m2m Trip to Port Elizabeth

Last week turned out to be another busy week spent outside of the office. On Sunday afternoon, after catching my breath at home for one day, I hopped on another plane, this time headed to Port Elizabeth. Port Elizabeth is a larger city (large enough to be a World Cup venue, at least) also located in the Eastern Cape on the Indian Ocean coast, a few hours west of East London. Most of my trip was work related, so I actually might not be giving the most accurate description of the city. On the whole, I saw highways, townships, and malls. I would say it’s more touristy than East London, but certainly not a major destination like Cape Town. Apparently there are some nice nature reserves outside of the city, and it does have a pretty developed beach area with good surfing. Mostly though, I think it’s an industrial city – at least it’s definitely the hub of the South African car industry. Driving around outside the city, watching enormous car plant after enormous car plant pass by (Ford, GM, Toyota, Mercedes, VW, you name it), I couldn’t help but think of Detroit.

Sunday evening I checked into yet another B&B, though this time it was much more like a hotel and less like just taking up a room in someone’s house. Nzwaki drove from East London and met me in PE. We got up pretty early on Monday to get started, once again working on data abstraction at the 5 sites funded by Johnson & Johnson in PE. There are certainly more than 5 m2m sites in PE and surrounds, but J&J only funds 5 of them, and we needed the logbook data from these sites in order to finish up the J&J report. Only one of the sites was close to where we were staying; the rest were scattered around the outskirts of the city. Fortunately (well, perhaps both fortunately and unfortunately, but I’ll get to that later...), Nzwaki brought her Garmin GPS. This was essential, as neither of us had any idea how to get from Point A to Point B otherwise.

Anyway, I looked up the first site on our list and found it pretty amazing that this small township clinic in was actually in the GPS database. Expecting nothing less than for everything to go smoothly, off we went, dutifully following the instructions of that nice little GPS woman. Lo and behold, 30 minutes later we arrived at our destination. I previously was impressed by our GPS being able to tell direct us through the remote lands of Eastern Montana, but having one able to tell us where to turn amidst makeshift township streets on the outskirts of a South African city seemed all the more amazing. Data abstraction at that particular site took about half the day and went well, at which point we hopped back in the car ready to tackle the next clinic.

Well, let me just say that GPS works really well when you can fully rely on it...but it can backfire amazingly when you are suddenly stuck in the middle of a township without it! As we started following the directions to get to the next clinic, all of a sudden the GPS just shut off. I tried to turn it back on, only to watch the screen go black again right away. Quickly realizing the battery had run out, I started to fiddle with the cigarette lighter. Try as I might, that little red light would not go on. Having a faulty cigarette lighter perhaps isn’t something you think to check when you get your rental car, but in the future, I think I will. So here Nzwaki and I were, driving around what essentially amounted to alley ways in the middle of a bustling township, looking very, very out of place and not having any idea whatsoever how to get to a main road or highway. At that point, we just started rolling down the window and asking passer-bys how to get...well, how to get anywhere, really, as long as it involved a highway. I will say that this situation would have been made much more difficult had a native Xhosa speaker not been present, but hopefully I won’t ever have to tackle such a scenario without Nzwaki.

Anyway, with the help of kind strangers, we eventually did make our way back to the highway, where upon we decided our next stop would necessarily be the PE airport where we could visit the rental car company and get the cigarette lighter fixed. To be honest, I really didn’t think too much about our little adventure, just that it made for a funny story, but Nzwaki later told me that she had been really worried that I was going to panic and be really upset and scared. I guess there’s a good side to not recognizing any township names! (Apparently we had been in the middle of one of the busiest township intersections, one that even Nzwaki, who doesn’t live in PE, knew by name.) I guess it’s a good lesson not to panic and to just trust that people are not evil and 99% of the time will likely try to help you if you need it. Of course it’s smart to remain on your guard, and of course I would never go anywhere by myself, but at the same time, there were women and children walking along the sidewalks and people laughing and being good natured, and I don’t want to fall in the mindset that I have to be terrified of everyone who is poor.

