Tanzania Solo

I ventured alone to Dar es Salaam in Tanzania after our ship docked in Mombasa, Kenya to meet with folks from several HIV/AIDS agencies. I had been listening to many excited conversations about the plans 645 members of our community had for safaris in east Africa. I felt out of phase but having both work to do and several previous safari experiences, I pressed ahead with my divergent agenda. I was rewarded with lessons both professional and personal. And, despite much angst, I easily made it back to the ship in time to depart for South Africa.

Not many of you, I’m fairly certain, are interested in the details of what I learned about HIV/AIDS in Tanzania, but a few observations might be worth sharing. If you’ve come to this site looking only for travel color, skip down a couple of paragraphs.

As I’ve read and tried to learn about HIV/AIDS in the developing world, I have noticed a progression of preoccupation with different components of the issue as a country attempts to respond to this horrific pandemic. The first stage seems to be recognition of the problem and its extent. Russia, former Soviet states and Eastern Europe appear to be at this point now. The second stage is to formulate a coordinated response in each country, usually done by the Ministry of Health, often with the help of other partners such as the Clinton Foundation and/or universities like Harvard and Columbia – the process China and India, for instance, are now involved in. The third step centers around finding huge sums of money to address prevention, testing and care and treatment of people living with HIV/AIDS (known as PLWHA). The Global Fund for HIV/AIDS, TB and Malaria, PEPFAR (President Bush’s program), NGO’s of all sizes, faith-based organizations, and donor nations such as former colonial powers all have a role to play in funding these enormous efforts. Once the extent of the problem is known and money has been promised, the focus shifts to rolling out plans that have been made that entail resources such as drugs, labs, information and tracking systems, distribution systems and, my personal focus, health care workers in adequate numbers with appropriate training. These components of a country’s response are both crucial and exceedingly difficult, not that the previously mentioned ones aren’t as well. Problems get highlighted such as brain drain of newly trained workers to other, more developed countries (there are more Malawian doctors in just Manchester, England than there are in all of Malawi) and the disparities of health care facilities between urban and rural areas. These are not new problems but they are demanding new solutions if this pandemic is going to be addressed. All this I was aware of before I came to Tanzania.

Now I have seen firsthand the next stage: the intersection between solving the problem of HIV/AIDS and the complexities and intransigence of poverty in the developing world. At two agencies I asked what was the single largest impediment to addressing HIV/AIDS and the answer came without hesitation and identically in both: food. At Pathfinder International, we talked about their home based care program in which volunteer community health workers visit AIDS patients in their homes, taking basic medical supplies like gloves and bandages but also providing teaching, support and caring. We would think of this as hospice care. They kept reporting on the starvation of these patients due not only to the wasting of the disease but also to their social isolation because of stigma. So Pathfinder started sending food to the patients as well. But, of course, much of it never made it to the patient. The volunteers and their families were also very hungry. Now they send food for both the patient and the health care worker. I visited PASADA, a model program run by the Catholic Church in Dar and spoke with a small group of nurses there. I love connecting with these talented, creative, tireless, and caring sisters of mine who are on the front lines of this enormous battle. They said that adequate nutrition was the single largest barrier to starting their clients on anti-retroviral treatment. This large, well-funded program has only 100 people on ARV’s. One reason was that people could not demonstrate an ongoing food supply necessary for successful treatment, often because they were too sick to work and, again, cut off from their families. In the developing world, huge amounts of food are needed for these patients, their dependent families and even the volunteers. The World Food Program is working to deliver food to Tanzania but only to a few geographic areas that are in the worst shape. Unfortunately, poverty and HIV/AIDS are everywhere.

