Charlotte and I spent a fair bit of last week in the TB unit. Due to financial and staffing constraints, the hospital has not been able to commit a dedicated staff member to running the program. Dr. Elspeth Young, who also runs the HIV/AIDS clinic, has been trying to give some guidance, but she is very stretched with many other duties and is supposed to be only part time. I think I mentioned earlier that she and her family will be returning to Australia this summer indefinitely to help their son (who has grown up here in Nigeria, as Elspeth did) transition into university there. Pip Mychael, an occupational therapist also from Australia, has also been helping- but they will be leaving for at least 6 months later this year as well. Char and I attended a one day TB training put on by the state TB program a couple of weeks ago which was quite good. The state program is designed to be largely implemented by primary health care workers who may not even have nursing training, based on WHO/STOP TB materials. We are lucky that there is a fairly good infrastructure in place to support the TB program, with free drugs (except when they run out, which creates quite a mess). Unfortunately there is no compensation to the hospital for providing the TB services, other than it being an important community service. Most TB services are provided through the state run primary health centres. So it has been difficult for the hospital to prioritize a dedicated staff member for the program. It ends up that whichever nurse is in the outpatient department when someone comes for meds ends up going to the TB room to dispense them, but since they are often not familiar with the intricacies of the program many things end up getting missed. It has reached a point that the state program has suggested that they may transfer the TB program elsewhere. Although we are able to get chest x-rays at the hospital here, in the smaller centres, diagnosis is just by sending sputums for AFB’s. We do not have the ability to do cultures (at least routinely), so that makes things difficult- also no bronchoscopy. Many of the HIV patients end up being treated for a suspect CXR alone. Apparently here ½ of the HIV patients presenting have TB, and 1/3 of the TB patients have HIV. Contact tracing consists of letting patients know that any family members who are also having prolonged coughing should come in to be evaluated. Very little prophylactic treatment is done, although I did see that one infant of a positive mother is on prophylaxis. Patients who have defaulted are not routinely followed up on due to lack of resources, although I am hoping we can work at that in the future. The medications being dispensed are not tracked or recorded, much information is missing from the treatment records, and the hospital does not keep a current comprehensive record of patients being treated (although the state may have a record). There is only a box with close to a hundred treatment cards, at least a third of which look to be defaulted. Charlotte has agreed to focus her energies on the TB program along with a community health extension worker, so I am hoping that we can spend the next few weeks doing some focused training and improve the clinic functioning. It is satisfying work, since I have a fair bit of knowledge about the different components of TB management from a public health perspective, the problems we are seeing are very fixable, and it will likely be of significant benefit to the individuals in the TB program as well as the community at large. So I am hoping to focus my energies here for the next while, although I am also starting to help with some things for the HIV/AIDS clinic.