We weren’t able to get anything else accomplished on Monday once we had to backtrack all the way to the airport and get the car sorted out, but Tuesday with new found confidence in our GPS, we once again headed off to find the next site. This is when I discovered pitfall number two of relying so heavily on the GPS. After driving down the main national highway for a few kilometres, Ms. GPS told us to exit and turn onto a much smaller road that started heading through the township areas. This all seemed quite normal, until I heard her say “go straight for 17.8 km” as opposed to the 1-2 km I was expecting. Apparently she was trying to be helpful in finding us the most direct route to our destination, but obviously it would have been a lot more pleasant to be on a fast, easy highway for an extra 10 miles as opposed to the local township road. Oh well, lesson learned, haha!

Tuesday also happened to be Nzwaki’s 40th birthday, and I felt terrible about her having to spend with me instead of with her kids at home. Luckily, however, her youngest sister (who was my age) was going to school in PE, so she at least had some family in the area. We actually went out with her sister and her sister’s boyfriend for dinner both on Monday and Tuesday. It was nice of them to be so inclusive of me, and I definitely had a good time with them. Prior to dinner on Tuesday, Nzwaki and I took a little break to go for a nice walk on the main beach of PE before sunset. The weather wasn’t great (a little cold and incredibly windy), but it was still quite scenic. I can’t believe some people are insane enough to surf in such weather, but I guess I’m not a die-hard water person to begin with. The PE beachfront is nice enough, but it’s a little on the neon mall side for my taste. At least I’m glad I didn’t spend the whole week in PE without ever seeing the beach!

Wednesday we actually managed to finish up our data abstraction work, 2 days ahead of schedule. Fortunately, it turned out that none of the PE sites were that big, so even though it took us a lot of extra time to navigate between clinics, once we found the sites, things went pretty smoothly. I’ve really had a great time these last couple of weeks getting to work on the site level and having the opportunity to meet a lot of the Mentor Mothers and Site Coordinators. I’m not sure if I’ve explained this before, but Site Coordinators are in charge of usually 1-3 sites depending on the site size. They are basically responsible for monitoring the site, organizing group meetings, making sure all the supplies are up to date, and most importantly keeping track of the client information for all of the women the Mentor Mothers counsel. In essence, MMs spend their days meeting with people and recording basic stats, and then SCs go through the MM data and keep track of all the people they saw, making sure infomration gets properly recorded in the antenatal and postnatal notebooks and then transferred to the logbooks. SCs were once themselves Mentor Mothers (MMs actually only have a one-year contract with m2m; the organization purposefully wants lots of turnover to offer more women the chance to be employed and learn how to be role models) so they relate well to the MMs and know how to keep track of everything.

For the most part everything was recorded fairly well, but there was one particular site we visited in PE where it was obvious that the SC was not properly transferring information from the AN/PN notebooks (where each day’s visits are recorded chronologically) to the logbook (the “bible” where clients are tracked by name over time), with a lot of clients left out of the logbook. Nzwaki and I had a really long conversation about how to proceed, and it was very eye opening for me to hear her perspective.

My gut reaction was bafflement at how, when a SC’s entire job was essentially just to spend the majority of her day making sure data for a relatively small number of people is transferred from one book to another, the task still wasn’t getting done. The SC was home sick that day and Nzwaki told me she didn’t want to bring up the issue to the MM’s because it wasn’t their fault and she doesn’t like being negative and discouraging towards them regarding data logistics when their main focus is to be a good mentor. Beyond that, Nzwaki felt it wasn’t her place to speak up since she wasn’t a manager (after SCs there are Provincial Managers, and above that Regional Managers, who together create a ladder of management for each area). She also reminded me a lot of these women are under incredible emotional stress for various reasons and for many of them this is the first formal job they’ve ever held and they may not be used to such stringent standards or accountability.

