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Lori DiPrete Brown, Njekwa Lumbwe, Jim Cleary, and program leader from African Palliative Care Association.

 During August of 2012, The UW Madison Global Health Institute was privileged to welcome Njekwa Lumbwe, that National Coordinator of the Palliative Care Association of Zambia, for an exchange visit to Madison where she participated in a Pain Policy training session led by  GHI Program Director Dr. Jim Cleary.  Dr. Cleary works with leaders from around the world to develop and scale up effective state-of-the-art policies and programs related to pain management.

Mrs. Lumbwe made valued contributions to the meeting and also gained insights about the way forward for Zambia, as she learned from the experiences of 9 other countries from Africa, Eastern Europe and Asia.  Engagement with global experts and national leaders from around the world helped Lumbwe to envision policy options and implementation strategies that could be applied in Zambia.

Her commitment to palliative care defines her as a leader, and the participation in the meeting reinforced this commitment.  “The meeting opened up a whole different perspective of the global state of pain control.  I pledge to use this experience to bring out the desired change.  I look forward to stronger future collaboration,”   said Lumbwe in her report to the group.

Soon after in November of 2012, we found that Njekwa Lumbe was following through on her promises, working nationally as a change leader, and collaborating with the First Lady of Zambia to make palliative care more accessible. We look forward to welcoming Njekwa back to Madison in the future!

FLzamiba

It has been a wonderful week and a great privilege to collaborate with leaders from Zambia and Botswana ton plans to improve the quality of health and social services.  At the invitation of the  CDC-funded American International Health Alliance Twinning Program, and with the collaboration of their Zambia Country Director Ann Mumbi, I led a QI implementation workshop with a team of UW facilitators that included doctoral candidate, Jason Paltzer, and UW alumna and Global Health Institute staff member, Sweta Shrestha.

One challenging and exciting aspect of the program was that we brought together some very different types of organizations –  believing that the concepts about quality, the practical problem-solving tools, and the leadership principles would be relevant for all.  The partners in the group included the Palliative Care Association of Zambia, several Zambian teaching hospitals, leaders from ZAMCOM, which provides health communications expertise for the country, and leaders from the Zambian military health services.  From Botswana we had faculty members from an academic medicine setting,  leaders from an NGO umbrella organization that serves highly vulnerable children, and directors from two programs that do voluntary counseling and testing for HIV/AIDS.  They all worked in small group to develop improvement projects, giving each other feedback and encouragement along the way.

Did it work?  We think so ….. By the end of the week the participating leaders presented their strategic plans to each other and an audience that included national leaders, representation from the CDC, and the AIHA Twinning Program leaders.  We tried not to let the radio and TV crews go to our heads, but it was nice to see the work of the participants noted and celebrated!  Of course, this was not the end, but rather the beginning of the quality improvement efforts, since everyone hoped to go back to their organizations to carry out the planned changes as soon as possible.

While geography often conspires against us, this meeting is, thankfully, not our last time together, as many of the participants will be coming together again in July 2012 in Madison, Wisconsin to continue this work together!

Lori DiPrete Brown, Associate Director, UW Global Health Institute.

April 2012

“Is that smoke,” I asked, pointing to the cloudy billows on the horizon as we headed toward Livingstone.  “No,” I was told, “it’s the mist from Victoria Falls.” In Tonga, one of the local languages here in Zambia,  the name for the falls is Mosi-O-Tunya, which means “the smoke that thunders.”  Now, as we approached from a distance, I could see why.  The falls are amazing and grand. The smoke appears first, from out on the highway before you even get to Livingstone.  Then, as you approach the gateway to the falls, you hear the force of water, a thunderous whooshing that is too strong to be taken for wind. As you walk toward the sound  you see and feel the spray, and then, suddenly, or so it seems, an immense wall of sheer gushing water.  The water force is so strong that the thick showers of water falls and rises with a bounce, with droplets breaking off and defying gravity, so that it feels like it is raining from above and below at the same time.