Next Stage

We are now entering the next stage of our mcc assignment—although we plan to continue our studies in hausa. Randy and I are beginning to move into our work fields. Obtaining our licenses has been quite an ordeal. For instance, they require some original documents sent directly to their offices. This is difficult when one does not have good access to email and no fax machines. I was finally able to get a receipt from the ministry of health in jos—basically showing that I handed in the required info, application and paid the money for the license. I do not know if I will ever receive the license-from what I am told the nursing council of Nigeria (which is in lagos) does not have the funds to adequately complete the process for foreign nurses to receive the actual license. I am able though to practice because i received a receipt. Randy has made one trip to Abuja (which takes about 3 1/2 hrs by car each way) and returned with more papers to complete before trying again. I have started with attending workshops on home based care focusing on the hiv population. I have been impressed with the wealth of information provided with regards to nutritional needs, other illnesses associated with hiv, ethical dilemmas, and confidentiality and stigma issues for families affected with hiv and aids. It can be difficult at times to know how to treat a pt that has tb and then also develops hiv or vice versa. The combination of meds in their treatment can cause more havoc on their immune system. It is also difficult to counsel a hiv mom who has just delivered her baby as to the pros and cons of breastfeeding or formula. There is a fair percent chance of the baby getting the virus from the breast milk, but there is also a great risk of the infant receiving severe diarrhea from unclean water used with the formula. The dilemma is compounded because the hospital does not have the funds to reliably provide formula or clean water for the infants first year. The mom also does not usually have money to buy wood to heat water or pay for the dry formula. This next week I hope to start in the outpt dept which houses hiv and tb clinics, a small triage and assessment rms for incoming pts. Randy has started to shadow another dr in the hiv clinic but soon realized the need for him to do direct pt care. His long term goals are to work on a more program/community advocate level focusing on the hiv population-but is a little concerned with the black hole that will be left when one of the clinical drs leave in june. Speaking of randy, he was up most of last night retching and with diarrhea. I must confess I broke out into laughter after witnessing him on all fours in the bathroom with his head in a basin. It is a rempel trait-where we tend to enjoy watching close friends/ family members in pain. We took him to get tested this am and discovered he has malaria. We have another addition to our family- a cute little kitten. It is great fun watching our puppy and the kitten play with each other, although our dog at times would probably rather not have the kitten dangling from her face with its claws. Our electricity and water is still very limited or non-existent at times. We have had a few nights lately where we were forced to use candles or flashlights. Our water tank, which serves our house, has also emptied a few times these past few weeks. We then bucket water out of our storage bins from our bk courtyard. Our kids now leave our house at about 6 20 am-we felt this was the best option with the transportation angst we still have. They join another group of kids driven by an ex-retired military officer—which helps put our minds at ease. The girls did mention that they witnessed a girl about their age get struck by a motorcycle and was then dragged off the road by her feet due to oncoming traffic. Randy also witnessed a horrific recent accident on his trip bk from Abuja where few people were seriously injured. There was also a recent accident where about 15 young men were killed – three of them were brought to our hosp whom expired later in the operating rm. The motorcycle drivers are also required to wear helmets as of jan 1—also providing one for their passenger/s. It has been quite interesting seeing the diff types of head gear from sport helmets, hard hats to old race car driver helmets used by maybe about half of the drivers. Then I would say about half of them or less actually have them strapped on. I have been told that some of the passengers refuse to wear them because of the ju-ju spirits. They feel, I think that one can get an evil spirit from the last person who wore that helmet. The flowers are still coming out on the trees—quite amazing in this dry season. Mangoes and avocados are now coming in and some strawberries were available at one market. I tried a passionfruit recently—quite sweet and tasty. Hope all is well--charlotte

Holiday Greetings

Hello-

A belated Holiday greeting to everyone. We have had a pleasant Christmas break thus far. People have included us in numerous celebrations and we have had lots of time to play games with the kids. A Nigerian work colleague of Char’s from Winnipeg came to Jos to visit family last week and graciously carried along our new laptop for us. It is nice to have one again. (He also brought along a care package from Char’s family with chocolate, jolly ranchers, and the newly released Prince Caspian DVD- what a treat!) There are even plans for an internet café offering wireless access to be developed right next to our house in the next few months, so we are keeping our fingers crossed. Family Christmas gifts enabled us to have some extra meals out, an overnight stay at the Miango Rest Home, and a new table tennis setup for the children, which is a big hit with their friends here as well. Thanks!

On January 2-3 our Mennonite Central Committee had a team meeting here at the guest house in Vom. (We had originally planned to have a retreat in Abuja, the capital, but due to the crisis some felt that we should not be away from our homes for that long.) All the families of the national (Nigerian) staff as well as our family and the Hartman-Souders met. It was nice for us to get to know the families a bit and it now feels like we are really part of a team. Our team benefits greatly from having the long term national staff. Just briefly, Athanasius is involved in programs serving the deaf community, Gopar does peace work, and Matthew runs the office as well as being involved in programs like the EPRT (see below), and the Hartman-Souders are the country representatives (overall MCC Nigeria program planning and connecting with partners). The MCC Nigeria program/staff is fairly small and its major mode of operation is to work through local partners. The balance then comes in being more than just an external funder- We can see that MCC works very hard at the relationship to these organizations. MCC currently has multiple partners with HIV/AIDS programs and has asked me to use a portion of my time to add a public health perspective to our connection with these organizations.

Char and I look forward (with a bit of anxiety) to starting our health work assignment this week at Vom Christian Hospital (on whose extensive compound we live, a 35 minute drive from Jos where the kids go to school). My position particularly is vaguely defined now, which is fine at this point. Clarity would be nice, but I am often tempted to try to impose clarity when it isn’t really there. I remember a communications professor at seminary once saying that it is a gift to be able to wait for clarity- So that is what I will strive for.