We had an interesting conversation about how truly hard it is to develop a good system for Monitoring and Evaluation. Sure, I’ve caught on to the system m2m uses to track clients, but it’s definitely not simple, and I can see how it could be overwhelming to some people. Nzwaki said she also feels like a lot of women just aren’t interested in doing it well – they see their job as helping other mothers, not monotonously recording data. Unfortunately, at the organizational level, having real numbers and being able to talk quantitatively about the program effects, makes all the difference when it comes to funding – and thus being able to do the real mentoring work in the first place. Additionally, large scale data management is incredibly complex when you take away the use of computers for entering and tracking information! Such a foreign concept to us these days. It will be interesting to see how M&E evolves with m2m...on the one hand I can’t imagine them continuing to grow at such a large rate without implementing some sort of electronic data entry mechanism at the site level. On the other hand, I can’t imagine most of these MMs and SCs feeling any more comfortable working on a computer than their current set up. For some of these clinics, I don’t know if there’s a single computer in the whole building, so I really don’t know how strange it would be for m2m to have their own computers set up at each site...not to mention how expensive it would be to implement and maintain. Whew! When it got down to it and I was able to take a step back from my research-oriented mentality, thinking about all the MMs who are such invaluable women in their communities and admiring the strength they have for doing what they do...well, I felt pretty bad about being so quick to judge them about why they couldn’t just fill out a form correctly. Nothing is that simple, I suppose.

Wednesday night Nzwaki and I had dinner with Nomonde, who is a Regional Manager for the Eastern Cape. She is normally based in the Cape Town office but visits PE and other places in the Eastern Cape regularly. We were all staying at the same B&B, which was nice. I had a really great time getting to know Nzwaki so well over the past few weeks, and it was also really fun to spend time with Nomonde too. I ended up flying home early since Nzwaki and I finished up our project in PE ahead of time. It’s nice to be back in Cape Town, but I must say, I will definitely miss spending my days with Nzwaki! It’s too bad because she is only working with m2m temporarily on a few specific Innovation Center studies and the J&J report, and of course she’s based in East London. I don’t know if I’ll ever see her again, but I feel very fortunate to have become friends with her. Over the past weeks, she introduced me to a little bit of Xhosa culture, and I think I actually miss being called Sissy, haha! (The Xhosa all seem to greet each other using “Sissy” or “Mama,” and then they also refer to one another as Sissy, etc. in conversation. I think you generally call your peers and younger women Sissy and older women Mama?) And something else I think I’ll miss is always being greeted with hugs. I wish I was better at picking up the language, but it’s so different from anything I’ve ever studied and the clicks make a number of things nearly impossible for me to pronounce. Luckily enkosi, which means “thank you,” and molo or molweni, which mean “hello” don’t have clicks! Anyway, I really learned a lot these past couple of weeks and I hope I get out to more sites in the not-too-distant future. For now though, it’s back to Cape Town and back to the office!

Some views of the PE beach:

Return to East London

After getting back from Knysna late last Monday evening, I had just enough energy to unpack my bags and then repack them for my return to East London on Tuesday. This time I travelled alone, and Nzwaki picked me up at the airport. We wasted no time getting to work, and we spent the whole week at different clinics and hospitals trying to finish all the data collection for the East London area.

Once again, I stayed in a lovely B&B with very hospitable owners. B&Bs are so popular here! I’m not terribly used to the idea of eating breakfast and dinner with strangers and it feels somewhat funny just moving into someone’s home for a few days as opposed to the hotel culture in the States, but it’s also a nice change of pace. The hosts are really friendly, and the food is delicious. I’m even able to run outside around here, as long as I stay on the main road and go during daylight (and yes Mom, I promise I only did this after checking with the hosts about whether it was safe and where to go!). I’ve been going for morning runs, and it’s sort of interesting to be out on the road with all the commuters. By commuters, I mean people walking on their way to work or school. I pass people singing to themselves, or big groups of women gossiping, or teenage boys trying to look really cool with their hoodies and headphones, or little boys in uniforms heading to school, etc. I’m not sure if it’s because people aren’t used to seeing a white girl out running, but I will say that people definitely DO NOT move in the least and that it adds a whole other element to running when you have to dodge and weave in between people. Regardless, it makes for a much more dynamic sidewalk culture than we have at home!

My first night at the B&B I was a little taken aback when, during dinner, another guest named Thandi started reading me the riot act on what is being done about HIV/AIDS in this country. We were the only two at dinner that night, and it all started when she asked me why I was in East London. I barely had a chance to get in two sentences about what m2m does when she got really loud and animated complaining about why wasn’t our organization doing things that actually worked, why weren’t we working in the township clinics, etc. (She originally thought I was only here to be at Frere, the large maternity hospital in East London, which according to her isn’t where most “real” people go, though I was able to explain later that m2m actually operates out of a large range of clinics in different areas). She told me she grew up in the squatter camps in East London, and with a memorably intent tone she looked in the eye and told me it’s just terrifying how vastly spread the virus is and how it’s taboo to talk about it so nobody discloses and as a result how teenage girls are just “doomed,” in her words. Listening to her really put a damper on the positivity and productivity I usually feel as I work for m2m.