That’s probably more than you wanted to hear about HIV/AIDS in Tanzania and it was only a tiny fraction of what I learned there. It was a very professionally productive trip. I also had a few personal experiences that have been rolling around in my mind ever since, trying to fit into my concepts of myself and the world. Traveling alone proved to be more of an obstacle than it has before. My tentative explanation has to do with a new realization about my attitudes in this post 9/11 world: I feel more uncomfortable in Muslim cultures – and I hate that feeling. I could see four mosques from my hotel window in Dar and I enjoyed the rhythms that periodic calls to prayer gave to my days. When I heard them, I began pausing in whatever I was doing and just spending a couple of minutes reflecting, nothing elaborate or ritualistic, just a moment to refocus. What a wonderful tradition. But then early one morning, looking out my hotel window, I saw a group of about 30 young men running down the street, chanting, carrying a flag and being joined by a few other pedestrians. My mind went immediately back to the embassy bombings and the anti-American demonstrations of a few years ago. Two explanations occurred to me: either this was some kind of demonstration or a running group taking advantage of the cool of the new day. The ordinary logic of the second explanation was overwhelmed by the small undercurrent of fear in the first. If it was a demonstration, why would I feel in any way threatened? Instead of some anti-American, radical Islamic group, it could have just as easily been local plumbers rallying for better wages. I had a day on Sunday in which I thought about going to Zanzibar on the local ferry. I’ve done that kind of thing many times in plenty of developing countries. But there were no other tourists around and I just felt like I stuck out too much. We had had an onboard briefing by diplomats from the American embassy in Nairobi who told too many horror stories and advised us to do our best to blend in. I wanted to go but my gut was telling me not to, so I didn’t. My loss, my lesson.

One delightful consequence of my traveling alone was getting to meet Jumani, a wonderful cab driver in Dar. My colleague, Ed Wood, the clinical director of the Clinton Foundation HIV/AIDS (CHAI), had recommended him to me before my December trip; they have become great friends. Edwin Macharia, the assistant country director for CHAI who facilitated my time in Dar, mentioned Jumani again so I engaged him to drive for me for two days, one working and one exploring the city. Jumani is a treasure. He has a brand new, three-week-old baby whom he named Ed. I asked Jumani if the baby was keeping him up at night and he said, “Oh Mahjorie, that baby he cry and cry!” At the end of our time together, he said, “Oh Mahjorie, you’re leaving. That makes me soooo sad!” I wish Jumani could have driven me to Zanzibar.

I went to a cultural village museum that had recreated about 15 different types of houses lived in by the various peoples of Tanzania. It was a very low tech place and I was the only tourist on a sweltering Saturday afternoon. About 150 secondary school kids were also there, all dressed up in their school uniforms complete with navy blue jackets and ties. We all gathered on wooden benches under a large leafy tree for a drumming and dancing performance. I’ve come to love this African tradition I’d seen in Zambia and Rwanda as well of choosing the space and shade under some wonderful tree to hold public meetings and celebrations. I felt welcome there, if something of an oddity. A few girls came to sit with me and shyly answered my questions in fairly good English. Most of these children are trilingual, speaking their tribal language, Kiswahili and English. Their first question for me was, “What tribe are you from?” They didn’t pay a lot of attention to the dancing, giggling and talking behind their hands. But they loved the skits that followed, laughing uproariously and trying to translate the jokes for me. They told me they wanted to be accountants and teachers, doctors and lawyers. They made me want to work harder, to keep on trying to make my small contribution to the gargantuan task of ensuring a healthy future for them and for baby Ed.

Technical Difficulties

I'm sorry that there are three copies of my India post. The Internet on the ship goes down frequently and I can never tell whether something has posted, because there is also a delay on the site. All this because at $.40 a minute you have to do things as fast as possible. So far when I try to delete one, all are erased. Don't you just love these little technical glitches? I am in Dar es Salaam, having flown here yesterday from Mombasa where the ship docked. I'm meeting today with Clinton Foundation folks and their partners to look at the progress of the rollout of HIV/AIDS drugs here. Across the weekend I hope to see a little of the city and then will be meeting with Pathfinder International people on Monday. I'm glad to finally get here after my aborted trip in December. 645 members of the shipboard community were headed off on safari as I left. I know they'll bring back wonderful stories and pictures.