The rushing water, cool mists and sunny skies had me dizzy with delight.  Soon I was hoping for a rainbow, and I was not disappointed.  In fact, it seemed as if every time I asked,  the universe indulged me with colors of reassurance. So many rainbows on demand couldn’t be a coincidence!  Eventually I had to accept that miracles are ordinary and everywhere.  If you are looking. And if you remember to ask for them.

Our stay in Zambia was short, yet we had seen and learned so much.  I had wanted to see the falls, to put my toe in if I could, and now we were here.  Water in abundance,  rushing like thunder, cold sprays, powerful currents that can sweep you away.  The gift of color.  Again and again.

Hiking just above the falls we came to the still headwaters. It seemed impossible to me that I could stand so close the edge without being swallowed.  In spite of the kinetic frenzy just a few hundred feet away, the headwaters were a quiet pond.  There was so much more underneath the still current, and, I knew, so much more below the surface of this country, Zambia.

On the long ride to the Falls I had insisted that our friend and guide, Ali Sad, teach me a Zambian song.  It is an absurdly short visit, I reasoned, there will be no evidence that I was here at all if I don’t at least learn a song.  He taught me the following song/chant which is often sung when people gather.

    Nchale wo wau, nchale chi wau tu,

    Nchale wo wau, Nchale chi wau tu.

It means, loosely translated, “Everything is good.  It should be like this.”  And then it repeats, so there is no mistaking about anything, “Everything is good. It should be like this.”

Zambia — just a toe in….

“You cannot save what you do not love, and you cannot love what you do not know.”

Aldo Leopold said that, or something close, and I think of it as I enter Zambia’s Mosi y Tuna National Park to experience my first safari game drive.   It is  6:30 am, and it is cold. I am wearing a coat, I am under a blanket, and the jeep’s windows are all shut.  As Jason Paltzer, who is driving, tells us about an encounter he had with an aggressive elephant in this very park,  I am both disappointed and comforted by all the layers between me and the animals that we hope to see …. After a few moments, the grimy pane compels me. I open the window, leaving only air between me and wild nature.

Soon we see an impala.  It looks fragile, knowing.  It freezes, but then, at the sound of a camera shutter, it runs.  Its effortless gait reminds me of the way my daughter Kristen runs.  I love the impala for a moment, and then move on.  Next up is a warthog, awkward and muscular.  There is nothing beautiful to recommend this animal, yet we are taking photos and saying his butt bounce is cute. If we can love the warthog as he is, maybe there is hope for us?  We slow down for some guinea fowl who walk in the road in front of our jeep, seemingly unaware of us.  For some reason completely at odds with ornithological precision, I am reminded of Flannery O’Connor and how she loved her pea hens, and saw a map of the world in their plumage.

Next I am struck by the eyes of the giraffe, plaintive and loving, not unlike my golden retriever at home.  Then the zebras amaze me.  They are all perfect specimens, as if a doting zookeeper has been following them around. Their stripes are so contrary to any idea of camouflage. They don’t want to hide.  Instead, they are designed to find each other,  for the purpose of solidarity and survival. Their stripes also cause them to blend into each other, which makes life safer for the young and vulnerable. They have no natural predators in this park.  They pretty much thrive in peace.

I am the first to spot the crocodile.  He is underwater, but I see his long slender nose.  In the face of this fast, sharp-toothed endangered species, loving wild things becomes complicated… He is the reason we cannot swim in the river. I want life for this crocodile, yet the idea of his extinction provokes a whisper of relief in me that I cannot deny.

Baboons are a nuisance, we have been told. A few weeks ago one of them actually fought a tourist for a candy bar (or something), knocking him to his death, near Victoria Falls.  Now several baboons are prowling around our truck.  I am uneasy, and avoid looking them in the eye, afraid I will accidentally send the wrong message.  Then we see one in a tree — likely a female, she has a baby in her arms.  Slowing down for that we see another, also with a baby in her arms.  Once I know how to look, I see that the tree is full of mother and baby baboons, as if it is a scheduled play group!  This incredible act of social organization fills me with awe.  I decide to defend the baboon from now on.  It seems they are judged unfairly.