Anyway, it was an incredibly challenging conversation, trying to explain the reasoning for how our organization works, especially after hearing her perspective on the situation. I have to admit, it felt just wrong trying to explain to her why m2m’s operating model was in fact really productive, as I clearly am pretty much the opposite of someone who is black, poor, and HIV+. I also really found myself struggling about how to use the right words when she asked why I wanted to be here (here being Africa), when everyone here just wants to escape. How do you talk to someone about wanting to “help” them, as if they are completely helpless and wouldn’t make it without white do-gooders? To be completely honest, I felt really intimidated and was at a total loss for words as I tried to respect her position. It’s funny how much we dance around these types of conversations in the U.S. – I found myself trying to be so completely politically correct that I just could not get any words out of my mouth, I was so afraid of saying something offensive. In the end, Thandi softened up completely and concluded by saying that she was really touched that I was here and that someone is trying to do something about the state of things. In her words, spoken ever so seriously, “something has to be done.” Her desperation, stemming from her perspective growing up in a desolate squatter community, was a stark reminder of what HIV is actually doing to this country...or rather a certain population in this country. I hate to say this, but sometimes when you work in an office, numbers just become numbers, especially when they slide into incomprehensible magnitude, such as the fact that 20% of the entire country has HIV. I’m grateful to be humbled by people like Thandi and have a reality check every once in a while to remind me of why in fact I am so passionate about trying to “do something”... even if I haven’t quite figured out how best to go about it yet.

Talk about numbers just blending together. At the clinics, as Nzwaki and I go over the logbooks with the mentor mothers and try to collect the data on each and every person seen, it’s easy to get swept up in just getting the numbers down. But then as I sift through the logbook entries, sometimes it hits me that each line isn’t just a number to be entered into our database, but a real person with a real story. Yes, looking at the logbook entries, it’s hard to comprehend how different life could be...I can’t even imagine being pregnant at my age, let alone being HIV+, poor, and often not having the support of a partner.

I get really upset with myself for undeniably feeling somewhat guarded and uncomfortable whenever I’m in these clinics – for lack of a better word, it just doesn’t feel “clean.” Sometimes it reminds me of being somewhere like an airport restroom, where you just want to get out as fast as possible. We often sit in dirty, cramped offices or patient check-up rooms with raggedy posters and textbooks looking like they would date back to the 70s or 80s, going through obviously over-handled logbooks, all the while I try to find somewhere to set my bags so they don’t have to touch the floor and avoid using the bathroom whenever possible. Frankly, I’m terribly embarrassed by how the standards I’m used to affect me (I really debated about whether I should even publically admit this!), and I’m making a very conscious effort to stop caring. If someone offers me half a piece of (unwrapped) gum that they just dug out from the bottom of their purse, wiped off, and broke in half, then I suppose it’s not going to kill me, right? When I see someone walking around the halls with a mask on and looking as if they might have TB or swine flu (which has recently been taking South Africa by storm, at least psychologically so), then I just can’t waste any time worrying about it. It definitely takes a conscious effort on my part, but I’m really learning to just let go and go with the flow!

Hard to believe a few months ago I was going to work at a sterile, high-tech lab where money flowed ever so freely, and this month I’m half way across the world spending every day as very clearly the only white person amongst a struggling population whose only resort are these resource poor clinics. As I tag along behind Nzwaki wherever we go, I obviously stand out and consistently get stared at by the packed waiting room crowds as we walk by, but everyone is always very friendly and open. I wish I could have more meaningful conversations with people, but mostly I just try to smile and be pleasant. Still, I’m starting to learn that this culture is much more open to conversation than we often have been trained in the U.S. and that people really appreciate it when you just let go of formalities and be yourself. I’m really enjoying getting to know Nzwaki and have nothing but admiration for her, and I’m definitely excited that we get to spend all of this week together too! Spending time with her, I especially realize how stiff our culture is. She is always touching my arm, giving me hugs, or linking arms with me when we walk somewhere, and I’m embarrassed that I probably seem somewhat uncomfortable in these settings, not because I mind her openness but because it just feels so foreign to our standards of colleague interactions.