The Elephant that is India

THE ELEPHANT THAT IS INDIA

Looking down a narrow, crowded street in Pondicherry, a small city on the southeast coast of India, I saw the head of an elephant, a real one. For a weekend explore of the area south of Chennai, two friends and I had hired a car and driver and it was from him that the answer came to this puzzle and many others like it. He explained that down that street was a Ganesh temple. In Hinduism, Ganesh is a god with a man’s body and the head of an elephant. He is the son of Shiva and his consort, Parvati. When Ganesh lost his head, his mother replaced it with that of an elephant, the closest one handy. Ganesh is the god of wisdom but more popularly revered because of his powers to remove obstacles, in all things sacred or profane. People pray to him at the initiation of any endeavor, even an ordinary work day. Ganesh temples that are wealthy enough have their own live elephant in addition to many beautiful sculptures and shrines inside. I scrambled out of the car and proceeded to break one of the common sense rules of travel: If you’re not quite sure what’s going on, stand back and watch the locals for awhile. Had I done that first instead of later I would have seen that worshippers pass by and place in his outstretched trunk either food (which he immediately eats) or a small bill (which he passes to his handler). He then places his trunk on the believer’s head and they go about their day confident in his blessing. Rushing up to him, I ignored the rule and the kindly old guy must have decided to bless me on credit – he plopped his trunk right down on my head! Startled but wiser I went off to explore the temple.

My encounter at the Ganesh temple reminded me of the old fable, retold in a recent Global Studies class, about a group of blind men first encountering an elephant. Each one catches hold of a different part of the animal and argues adamantly about the characteristics of this new creature. The blind man holding the tusk remarks as to its cool smoothness while the one patting its side insists it is warm and wrinkly. The guy who grabbed its tail asserts that it must be like a snake while the one trying to reach around its huge legs will have none of that comparison. Our entire shipboard community ventured out to explore the elephant that is India. We returned with a multitude of sundry, colorful and energetically defended reports. Comments I’ve heard have ranged from “I couldn’t wait to get out of India! I am SO over it,” to “I felt incredibly comfortable in this country. I’m definitely coming back.”

People who never left Chennai formed conclusions that sounded like the blind man who had ended up around back and stepped in fresh dung. While there are many interesting things to see in Chennai, the situation at the harbor where we docked combined with the normal, Indian overwhelming assault on your senses to produce what most people agreed was quite an unpleasant experience. In order to go anywhere except onto a tour bus, we had to pass through two Indian immigration inspection stations showing two official forms and two pieces of ID, walk several blocks along a road filled with huge trucks carrying cargo and across three active railway tracks, and then face our nemesis, the auto-rickshaw drivers and their touts. With very few exceptions and no matter how firmly you gave your instructions, they always took you to at least one and often three shops that paid them a commission for delivering customers. I had been told to ask for the Connemara Hotel in the central shopping district, instead of a particular store which would label me as a shopper, but that rarely worked either. They lied, they cheated, and they pulled off onto side streets and demanded more money. They are clearly organized because the first day all the vehicles that left from the harbor entrance at the same time ended up at the same store, which was the destination of no one. The uniformed harbor officials are no help; I heard several stories of their various ploys to extract bribes for passing through the gates. Walking is not a solution because the harbor is far away from where most people want to go. Walking a few blocks into the city to escape the rickshaws at the harbor is hazardous due to the traffic and lack of sidewalks and anyway the rickshaw driver you hail will probably not speak English or be able to read a written address. The buses are unbelievably crowded and confusing; there is no other mass transit. Arranging a private car and driver that would pick you up beside the ship was really the only viable solution. Even though it was quite inexpensive for what it was, most students felt it was outside their budget.

When you do finally get out into the city in an auto-rickshaw, you white-knuckle it through traffic that makes downtown Saigon look like a country lane. Indian drivers love their horns and hate to have anyone in front of them. The air pollution is atrocious; I wiped black soot off of my arms, legs and face after every trip out. You quickly learn to watch ahead for the approach of the bridge over the Cooum River so you can put something over your nose or hold it. Our biology professor told us the river was considered dead and it certainly smelled like it; it is a huge open sewer.