My goal is to connect with people in a meaningful way as I work at public health (which is the basis for our family’s being here with MCC, reflecting the “transformative” aspect of MCC’s mission). There are pre-existing givens and needs of the hospital that I will try to meet as much as possible, while also hoping to utilize basic public health precepts in shaping my work (e.g. looking at what information is available on illness and death in the region and what are the existing public health efforts to address them; what has program evaluation shown; what issues have the attention of the community, its leaders, and potential funders; what evidence based interventions are there for these issues). One of the expatriate physicians will be leaving in 6 months, and it is likely that I will try to fill in for some of the administrative/program planning HIV/AIDS clinic (PEPFAR funded) work that she currently does. They are also hoping to tie in to more home-based care and perhaps work with the existing extensive church networks in some way. Their Tuberculosis clinic also is in need of strengthening.

Hopefully that work will still allow for me to spend some time looking at some other public health issues- things like basic sanitation (e.g. latrine use, water quality, and other environmental health issues which are readily apparent) or malaria prevention. Injury impacts people heavily (particularly traffic related- the risk of driving here feels about ten-fold greater than in North America- it would be interesting to see the stats), and the recent hundreds of deaths in the Jos crisis of late November is a reminder that violence in its many forms takes a heavy toll. (Mennonite Central Committee was instrumental in the formation of an Emergency Preparedness and Response Team for the Plateau State a few years ago. This diverse, government connected network has played an important role in the response to the recent crisis and has likely helped to prevent other violence in the past. Peace work is a major focus of MCC and is considered a unique lens we have to offer in our service here.) Polio survivors are often seen on the streets, although it is further north in Nigeria where they are still experiencing outbreaks. Tobacco use seems very low, although I am told substance abuse is common and increasing. (The Vom Christian Hospital has actually formed a partnership with the Jos University Teaching Hospital in the last year to run a couple of wards for inpatient substance abuse rehab here- an important service as well as generating much needed income for the hospital.)

A 2000 WHO report ranked the Nigerian health care system 187 out of 191 countries. Nationally, the fertility, infant and maternal mortality rates are very high, with immunization rates and life expectancy very low.

On the positive side, I see amazing examples of community networks and support systems for community capacity. I have read that historically, the western medical model brought by missionaries was not always readily accepted/utilized by local cultures. Although western influences are readily seen today, particularly in urban settings, I have to think that such considerations will still guide my involvement in community health. The balance and tension are always challenging between sharing knowledge and listening, taking direction from communities and also being rigorous in the application of established public health principles. I look forward to learning a lot.

So the New Year has started and we hope to settle into some new routines. The Jos crisis still hangs heavily over life for everyone here. Military checkpoints and curfews will likely be maintained for months yet. Figuring out how to get the children to and from school when they start back the 14th is another major decision. We will likely rely on drivers, but due to the high risk of travel here, we are quite anxious about how this will work out. The 3 ½ months we have been here in some ways seems so short, in others so long. Living day by day is always a good idea- I’m not sure if that’s harder or easier to do here.

Thanks for your thoughts and prayers.

Randy

First contact with malaria

Charlotte has been quite ill the past 3 days with malaria and likely typhoid on top of it. She is feeling a fair bit better this morning and had a bite to eat. Our family has been faithfully taking malaria prophylaxis and also received typhoid vaccination before coming, but they are known to be less than 100% effective.

We have learned a little bit how to use the hospital’s services through the experience. A Scottish doctor we know has been helping Charlotte, along with one of the Nigerian staff doctors. The lab test to diagnose malaria can be done for 150 naira (about $1.25). I had the lab tech give me a refresher on how to prepare a thick smear slide for microscopy and was able to see the parasites giving Charlotte such trouble. Although medications may be inexpensive by North American standards, their cost is often a heavy burden for families here. Medications are readily available in pharmacies, even without prescriptions. (Apparently the national government has been making progress in ensuring that ineffective fake medications are kept off the shelves, but we are still advised to always ask, “Is this the orginal?”)