After we wrapped up our work for the week on Friday afternoon, I still had about 5 hours to kill before my flight, so I ended up going back to the B&B where the hosts were kind of enough to let me hang out. They even took me over to their friends’ house for cocktails before they gave me a ride to the airport – talk about feeling like you become part of the family when you stay at a B&B! They also had a really adorable 7 month old daughter who they had recently adopted. As Alexia mentioned to me, and as I’m beginning to see for myself as I open my eyes to observing mothers and children, a lot of white South Africans adopt black babies who were orphaned or given up for adoption by HIV+ parents. It’s heartening to see people crossing cultures and reaching across racial lines like that. Anyway, it was fun to spend a few hours with the B&B owners and their friends (who also ran a B&B) – I heard lots of stories about them taking care of Annie Lennox (who, by the way, is a big m2m supporter and visited some of our Cape Town sites last month), taking the President of Botswana on private safaris, etc. I guess being in the tourism business means you get to meet lots of interesting people!

All in all, I’m really enjoying the opportunity to be out of the office and spend time in the clinics with the mentor mothers. I certainly have a lot to learn, not just about combating HIV and managing M&E operations, but about fitting into other cultures and opening my eyes to my own shortcomings.

Knysna

To celebrate National Women’s Day and take advantage of having Monday off, Byron, Wenli, Julia, and I headed off on a mini road trip to spend the weekend in a town called Knysna. Knysna is on the Garden Route, which consists of a series of quaint, touristy towns with lots of great beaches and forests stretching along the Southern coast. Saturday morning we got up extremely early and were on the road by 6:30 am. On the way over, we followed directions from Byron’s boss and took a more circuitous route to Knysna, which ended up being well worth it.

First we watched the sun rise over the mountains in the wine region as we headed out of town – it was stunning. Then we made our way into a cute little town called Barrydale in the Klein Karoo (literally translated it means something like small, dry/semi-desert area) for brunch. The first sign we saw advertised the Blue Cow Cafe, so off we went, following the signs through town and eventually ending up at a picturesque little cabin where we had brunch on the deck, looking out over the pond and town below. The owner was incredibly friendly to us because he said they don’t get many Americans passing through and his daughter is living with a family in the U.S. so he wanted to be sure and show all Americans great hospitality. Talk about nice – he even invited us to stay in their house next time we came back to Barrydale!

After breakfast, we were on the road again, making our next stop in a town called Oudtshoorn (and yes, Afrikaans is waaaay more prevalent as soon as you leave Cape Town get into the more rural areas). In Oudsthoorn we went on a tour at an ostrich farm, and it was actually pretty interesting. Did you know ostrich feathers used to be worth their weight in gold? Too bad they went out of style! We also learned how to distinguish between real and fake ostrich leather (real leather has small holes/actual edges where the feathers were plucked out; fake leather only has polka-dotty indents to make it look like it had feathers in it). And who knew about all the different varieties! They are such weird animals, especially when you see them up close. Staring at them, as Byron commented, you can really see the connection between dinosaurs and birds. With their legs that bend in funny places, their giant clawed toes, and their weird, rubbery necks, you really can’t help but think of something like a velociraptor, haha. Anyway, the main reason we went on the tour was so Wenli and Julia could ride ostriches afterwards, and I must say, it looked quite difficult. And definitely amusing!

Once we left Oudtshoorn we started dropping South and heading towards the coast. There was certainly some spectacular scenery to take in as we traversed a few mountain passes leading us down into the green coastal land. In Knysna, we rented a self-catering cabin located right on the lagoon waterfront, and it turned out to be as quaint and beautiful as we hoped. The cabin seemed fairly upscale, but since it was the off season we each only ended up paying about $60 total for the whole weekend. Saturday night we had dinner at one of the waterfront cafes in Knysna, getting our fill of fresh seafood. Knysna is famous for its oysters, though Julia was the only oyster-eater among us.