Now imagine yourself on this auto-rickshaw ride, stopped at a traffic light, and suddenly you get a whiff of the sweetest scent you’ve ever smelled. Inches away, a motorbike has pulled up beside you and on the back is a beautiful girl whose raven hair is draped in long garlands of creamy white jasmine flowers. That is India. As they say, for everything that is true about India, the exact opposite is true as well.

In sharp contrast to Chennai, beauty was all around us on our trip to Pondicherry: emerald green rice paddies, breathtaking temple decorations, cool forests (where we watched a movie being filmed) and the calm waves on the post-tsunami seashore. We stayed at a delightful and very inexpensive guest house in the middle of town, right on the water with only the seawall and the main street between. I think it was that wall that saved the city from too much tsunami damage. Early one morning I sat out on my balcony and watched people taking their morning “constitutional,” as my grandfather would call it. We visited the famous Aurobindo Ashram, the local market and a paper-making factory. We were fascinated by the low tech process that produced gorgeous paper in many colors and containing many natural materials. They explained that they did “one color, one day” and lucky for me the color of the hundreds of sheets hung up to dry that day was an exquisite peacock blue, a feast for my eyes. In contrast, we saw working conditions that would give an OSHA inspector apoplexy, like women sorting small pieces of cutup rags amid a cloud of cotton dust you could barely see through; only a couple of them had masks. The beauty and the horror that is India.

On the way down to Pondicherry, we passed several relief camps for tsunami victims near the highway so we stopped at one on the way back. I wanted to try to talk to the people there and see how they were doing. We asked for the village leader but were told, through our intrepid translator/driver, that he was away for the day. So we plunged in and started asking them questions and letting them tell us about their life. We were taken down through the part of the village that was not too badly damaged to the pile of rubble on the shore that used to be their homes and boats. Large, brightly painted new boats, enough for one for four families, had been donated by Rotary and sat unused on the beach. We asked if they were fishing again. They said that they had been promised compensation by the Indian government for their losses but that they had not yet been paid. They felt that if they went back to work they would not receive the payments. Such is often the dilemma of aid. As I walked through the camp with its crude lean-tos, thatch shacks and even North Face style tents donated by the Brits, my heart ached for these families who had so little and lost it all. I tried to find the words to tell them that the whole world cared about them. They are human so they talked of being jealous of other camps who they felt were getting more. Our driver said that actually he thought these camps were doing relatively well because they were so near Chennai but that camps south of Pondicherry were less visible and still needed help. We left them some cash with a strongly worded request that it be used for the benefit of the whole camp. The survivors told us about relief agencies that came and went but praised World Vision, a large international NGO, as the one that was still there, still helping. I told them I would tell you that.