After an hour or so we arrive at the far end of the park where we can get out and stretch before we head back. There are some guards and another car nearby.   I wish I could walk alone for a bit.  I wish that the cars, and my friends, and even the strip of road that we rode along, were gone.  I would linger here, trust the peace, and accept the occasional predation– which seems to be the price of this particular kind of beauty.  I would live from truce to truce like the animals, abiding by their cautious rules of engagement.  Would I be able to freeze and run and fight at the right times, I wonder? ….  I stand under a tree for a bit, then explore a little ways in each direction, but I don’t stray too far from my tribe.

As I get back in the car I realize that there are things that I will never do–like hang glide, or swim with crocodiles, or walk alone in the wild.

I am 35,000 feet in the air, moving at 550 miles per hour toward Lusaka, Zambia. It is -47 degrees Farenheit outside. Although I have been travelling for 27 hours, it is only now, on this final 9 hour leg of the trip, that I begin to seriously contemplate the freefall that is possible from here.  During the first 4 legs of the journey I had been distracted by a missed flight, several reroutes, 2 “flying pills,” and 4 compensatory glasses of wine. But now that I have procured the desired place in the air, I am hit with the realization that I am seriously and dangerously far from everything I know and love.

The other passengers seem nonchalant, even confident, completely unaware of how helpless and absurdly unfit for life we are up here. None of us could withstand the cold temperatures at this altitude for more than 30 seconds, we could not breathe without the pressurized cabin, and there is only enough food and water for a day or two. We are physically incapable of getting ourselves home, both in terms of physical endurance and temporal feasibility. None of us would know the way home anyway.

I am so far away from my children! This thought makes the vertigo the most profound. I try to put down what I feel in my veins, turning my attention to the numbing mechanical buzz of the plane. But the mental and emotional clarity lingers. This trip which I have chosen, not just once but as a regular part of my life, is completely contrary to the instinctual logic, be it maternal, human or animal, that is hard wired  into me. Better to measure things in time than distance, I reason. It is only 10 days. They go to camp for a week in the summer…Going 7000 miles away to a landlocked country in Africa is sort of like that, isn’t it?

I have never been to Zambia, but as I watch the locator arrow move across the map of Africa I am comforted by the idea of getting there. Right now I am in an unnamed space between Cairo, Addis Ababa and Johannesburg. The Lybian Desert and Darfur Mountains are labeled, but other than that I cannot say where I am with much precision. Zambia, a landlocked country the size of Texas,  is still 2500 miles away.  Formerly Northern Rhodesia, the culture is a blend of Bantu and European influence.  It is one of the poorest countries in the world, per capita income is about $1000/year, life expectancy is 41 year of age,the  infant mortality rate is 119/1000 and the maternal mortality rate is 591/100,000.  The economy is showing hopeful signs of growth, with copper and agricultural as principal sources of livelihoods.  Zambia is home to 13 million people, and 3 or 4 of those people are expecting my arrival. I am going to work with a variety of health and social service programs, and visit a village where my colleague Jason worked and lived for two years. I hope to see a hippo and avoid altercations with baboons, and I am going to stand in the mist of Victoria Falls.

I know I will be able to fall asleep soon, and the flight is beginning to feel normal.  I realize that the noplace between places is always like this. God makes a flash appearance, reminding me that this space, so many miles above everything, is something sacred, to be savored. I am the same distance from everything, and from here the world is interconnected and whole. I will try to enjoy how large and small the world is. I will trust sleep and time to take me where I am going, and home again.

Half the Sky, by Nicholas Kristof and Sheryl WuDunn  documents the hard truths about being a woman on this planet. While some of us choose our spouses, share parenting, and become doctors or astronauts, many are stuck in a cycle of poverty and suffering that includes unfulfilled potential, maternal mortality, slavery and human trafficking, prostitution and survival sex, every  kind of violence, and a lack of choice and safety in relation to their sexual and reproductive lives.  Because I work with programs that address the health of women and children, people often ask me what I think of the book.  Is all this really true?  Did they get it right?