Sunday we had our hearts set on hiking (the forests around Knysna are very nice), so we asked the lodge hostess where to go...she responded with “I don’t know...do I look like a flipping walker?” but luckily we had also brought our own guidebooks. She at least directed us how to get through town and up to the forest access road, though her description included something like “turn left once you get to the black section of town,” and it always takes a second to remember where you are and translate what that means. The “black section” obviously meant the township area; it’s just so strange to hear phrases like that since we obviously have such different standards for racial dialogue in the U.S...and of course it is just yet another reminder how segregated things can still be in this country.

Anyway, we made our way up the gravel road and set out on the trail, excited and hopeful that we would see animals. The Knysna forest actually still has one remaining forest elephant, which is obviously very, very rarely seen, and Julia had read that if you were quiet you could often see monkeys in the trees, too. Well, we started off being quiet...until we were walking along and all of a sudden heard something rather large rustling around in the ferns. When it started grunting, Byron picked up a very large stick and we debated heavily about how to proceed. We ended up scurrying past that area and spent the rest of the hike talking loudly, deciding we would actually rather not see any animals than hear strange noises in the bushes. (Later when we got back to the trailhead and read the wildlife information signs we confirmed what we had suspected – we probably ran into a bushpig, and I must say, I’m really glad we never actually saw it!) Despite that, the hike was very enjoyable. The forest was really beautiful, and obviously extremely different from anything in the Rocky Mountain West. We all commented on how ancient the forest seemed, with all the ferns and old trees (one big one was marked as being over 600 years old!). I’m glad we took the opportunity to get outdoors.

Sunday night we made good use of our self-catering cabin, braaing (“braai” means BBQ in Afrikaans) away and roasting veggies. It was delicious. And perhaps the best part about the cabin was the electric blankets accompanying our beds!

Monday morning we hit the road again, this time driving back to Cape Town on the major highway that follows the coast. We stopped for lunch at another famous Garden Route town called Mossel Bay (I probably don’t need to explain this, but that means Mussel Bay in Afrikaans). We spent over an hour watching the surfers, exploring the tide pools, and collecting seashells on the beach before tearing ourselves away to eat and get back on the road. There is something so fascinating about hunting for sea urchins and starfish! We ended up eating lunch outdoors at a beachside cafe, and a very pleasant afternoon was made even better when we spotted a whale. I was pretty amazed that such large whales (I wouldn’t be surprised if we had seen a humpback whale – and I say that with years of Cape Cod whale watching experience!) were so close to the beach. The water must get deep very fast because the whale we saw really didn’t look that much farther out than the surfers.

Back on the road we enjoyed much more beautiful, green mountain scenery as we made our way back to Cape Town. Unfortunately about an hour outside of Cape Town the traffic became bumper to bumper as we caught up to everyone else heading home from weekend outings...but it’s hard to complain about such a successful weekend!

Sunrise in the winelands



Breakfast in Barrydale


Oudtshoorn ostrich


Traversing the pass down to the coast



Our cabin on the Knysna lagoon




Knysna forest


Mossel Bay




Heading back to Cape Town

m2m Trip to East London

Monday morning instead of heading into the office as usual, two women from work, Alisha and Chloe, picked me up on the way to the airport. One great thing about flying in South Africa – they don’t care if you board with your toiletries in a Ziploc bag or not! We took short ~1.5 hr commuter flight to East London, a city which lies on the Indian Ocean in the Eastern Cape province. After landing in a dumpy little airport and procuring our rental car, off we went. To do what, you ask? Well unfortunately, Chloe (an evaluation and operations research specialist in the m2m M&E department) is leaving in a few days to start grad school back in the states. Before Chloe leaves, there is a lot of work to be done orienting Alisha (another relatively new m2m employee, working as an international M&E systems manager) to a bunch of the ongoing M&E projects, many of which are centered in East London. And along with that I fit in somewhere in the mix too...