There’s one more experience I want to share – a visit to a hospital dedicated to several Eastern medicines such as Ayurvedic, homeopathy, naturopathy and Unani which is practiced by Muslims. As most of you know, I’m a nurse and a dedicated defender of Western medicine. I’ve been able to intellectually understand that other systems of health care probably have valuable practices but, in truth, they scare me. I worry when people depend on naturopathic remedies when I think they desperately need antibiotics. I worry when high profile celebrities turn down chemotherapy and treat cancer with diet and massage. But I went on this FDP to try to open myself to what was being offered there. It was a stretch but I was amply rewarded – I finally got it. Indians, like Chinese and many other Asians, are quite selective in which philosophy of health care they choose for their various illnesses. Unlike some Americans not raised with these choices, they know the value – and limitations – of each. We talked extensively with the head of the Ayurvedic section. His facility could have been run almost entirely without electricity. There were massage tables, magnet belts, water baths and rooms where yoga and diet were taught. I thought my long held skepticism had been vindicated when I saw a poster that proclaimed in several languages, “Germs do not cause disease.” He later talked about why they had individual steam cabinets instead of steam rooms, that people in steam rooms could make each other sick. I was confused so I asked him about the germ sign. “Ah,” he explained, “we know that germs cause TB, which we don’t treat here anyway, and that patients can catch it from each other. What we believe is that it’s a person’s immune system being weak that is really the cause of the disease, the reason why one person contracts it and the other doesn’t. That’s what the sign means.” I thought of the germ soup that most Indians live in and the emphasis in Ayurvedic medicine on healthy living through exercise, diet and yoga to prevent disease and promote wellness. I got it. Western medicine emphasizes killing germs and combating disease and Eastern medicine promotes healthy living so you won’t succumb to the germs that are perhaps more of a given in their world. We learned that the patients in this facility were mostly stroke and arthritis patients who, I now understand, might benefit from the types of therapy offered. Patients with TB or needing an operation wouldn’t come there and they wouldn’t be treated if they did; the Ayurvedic doctor enthusiastically endorsed Western medicine for those problems. In another part of the hospital, the head of homeopathy explained that they use the products of disease, in very small quantities, to treat the disease. Where am I familiar with that principle? Sure, vaccinations and allergy shots. I asked her what illnesses she treated. She said that the large majority of her patients were there for allergies. Another light bulb moment. One of the medical staff members from the ship who was also on the trip offered the final illuminating idea to me at just the right time. When I was mumbling about “alternative medicine,” she said, “You know we really don’t call it that any more. Now we say ‘complementary medicine.’” Exactly.

On this my second visit to India, I felt as if I got to explore more parts of the elephant. In many ways, I’m still as much in the dark as the blind men. The vast complexities and contradictions of this country boggle my mind and challenge my attempts at understanding. The difficulties are mine. India stands wise and benevolent, and ignorant and corrupt. But like the elephant at the temple, she freely bestows upon me the blessings of rich experience.

Vietnam and Cambodia: The Power of Seeing the World

So many factors affect how you perceive a place. Returning to Vietnam after only three years, I had a ready comparison with how I responded before, whereas Cambodia was a new country for me. This time I had the added benefit of traveling with Scottie and learning about her reactions. But there are so many other things that shape your perception:
· which experiences you choose to focus on – Scottie and started in Ho Chi Minh City with a tour of the Reunification Palace complete with what can only be described as propaganda video that certainly influenced how I felt about the city, less warmly than on my first visit;
· how hot/cold/tired you are at the time – we were so hot in HCM City most of the time that our shirts were drenched and sticking to us and my whole head poured sweat down the full width of my face, not just rivulets from my temples, meaning that I literally couldn’t see. Scottie commented, “I remember Gran telling me that ladies don’t sweat, they glow. Well, I’d have to say now ‘Gran, I’m SWEATING!’”;
· how extensive your expectations are – Scottie and I had both read a poignant and very well-written autobiography of a girl who survived the Khmer Rouge genocide, First They Killed My Father, and had some idea of the horrors we’d learn about at the Killing Fields. The students who had chosen this particular trip had done so fully aware that they had the alternative of doing only the temples of Angkor on another trip. They chose with varying degrees of preparation and differing expectations but all of them wanted to see and learn and try to understand. I am in awe of their courage at such a young age. Watching them force themselves to take unspeakable, incomprehensible horrors into their consciousness and grapple with them both breaks my heart for a world that contains that hell and deeply inspires me;.
· who your guide is and how free s/he feels to speak – we were divided into two buses in Cambodia and the guide on the other bus was a woman who took as her mission the telling of her story, but only while she was safely inside the bus, out of earshot of officials in this still largely Communist country. While our guide was a baby when he lost his father during the genocide, she was a teenager and told the powerful story of her tragic life and losses. I’m told there was not a dry eye on the bus, including hers. When I remarked to someone who had heard her story that I was sorry I missed it, he said, “I’m not sure you should be sorry. I don’t know if I could have chosen to hear it.”
· And so many more. We all wear lenses shaped by so many things; we all see and yet sometimes don’t see. Such is the nature of experiencing the world.