I have read the book three times and each time I am more impressed.  In addition to portraying the lives of women with great dignity and respect, Kristof and WuDunn provide the reader with stories of resilience, cause for hope, and suggested  action that will make a difference.

The first time I read Half the Sky was just before Sheryl WuDunn came to Madison to speak about the book for our local Planned Parenthood chapter in 2011.  I sponsored a table with my neighbor and friend Joyce Bromley, and we decided to invite some of my global health graduate students to join us.  Sweta Shrestha, a “Madison girl” from Nepal,  Aaliya Rehman from Pakistan, Middleton’s own Roman Aydiko, originally from Ethiopia, and Chrstine Kithinji from Kenya.  The topics were difficult, but the evening felt like a celebration — these young women in my circle were saddened but not shocked by these realities. Empowered with education, they are hopeful about being leaders and making change.  As the crowd departed we found ourselves in a circle sharing stories.  Each of these women told of someone who had fought for her: an uncle who defied the family and took his bright young niece to school because he knew she could realize her dream of becoming a doctor, a mother who defied tradition and married for love (and she wore pants!), parents who braved the immigration journey to the US with their children, and a foreign sponsor who kept investing in a young African woman, by providing scholarship support.  All of these young women are leading international lives now, making a difference in public health work here in Madison, and staying engaged in  their home countries.  Sweta leads service learning programs for UW students in her native Nepal,  Roman is engaged in research and quality improvement in Ethiopia, Christine is building a clinic in her home town, and Aaliya, an obstetrician who is proud of her Pashtun origins, is now in Pakistan working to improve maternal mortality.

This fall I assigned the book to my global health honors class for first year students.  “The book made me tremble,” one student told me.  Rereading the book through her eyes somehow made what was already real to me more real.  The raw facts lingered, and the numbers and the truth of the stories sunk in.  Is this really true? I realized it would be almost impossible to tell a false story about the oppression of women and girls, because everything  you can imagine is already happening to a girl–just about every girl you could make up is actually out there.

The subject of the book came up with again with students in my global public health class this spring.  We  discussed the book over coffee before class, and someone asked if I would blog about it.  So I gave it another read through yet another lens.  This is a class where we focus on action: What is the problem? What are the root causes? What works? How can we close the gap between the world we are in and the world we want to be in?  That is our public health mantra, and Half the Sky did not let us down.

Educating women, creating livelihoods through mirco-enterprise, providing health care… these things work.  At the end of the book Kirstof and WuDunn suggest 4 ways to support the  women and girls all over the world who are trying to change their own lives.  It will only take about 10 minutes and it probably will cost you less than you spend on dog food or coffee in a month.

1) Make a people to people microlending loan  (www.globalgiving.org or www.kiva.org).

2) Sponsor a girl (Plan International or Womenfor Women International).

3) Mmonitor news about global women’s issues through www.womensenews.org or www.worldpulse.com.

4) Become a citizen advocate at  the Care Action Network (CAN) www.care.org/getinvolved/advocacy/index.asp

I hope people will read the book and get involved.  As hard as it is to stare down what is happening to girls in our world, change is possible, and women and girls are surviving and rebuilding their lives.

There is a movie based on the book coming soon.  See trailer at:  http://www.halftheskymovement.org/

What will the world look like in 2015? And how can we make it a place that offers sustainable health and well-being for everyone?  At the Annual Symposium of the UW-Madison Global Health Institute, Ruth Levine described the burgeoning youthful population that is projected to dominate the global south as an asset rather than a liability, provided that we make the right investments, and provided that we “Start with a Girl.”