Anyway, to make M&E orientation matters even more interesting, there is a very large and important M&E report due to Johnson and Johnson by the end of the month, completion of which still requires all of the actual data collecting. Ok, let me back up. m2m has a group of sites in the Eastern Cape (10 total) that combined are called the “Innovation Center.” These 10 sites serve as an ideal place for m2m to focus its operations research, as the urban location, high HIV prevalence rate, and relatively improved literacy rate in the area simplify the logistics of working with this population. As m2m wants to improve the quality of its services and test out new ways of educating mothers and tracking clientele, it uses the IC sites to run tests and try new practices before rolling out changes in all 500+ sites. Johnson and Johnson funds 7 of these IC sites (in addition to 8 other sites throughout South Africa) and is invested in the research done there. The upcoming J&J report must give feedback not only on the basic services of all 15 J&J sites, but also on an ongoing IC study trying to test the effectiveness of contacting clients via phone and home visits after birth in effort to improve the rate of 6 week infant PCR testing (to see if the baby is HIV+), as opposed to only interacting with clients as when they choose to seek out m2m in clinic sites. There are, unfortunately, myriad complications with this seemingly simple, yet very important, task. To start, clients must give permission to be contacted via phone and home visit – and for some people who have not disclosed to their friends/neighbors/children/partner, the idea of having a mentor mother (who is often well known for her role in the community) seek them out at home is unacceptable. Beyond that issue, many women do not have the same phone number and/or address 6+ weeks after birth compared to the contact info they initially give the mentor mothers – they may not have the money to maintain their cell phone number, they may move (and poor people especially are obviously very migrant), they may live in an informal settlement and not have an address, they may lie about their contact info so as not to be bothered by the mentor mother, they may leave the city and return home to rural areas to have their babies where there is more family support, etc., etc. There are also a ton of logistical issues in even asking the mentor mothers to do this sort of follow-up, as they must have m2m give them advances on airtime and money to take taxis/minibuses to homes. Truly, the list of complications goes on and on (and again, is so daunting!).

As for where I fit in, I’m going to spend the next few weeks helping with the Johnson and Johnson report, particularly with data collection...which is why I went to East London, as I myself only found out on Monday. Haha, what I have learned recently is that when someone mentions on Friday they’ll be picking you up to go to the airport Monday morning, then you say ‘ok’ and go with the flow. No, in all seriousness, I’m very excited to be helping out with this project and I’m more than happy to travel, experiencing South Africa beyond Cape Town and learning more about m2m operations at the site level. So back to our trip...

I don’t know much about East London, but it didn’t seem anything like Cape Town. From what I could tell driving around, there were much fewer white people and the city streets themselves appeared more run down with lots of swamped sidewalks and street-side craziness. The weather was beautiful and warm, and the beach looked very enticing, but sadly we never make it down to the water’s edge. Leaving the airport, we drove into the city of East London, to a major maternity hospital called Frere where we met our local m2m study coordinator, Nzwaki. What a great woman! She was so open and kind and helpful. After lunch together, Nzwaki took us to a few sites to introduce us to the mentor mothers and show us all the logbooks so we could familiarize ourselves with the data collection tools and talk about any foreseen issues with Chloe and the mentor mothers before we actually begin data abstraction.

FYI, at each m2m site, mentor mothers must fill out notebooks on all the antenatal and postnatal clients they see that day, and then they must take those books and transfer all of the info for the known HIV+ women into what is called the logbook. Instead of being organized by date, the logbook is then organized by client, so under each client you can enter numerous appointments and update her info as she progresses in the program. What Alisha, Nzwaki, and I will be doing is now creating electronic databases for the logbook data. (We also have to do the same for special logbooks which are tracking the baby PCR follow-up study.)

I’m sure you’re wondering why this work requires headquarter M&E staff to fly to East London, but this data abstraction is far more complicated than one might expect. For one thing, mentor mothers are not given computers (nor would many even be trained to use one) so the logbooks are all updated by hand and must not leave the sites. The process of recording each pregnant woman seen, and then transferring the info for all HIV+ women into a separate book and keeping track of each woman over many months is time intensive and fairly complex (it definitely took me a good while before I had completely oriented myself to the logbooks, so I can imagine mentor mothers must feel somewhat overwhelmed being required to do this work). Of course human error and data omission comes into play, be it because mentor mothers don’t understand something or clients don’t give accurate information/don’t know their own statistics (e.g. CD4 test date and results). Or in some cases, the M&E logbook design itself causes problems. For example, we now know it must be clarified that mentor mothers are not to fill out the box on infant feeding practice until after birth because right now many are interpreting that field as the planned infant feeding practice (which of course may vary from what occurs after birth). We also learned that “complimentary” doesn’t mean anything to many women whose first language is not English, so the logbook shouldn’t have a box to mark for “complimentary feeding,” but rather something more simple like “breast milk plus other foods.” It’s always quite the reality check to be in those settings and realize how much we as technology savvy, educated Americans take for granted. And just to add another dimension of confusion, the logbooks were newly revised and some women are had a few issues adjusting to the new ones, not to mention that some mentor mothers went back and transferred all their old client data to the new books while others did not, thus affecting the number of “new” clients seen at different sites over the past few months. Now we subsequently have to go through and interpret each client entry and filter based on dates and AN/PN status to ensure we control the data used for the J&J report. Suffice it to say, data abstraction over the next few weeks (especially with a tight deadline) is going to be challenging.