Someone told me the other day that they think Semester at Sea is a cult – and I had to agree, at least in the lighthearted sense the comparison was offered. Sharing the time in Southeast Asia with Scottie and watching her reconnect with memories of her SAS voyage in spring 1984, I saw how the core of this voyage continues through the decades and how its values, benefits and challenges endure. I won’t presume to summarize her impressions and hope that many of you will hear about them directly from her. But for me, to connect with her through this experience was a treasure and a privilege. I’m acutely aware of what it takes to get a committed mom away for a whole week and the courage it took to risk this adventure away from them. I am truly indebted to Phil, Dorothy, John and all Scottie’s devoted friends who helped out while she was gone and especially to my precious granddaughters Erin, Rachel and Lauren for sharing their mommy with me. It was a gift we’ll both remember for a long time. As she wrote to me in an email after she got home, only slightly tongue in cheek I’m sure, “We’ll always have Cambodia.”

What we have in Cambodia is a bittersweet offering, a rough-edged gem, a painful challenge to our hearts’ best tendencies. I relished the timeless coming of a new day over the splendor of Angkor Wat while trying to block out the din of the chattering Japanese tourists who had risen in surprising numbers to also witness the sight. I felt privileged to hear a student process out loud, in a sort of stream of consciousness, her emotions as she saw real poverty for the first time in a small floating village across the river from the spectacular Royal Palace in Phnom Penh. I took picture after picture at the Genocide Museum, wanting to have a record to verify the reality of sights I knew my mind might try to gloss over in remembering. But soon I had to stop, unable to do anything but the work of bringing into my awareness an incomprehensible horror.

Between 1974 and 1979, Pol Pot tortured and killed a million of his own countrymen, women and children. The genocide museum we visited was a high school that had been converted into a prison where people were interrogated for weeks to months in unspeakably cruel ways. No matter their answers, the outcome was always the same. They were herded into trucks, taken out to the Killing Fields, made to dig their own shallow graves and then killed in brutal ways without the swiftness of a bullet. As they were being processed into the prison, mug shots were taken. The black and white 8x10 photos are displayed in row after row, hundreds of human beings, even mothers holding babies, looking out at me with unmistakable emotions in their eyes – confusion, fear, defiance, despair – each one destined for unimaginable terror and death. I’ve no doubt they will be with me always.

I confess to my own despair. Perhaps it’s because I was just at the Rwandan genocide museum last March which told the story of a million Tutsis and their supporters who were killed by Hutus just ten years ago. All the talk after the Holocaust of “never again” and here we have two more genocides. And now Darfur in the Sudan. When and how will it ever end? We all can do our part certainly – committed work and money and small acts of tolerance can and do help. We need great leaps forward in local and global nonviolent conflict resolution. We need powerful and charismatic leaders like Nelson Mandela and Gandhi, whose portrayal by Ben Kingsley in that wonderful Attenborough film I watched last night during our own passage to India. But who? When? How?

Bereft of answers, I am also compelled to hope, inspired by these young people with whom I am traveling. Time and again I have heard them doing the heartbreaking work of processing what they have seen, bringing the horrors of poverty and man’s inhumanity to man into their consciousness. Whatever expectations they came with, whatever lenses they wear, their vision is clear. But they are bewildered and angry and overwhelmed. Their paradigms are imploding and they feel the loss of their familiar constructs of the world. I’ve done what I can to listen, to reassure them that they don’t have to have it all figured out, to comfort them as they grieve for this world we’re leaving them.

I’m convinced that what we can do is what Semester at Sea does and that’s why I am so committed to this program. I’m persuaded that providing the opportunity for these fresh, earnest, smart and caring young people to see the pain and joy of this world we all share is an answer with boundless power. I am reminded of stories of SAS alums I’ve known or heard of who are working for peace and justice in every way and venue imaginable from nutrition programs in Cape Town shanty towns to political campaigns in ordinary American towns. I love this program because it changes these powerful young people. Then they go out and change the world.