Levine identified the years from 12 to 14 as a crucial time in a girl’s life, where risks to health and well-being can increase, and her choices, her world, can become increasingly narrow.  If secondary schooling is withheld, a girl is confined to the home, child marriage is encouraged, and she is exposed to abuse and exploitation, she is destined to be trapped in a life of poverty and suffering.  On the other hand, for about a dollar a day, we can provide girls with community-based supported, health services designed to meet their needs, schooling and economic opportunities that can help us realize human rights for girls, and, at the same time,  benefit from a demographic dividend that will enhance the well-being of everyone.  See the keynote presentation here:   http://videos.med.wisc.edu/videos/39524

If you would like to know more about this effort you can read the complete report,  Start with a Girl: A New Agenda for Global Health by Miriam Temin and Ruth Levine, and review related news and resources at:  http://www.cgdev.org/content/publications/detail/1422899.

Further, you can see what change looks like for individual girls, and join the movement to change things for girls, at  The Girl Effect, where there are stories about girls from a number of countries and lots of ideas about how to get involved.

THIS VIDEO EXPLAINS THE GIRL EFFECT IN SIMPLE WORDS AND MUSIC:  The Girl Effect

What about boys, you might be asking yourself?  They don’t experience the same risks and narrowing of choice and agency that girls do, but their needs are important also.  This movement is about extending education and opportunities to girls alongside, not instead of, boys.  To really make change we will have to work with girls and boys, men and women, so that the rights of girls and women are respected, and they are allowed to achieve their potential.

On my recent trip to Ethiopia, I decided to reread Cutting for Stone by Ethiopian-American surgeon Abraham Verghese.  I first read it when it came out in 2009, a beautiful novel that  also provided a window into Ethiopia’s health system.  Now I wanted to test it out on its home turf.

From Addis I was less focused on the ways in which the book could “take me there,” since I was already “there,” working in hospitals, walking the streets, meeting people who had lived through the challenging times that Verghese described.  I wasn’t troubled by the license that Verghese had taken with some of the factual details relating to Ethiopian history or “Missing” Hospital itself…. He had told us it was fiction.  A fiction writer myself, I understood that sometimes you have to make some stuff up or move things around a bit to tell an authentic story. Would Verghese’s story and its messages about life and place and love and fate ring true?  For me, that was a more interesting question than whether his story corresponded to the material and chronological facts.

Reading from my hotel room in Ethiopia, where the hall light streamed into my room all night and the dogs began barking just before dawn,  I realized how much this novel transcends it’s particular setting, and speaks to so many of us who have been shaped by immigration, by separation, and by living in ways that leaves us with more than one place that we can plausibly call home.

Verghese tells us the story of twin boys, with two fathers, two mothers, two countries, and one woman they both love.   We all have so many possible lives and possible selves, and the story of Marion and Shiva his twin reminds us that it is hard to contain all we can be in one life and place, and it may be even harder to contain it in two.

The boys are attached a birth, share a bed, and then are separated by miles, oceans, time, revolution, and their own differences. The story unfolds through the eyes of Marion, as he tries to understand and reconstruct the truth of his past.  What happened?  And why?  There is always more than one answer — a double, an opposite, a twin.  The boys have two parents who raise them, and two others who gave them life.  Their birthmother, Sister Mary Joseph Praise, lived a prayerful life of submissive service, and, we are led to believe, also experienced the spiritual passion of Theresa of Avila.  Thomas Stone, their biological father, also had a divided life, on the one hand a focused, tireless and dutiful surgeon, and on the other a man possessed by binges of excess.

As I read in Addis I realized that many of the diaspora Ethiopians that I am working also have two lives and two places that are home.  I too, am divided, both the person who wants to go home, and the person who wants to stay.  Can we live these double lives, or does one of our selves have to sacrifice itself for the other?  Cutting for Stone asks this question and, as might be expected, shows that there is more than one answer.

For me the special thing about this book was not the fact that “it takes you there.”  In fact, when I look for scenes that capture what is like to walk the streets of Addis or be immersed in the setting, I find that they are few.  This made me realize that while I thought I was experiencing this place in a close up and personal way, Verghese was writing from a more intimate perspective, a surgical distance where the background fades as the human heart is dissected in ways that reveal truths common to all.  Verghese finds the truth and healing of our brokenness through the act of fiction, because, as he puts it,  “where silk and steel fail, story must succeed.”