Yesterday while at the MCC office in Jos, we heard a volley of shots being fired not far away. Apparently someone had stolen a motorcycle and the police were pursuing him. This caused some people to panic and start fleeing. In no time at all, rumors of “Jos burning” and renewed violence had spread via cellphone throughout Jos and further. One community had pulled a large bus across the road, blocking access to their neighborhood and fired a volley of shots to keep people away (which is what we had heard). So even though there had been no actual violence, it can be seen how high the tension remains and how close the fear remains below the surface of everyday life. On the way to and from school in Jos each day we pass through more than half a dozen police/military checkpoints.

Christmas is soon arriving here, although it still feels like late summer in many ways. Christmas without snow and cold will take some getting used to. I miss the crisp crunch while walking down the sidewalk, the glow of Christmas lights, taking the kids ice skating at the pond in the park, snuggling up on the couch in the den with a good book and the gas fireplace going, getting together with family and friends, egg nog, the smell of the Christmas tree, the climbing heating bills (oops- guess I don’t really miss that).

In spite of a hard couple of last weeks we are still grateful to be here in Nigeria, though. We have many new friends and continue to receive much support from friends and family back home. Charlotte does not mind the absence of cold in the least. The children have an excellent school, establishing relationships with other children from all over the world. The countryside here on the plateau is absolutely gorgeous with its beautiful spreading trees, rugged mountains, piles of precariously balanced huge boulders scattered across the landscape as if God were playing a board game and decided to leave the pieces out afterward, the fields everywhere with ripening crops and groups of villagers coming together to harvest each different crop as it is ready- the potatoes and yams, the maize, the acha, and now the guinea corn; the hundreds of children in their bright school uniforms filing along the side of the road on their way to school each morning. Even the bustle of the city has its appealing rhythm, with the frantic traffic and amazing loads being transported, the yellow fevers(traffic police wearing yellow jackets, controlling intersections in place of traffic signals) with their white gloves wildly flapping directions, the street hawkers selling everything imaginable at each stop(belts, rat poison, monopoly games, world maps…), people everywhere bustling, fruit stands, and the markets. The markets are the place I feel a wonderful “otherness” of Nigeria most acutely- with the press of people and amazing combination of sights, smells, sounds and jostlings. Vendors and other people we meet in the course of the day are overwhelmingly gracious and welcoming to us- we often receive wonderful smiles and greetings just for being here and trying to speak a few words of Hausa. Children often follow us, both fascinated and a bit scared of us, usually breaking out in group giggles when we pester them back. MCC and our country reps and staff support and provide for us very well.

We both look forward to starting work in January, feeling our way into new positions, but confident that we will have meaningful things to both give and receive in our work. Our family spends time together here in different ways than we did in North America and we have opportunity to talk about important issues in a different context. Attending a Christian school alone (which also enrolls those of differing faiths, such as Muslim), where most have a more conservative theology constantly sparks wonderful conversations with the children. It is exciting for us all to deepen our understanding of and relationship with God and our world together.

We also have much to learn about what our Mennonite background means in this setting, and our belief that violent solutions can only perpetuate violent systems. The country program review recently completed for MCC Nigeria identified the peacemaking lens as a critical, unique component of our presence here. Given the violent events of the last couple of weeks here, not unlike events that happen continually around the world (and it is easy to forget to include the structural and sometimes hidden violence occurring in North America), there is much work and learning for peacemakers.

Thanks for continuing thoughts and prayers. We also think of you and the work and lives you are all carrying on with elsewhere. It is comforting to think that we are connected and part of the same fabric of being and efforts towards wholeness.

Ku gaida ma iyalinku. (Greet your families.)

Randy

Jos

In the wake of the 2001 riots, the awaited Plateau State local government elections of this November 27th came with underlying skepticism of what would unfold in the following days. “No movement” was declared to prevent people from gathering and causing disturbances on Election Day, except for those attending to the polls on foot.

We ventured into Jos the next morning unaware of events that had transpired during the night. On arrival at the children’s school we were met with “No school today” signs posted on the gate and the principal stating that some youth were rioting and burning tires downtown.

We proceeded with our children to the Mennonite Central Committee house on a walled compound in Jos. We, along with the Hartman-Souder family, were shortly joined by Matthew, our Nigerian co-worker, who informed us of the escalating violence occurring in north Jos. It was best for us to stay put.

