoming us to his house and thanking us for joining him, he walked around the table clinking bowls with each guest and ensuring that we downed the vodka. The custom here is that your vodka glass should always be full, so each time you drink it is topped up. Our host spoke in Russian or Karakalpak, and after every couple of sentences this was translated into English for those who didn’t understand. After a few toasts (all 20 of us were to make one during the day) I realised that I would be drunk soon if I kept drinking the whole cup of vodka. Clearly I was the newby in town- I was soon spotted taking small sips instead of at least 100mls as the host required. I began to notice other people’s tactics for not drinking all the vodka, the person across the table from me would pour a vodka into his coke, and refill his cup with water just before a toast, or pour almost all of it out into someone else’s cup and then down only a small amount. I must have been a little typsy by the end, because our hosts tried to get us singing, and from the depths of my brain I remembered I’d learnt a song in Russian in school and began to sing – luckily several people joined in! We all went home clad in our gifts, girls in local scarves the women traditionally wear once married, and the men in embroidered dressing gown type coats with hats. What an experience- it was the perfect welcome to Karakalpakstan!