I walked in to the sound of sobs then a long moan.  It was the cry of an African woman, her head wrapped in a blue scarf, I think, lying on a narrow cot in her modest home.  Dying of AIDS?  Dying of cancer?  I wasn’t sure, but I did know that this scene from the the premiere screening of Life before Death was being viewed in 25 countries today, to educate people about the needless raw suffering that is taking place in homes and hospitals all over the world.

Having arrived late,  I took a seat in the back beside Dr. Jim Cleary, a UW physician and a leading global educator and policy advocate for the promotion of palliative care.  He was hosting the event for the UW-Madison Global Health Institute, and had himself been instrumental in developing the film.   I had to ask him, was the scene that I had just witnessed dramatized or real?

“It’s real,”  he said, and the words took on double meaning, because they meant both that this was a real woman, a woman like me, allowing herself to be filmed as she was dying in pain to benefit others, and also because the problem is invisible to so many of us.  We have to be reminded that “it’s real” and it is happening to 1 out of ten people all around the world.  We know how to address this, and it is not too expensive.  We just have to decide, as a human family, that everyone’s quality of life at death matters, and that no one should needlessly die in pain.

This “teaser” is a good way to get a sense of wht the film is about:

Life before Death portrays the realities of painful death, but it also shows life near the time of death as it should be and can be, with affordable pain relief, social support and care.  In addition to a longer film that can be purchased at www.lifebeforedeath.com  (proceeds benefit the cause), there are a number of informative shorts on topics such as chronic pain, hospice care, HIV/AIDS, the facts about opioid use, and others.  I hope readers will visit the site and share your thoughts here.

Sitting at the Java Den at University and Mills before class,  I was not sure what to expect.  Students from PHS 370 were invited to drop in to meet me, connect with each other, and talk about local to global perspectives on public health.  I was armed with a computer, a short novel, and the New York Times in case no one showed.  But I did not even get to read one headline….

Maggie arrived first wanting to explore how to make global health work a part of her life.  Relatively new to UW, she is shifting from a political science focus to a public health focus.  She told us a bit about her work in Bulgaria where she worked with the Roma population.  this video portrays the challenges that this ethnic group faces.

Abby had been on the Uganda Field experience led by John Ferrick and James Ntambe and she has done a lot of coursework related to public health and health disparities.   Pascale who joined us later will participate in the same Uganda program next year.   Laura, a global health certificate student,  joined us and shared that she will be working with Araceli Alonso on the Health by Motorbike program this summer.

Tahiya joined later in the hour and very generously shared stories about her summer in Bangladesh where she worked in the Geneva Camp focusing on children with disabilities.  The camp, established in 1972 to meet the needs of Pakistani’s who were still in Bangladesh after the transition, is now a crowded multi-generational community.  The video focuses on the health risks for children in the camp.

Liz, who is doing an  honors project for the class, hopes to consider homelessness in Madison in a global context through case studies or oral histories.  Stay tuned as she may be willing to share her project in  class or discussion section!

I blog as a reflective practice and to share information and experiences with my students, colleagues and friends. Some of the topics that I will cover this semester include my upcoming global health work in Tanzania in March — I will miss a few classes but will make up for it with some blog posts!  Also, I am working with a group of students who are planning to go to Ecuador to do service learning in a community where I have worked for the past six years.  I am going to “back blog” for them from my journals, so I can share some of my favorite memories and photos with them  and introduce them to the community where they will work.  I am going to cover campus events like lectures by Ruth Levine, who is coming on March 14th, to our annual Global Health Symposium.

I am also planning to do some global health-related book reviews.  Coming soon Is Cutting for Stone, by Abraham Verghese, which takes place in Ethiopia.  I am also reading Haiti after the Earthquake by Paul Farmer.  I will review A Sand County Alamanac, by Aldo Leopold, to explore the implications of a his “land ethic” for a new global health ethic.  Finally, I will reread one of my all time favorites, Cry of the Earth, Cry of the Poor, by Leonardo Boff.   I wonder if it will seem as good as it did when it changed my life many years ago….

Please feel free to comment on this post or make suggestions for future topics!