As the day unfolded we began to get reports by cell phone of the devastating destruction of homes, businesses and lives occurring mostly in the northern communities of Jos. From a hill on the compound we could watch the plumes of black smoke appear in succession starting in the west and moving throughout the day to the east. In the middle of the day we witnessed some fires just beyond the compound wall with families fleeing their community. Gunshots were heard throughout the day. We encouraged our children to stay inside the house.

During the day we had heard a colleague/pastor’s home had been burned down. A family arriving to the compound guesthouse had fled their home and informed us they had lost a friend, who was struck from behind. An MCC partner/colleague was trapped in her home and unable to leave to travel to Senegal for an HIV/AIDS conference there. A man on the compound was told the military barracks’ mortuary nearby had closed its doors because it was full. A classmate of Tanner arrived on the compound with his family (Christians), fearful of returning back to their home. A neighbouring Muslim family had hidden them in their home while rioters tried to find them. Many similar stories of hope have since come out, of neighbors and neighborhoods protecting neighbors of differing religions from rioters, refusing to participate in the violence against innocent people.

I was weak in the knees, reminded of the same uneasy feeling following the 9-11 attacks in the US. Although attempting to remain calm, especially for the children, we all felt the noticeable stress and tension. We knew we were safe but there was the unknown, unsure feeling wondering whether the situation was under control, if reinforcements had been brought in, or if the wounded were being attended to. Reliable news about what was happening was hard to come by. At times we were even unable to send or receive text messages by cell phone. Phone batteries and air credit were running low and needed to be recharged.

We hunkered down for the night and had a community meal with two other families on the compound. It felt good to gather together. Brenda H-S made a “comfort food” dessert with M&M’s (a rare treat here). We had oranges that the children had picked from the trees earlier in the day. After dark, the red glow of fires burning could be seen in the distance. The night was unrestful with dogs barking and gunshots heard in the distance. The early morning Muslim calls to prayer were regretfully absent.

We awoke to news of more concentrated riots in northern communities. The fires began again with smoke seen in the far east and moving back towards the west. Once again fires appeared in the neighbouring community over the compound wall with families fleeing to safety. Smoke started to billow into our compound causing greater anxiety for our safety. Other families were becoming more concerned, feeling a need to leave the compound. Some teenage boys living on the compound (boys our children knew and played soccer with when we lived on the compound for our first weeks in Nigeria) began sharpening machetes and fashioning spears, fearful that people may jump over the compound wall and threaten their families.

Thinking the roads were secure enough to travel on this end of town, we attempted to return to Vom that mid-morning. On our way to the gate, two men strongly urged us to obtain a military escort for the trip rather than trying on our own. At the same time we received a call from Matthew stating that another 24-hour curfew had been issued, effective immediately. I was saddened to not be able to return home, but yet relieved to not venture out onto the roads not sure of what lay ahead.

We returned back to Mark and Brenda’s house. The fires nearby had gotten smaller and the boys had laid down their machetes. During the day we ventured to the top of the hill and looked over the city towards the north. We were one with other groups of concerned people perched on surrounding hills, watchful, waiting for peace. Throughout the day people were slowly migrating back to their homes from the military barracks where they had sought safe haven. At times we would receive word that some MCC friends/partners were still in danger or could not sleep in their homes for fear of being burned out or attacked at night.

Before supper, Randy received a call from friends in Vom stating that our house had been broken into. We soon discovered that our laptop and cash were missing. We were disheartened. Although this invasion was minor in comparison to what other families were experiencing in Jos, our inner sense of trust and security was a bit shaken.

That evening Randy and I made tortillas and Brenda made beans and eggs, one of our favourite meals. After supper we received a text message that the US and British High commands would provide an escort for anyone wanting to voluntarily leave to Abuja (the capital). At the same time, word came of possible planned attacks on churches Sunday morning. The night once again was restless with absence of the morning calls to prayer.

On Sunday, after curfew was lifted, we ventured home to Vom with Matthew and Mark H-S graciously accompanying us to assess the damage to our home. We picked up a welder and our contractor and repairs/reinforcements were made. Our family was able to feel less shaken and further removed from the insecurities of Jos.

Tensions remain high in Jos, although the violence has been suppressed with the heavy military presence in the city. The children’s school resumed today after a week and a half suspension.

