Village visits by CHAKUNIMU and McGill M.Sc. (Nursing) students

A correspondence from Veronique Fraser, one of two McGill School of Nursing M.Sc. (Global Health) students working with Highlands Hope of Tanzania this term.

Visiting the Villages

We are sitting in a living room, on the wood framed couches that are identical to the wood backed seats that adorn each of the more prosperous of the fifteen houses we have visited today. Though structurally identical, the chairs come alive with their distinctive coverings; some use brightly colored Tanzanian fabric; others white cloth delicately embroidered with a care and skill that would make my grandmother smile with recognition.

The door is open and through it I can see chickens pecking and roosters strutting under a pale blue sky. This house has walls made of concrete painted a pale yellow and behind me there is a cartoon poster detailing the ABCs of safe sex. Otherwise the walls are bare except for a lonely gecko statuesquely defying gravity in a corner by the ceiling.

We are here to conduct Amy's field research which involves asking families about their health care needs in order to improve the services that local volunteers provide to people living with HIV/AIDS.

Over the course of the past month we have visited over 40 families in remote villages. We have been confronted with generosity in a context we commonly contextualize as lacking riches. We have slept in a mud walled, straw-roofed hut, lulled to sleep by the sound of scurrying rats and the dancing rhythm of hungry bedbugs.

We have learned to kill a chicken and been amazed at the ability of women and girls to handle metal pots burning over the heat of a smoldering fire with bare hands. We have observed that soccer can be played by twisting a number of plastic bags into a somewhat circular shape and kicking it around a mud courtyard with a lazy chicken acting as a goalpost.

We have come to understand that what is described in academic papers as "rural and remote" in practice means walking 40km in a single day, over dusty rutted roads through fading and at times charcoal black fields, in order to visit people that are otherwise unreachable.

We have often felt, at times acutely, that what is trying for us; walking seemingly endless distances on an empty stomach, waiting for someone who may or may not ever arrive, is routine for the Tanzanians accompanying us.

Our visits take on a pattern. We arrive at a house and move into the "sitting room" to conduct the interview. Most of the houses we visit are made of earth; earth walls and earth floors, sometimes a fire smolders in the center and when not used to this, it is difficult not to scrub the eyes like a tired toddler beleaguered by the unfamiliar. Often there are not enough seats for everyone and this typically causes a brief delay as our hosts hurry over to a neighbor's house in search of an extra stool.

Once seated, there is the inevitable five minutes of personal greetings and salutations that are the prelude to any interaction. It is customary here to greet everyone: from the stranger you pass on the street, to the taxi driver, to the workplace colleague. These exchanges sometimes seem to teeter on the brink of the absurd: "How are you? Good, how are you? Good, how is you family? Good, how is your family? Good, how is your work? Good, how is your work? Good, sorry you have to work. Thank you, sorry you have to work," and so on until every possibility has been exhausted. And it is not politeness per se but more like humanity shining in a way we seem to have forgotten about back home.

The questions we ask are always the same and the surprise lies in finding that the answers we receive are, in kind, uniformly similar.

We ask how far people have to travel to access drinking water. For most, it is at least a half hour walk away, for many, over an hour to make a trip. We see them often, women and girls walking with stately grace their heads supporting plastic buckets containing 20 L of water. According to the WHO, access to clean drinking water means living no further than a 1km or 30 minute walk to a water source; this means that almost 40% of the families we interview live without access to safe water.

All of the families we visit have at least one member who is HIV positive, most families have multiple members living with the infection. Some families are housing orphans, the son or daughter of a brother or sister, aunt or uncle who has died from the disease.

We enquire how far it is to the nearest hospital or local dispensary and how they get there. The vast majority walk; it is anywhere between a 6-8 hr round-trip, over dusty pitted roads, through rolling corn and potato fields to the closest dispensary. Old women, young men, the sick and the healthy, everyone must make this monthly pilgrimage to receive basic HIV care, treatment and most importantly, medication.

A 66 year old woman told us about the time she walked 4 hours to her local HIV clinic only to find that the CD4 machine was broken (CD4 counts are used to establish disease progression and help determine treatment), at which point she turned around and began the 4 hour walk back home. We ask people what the health care volunteers can do to better assist them with their day to day health care needs. The answer is always: we need money. Money to travel to the hospital, money to buy food, clothes, fuel, medication, money to live. We need an income generating project, we need a pig project, a pottery project, we need money.

Today is our final day of interviews and we are sitting on the wood-backed chairs - this time adorned with cloth delicately embroidered with apples, of all things- finishing an interview with a woman in her mid thirties who is living with HIV. The interview draws to a close and we ask if she has any questions for us. She looks at us with tired eyes and says: "You come here and asks about our problems. Everyone always asks after our problems, but what can you do to help me? What will you do?" Amy replies that she will write a report and that the results will be used by the village volunteers to provide better care to people in the surrounding communities.

Still, the woman looks skeptical and I can't help but share her sense of uncertainty. What will I do- what can I do? I am confronted by a sense of powerlessness and a sea of apparently endless contradictions. Ninety percent of the approximately 33 million people infected with HIV/AIDS live in Sub-Saharan Africa and yet, the technology, infrastructure and drug development required to effectively manage and treat HIV infection is overwhelmingly located in the west.

Tanzania is one of the poorest countries in the world and yet, it has been the darling of the aid community, receiving billons of dollars worth of foreign aid from 1960 to the present. Tanzanian has an appalling shortage of healthcare workers and yet, western universities send an abundance of students like myself over for a few short months potentially straining an already fragile system. While it would be naïve to think that development work is inherently good or that the best intentions lead to progress, the contradictions are nevertheless unsettling, as is the look in the woman's eyes as she thanks us and leads us out of her house.

It has been said that the way in which a problem is framed inevitably affects the response. I have been here for 3 months and though I will soon be on a plane returning home, I am still searching for a way to frame the problem in a way that makes sense. What can I do in the face of poor access to drinking water, broken equipment and lack of medication? What can I do for people who need income, who are too sick to travel to the hospital? What can I do to target the structural inequalities that contribute to the poverty I am confronted with in the houses I visit every weekend? What can I do where billion of dollars of international aid money have failed?

I know there are no easy answers, but perhaps, more so now than before, I am confronted with the complexity of asking the right questions. I hope that if nothing else, studying global health will allow me to better understand the problem and the next time someone asks me "What can you do?" I will be able to look them square in the eye and give them an honest answer.

Veronique Fraser