It has been said that the struggles in Jos exist between the Muslims and Christians, although the conflict is much more complicated than that and involves politics and power. It has been said that hundreds of lives have been lost and thousands displaced. But what I have seen on the faces of two young men recovering in the Vom hospital from bullet wounds is quiet fear and horror of what they had experienced and seen.

The atrocities and pain felt by many will need to be our common ground so that we may rebuild our hope and restore peace and safety for all. May our faith in God and humanity sustain us as we reconcile the suffering felt by many.

Charlotte

Safe

Hello. Just a note to assure people that we are safe. Jos has experienced some difficult unrest the past week and a half, with considerable loss of life and property. While we were trapped in Jos due to travel restrictions, our home in Vom was also broken into and we lost our computer. Friends and neighbors have been very supportive of our family through everything, but our problems are very small compared to many others who have lost much more. Although a heavy military presence has brought relative calm for now, tensions are understandably still quite high as life starts to return to some semblance of normal. Mennonite Central Committee continues to work at relief and peace efforts through their partner organizations. We hope to post a blog sometime soon with more details. Thanks for your thoughts and prayers, both for us and for all those affected.

Getting along

Sannu- It has been a while since our last entry. A few weeks back we spent a weekend at Miango Rest Home. It is a beautiful setting and only about half hour away. The weekend was peaceful and restful. They provided us with wonderful food and had activities for the kids. They played tennis, ping-pong ball, and miniature golf. We saw a chameleon for the first time. Quite an odd little creature, especially with its eyes rotating in different directions from the other one. It walked very slowly. The kids also said they saw a snake and it was standing up from the ground about 1-2 feet. I said latter that if it is standing up from the ground then it meant that you were too close to it. The girls had one of their friends from school along and the kids also met some other children at the rest home to play with. When we returned, the following week we had water working at our house and a small solar-battery run fridge. That was wonderful. It’s amazing how simple things back home that we take for granted make life so much easier here when it’s available. Needless to say the fridge stopped working because it drained the battery. So now the plan is to set up solar panels. Language study is keeping me busy. Every so often my head gets so full and I wonder if I’ll ever be able to communicate in sentences that convey a clear message. The kids are enjoying school and seem to be doing quite well. We like our home and the compound. The kids have found some local children to play soccer with. We visited another church last Sunday. It was about a half hour walk through the village and then up a hill. We were the first ones there because we did not know what time it started. Some curious children told us that they had gone to tell the pastor we were there. About half hr later the service started mostly in Hausa. It was a very lively church with lots of singing and dancing. The different choirs are great with their traditional instruments. At the end of the service many of the members welcomed us and the pastor offered us some minerals(pop). He then walked back down with us to our compound. Just found out today that he and the other pastor of the church are coming to visit us this evening at our home. MCC Nigeria has hosted a serve and learn group this past week and a half with doctors and nurses from US and Canada. We joined them yesterday evening for a cultural experience of some Nigerian dancing and singing. Randy and I offered to help the cook prepare the meal for the event. So yesterday we spent the afternoon cutting up fruit and watching them cook the meal over a fire for about 100-200 people. It was an interesting scene with dogs, a cat and chickens roaming around the cooking fire and listening to the mom and her daughters speaking in hausa. If they needed water it was carried in a bucket from the well on the other side of the house. Dishes were done on the ground and I watched one daughter grab some ruff sand to scrape off the bottom of a pot. They did not have any electricity at the time so another daughter took some of the coals from the fire and placed it in a metal iron to get the mom’s dress ready for the evening. She was singing in a group at the event that night. After the food was ready we assembled it into smaller eating containers on the kitchen floor. We then loaded the food and people into the pick-up ready to go when we discovered we had a flat tire. We all got out and changed the tire-got back in and then the new tire went flat. We called for someone to pick us up and then we all squeezed into a smaller vehicle. We felt at home in Nigeria. This morning we picked up our dog. We have decided to name her Kyra—a combination of our last 2 dogs Kiva and Kyr. It will be a challenge to keep our kids on task with their school work with the addition to our family. Culturally though a dog is considered a watch dog or a meal. We have seen women on the side of the road selling dogs for meat. I look forward to having another companion for my and westen’s walks in the morning. Happy up-coming US Thanksgiving-may your travels be safe-charlotte