Monday afternoon as we drove through a township to get to another clinic site, we encountered a lot of road destruction (large concrete blocks, tree trunks, scrap metal, trash, rocks, etc. strewn all about some streets), likely coinciding with the unrest arising from the recent nation-wide strikes...though sadly I can’t see why destroying your own township would be helpful in expressing your frustration towards the government. Luckily we still managed to weave our way through the rubble and make it to the clinic, where we met with more mentor mothers. Everyone was surprisingly friendly and embracive, making me very conscious of the fact that Americans are not generally comfortable with being touchy and open in work settings. I was greeted with hugs by everyone even though obviously no one knew me, and then they all had a good laugh at the fact that they thought Morgan was a man’s name, haha.

Anyway, after the day wrapped up on Monday, Alisha and I drove Chloe back to the airport (she had to get home since this is her last week in South Africa, but the two of us stayed on to start the data abstraction process on Tuesday) and then settled in at our very lovely B&B where they also served us a tasty dinner of bobotie (a Cape Malay casserole dish made of minced beef flavored with curry and other spices, dried fruits, and an egg custard topping – yum!). m2m knows how to treat people well on work trips! Tuesday morning Alisha and I met Nzwaki at the maternity hospital and went through the report outline and then spent the day working at a smaller clinic, beginning the long process of data abstraction. At the end of the day we drafted up the schedule for completing data abstraction for the 10 sites in East London, 2 in the Western Cape, and 5 in Port Elizabeth...which means Nzwaki and I have a lot of travelling to do over the next two weeks!

Stellenbosch Wine Festival

Byron and Wenli enjoying the wine festival:

For those of you who aren’t familiar with the South African wine scene, I don’t know what to say other than that’s really too bad, haha…South Africa has a very strong wine industry, though it may not seem like it in the U.S. (I think I heard South African wines are generally marketed more in Europe). Having such a strong wine industry also means that your average grocery store bottle of wine is consistently good and extremely cheap – a rare treat if you’re used to living in the U.S. I’ve bought bottles of wine for approximately $3-4 here that I know I’ve paid $12-13 for in the States!

Anyway, the biggest wine region in the country is spread across a few valleys that are located just outside of Cape Town, so on Saturday the four of us ventured out of the city in our trusty car with our trusty driver (thank you again, Byron!), driving for about an hour before we hit Stellenbosch. Not only are the winelands near Stellenbosch charming and quaint as many winelands tend to be, but the dramatic mountains all around Stellenbosch make really enhance the scenery. After driving around the town for a while (signs were not easy to come by) we finally managed to find parking. Though the annual Stellenbosch Wine Festival was a week-long event, I think we were all more than satisfied just to have the opportunity to enjoy Saturday’s events. The festival was set up so that your entrance fee (roughly $16) covered a glass and two ticket booklets, and armed with a sticker you were allowed access into 3 large tent and gymnasium areas which were lined with booths from individual vineyards. Each vineyard offered 4-6 wines for tasting, which you had to pay for with your tickets…although not many people would take tickets, even if you offered, so when I got home I still had 1.5 ticket booklets left, haha. If you liked a wine, then you could ask for a barcode sticker and put in your booklet, and then at the end of the festival you could purchase all of the wines you wanted based on the stickers you collected. There were tons of people there, including a lot of people our age (probably because Stellenbosch has a large university), and also friends of Byron and Wenli (evidence once again that the large city of Cape Town segregates itself into truly small communities based on what activities one can afford). Beyond wine, there were also numerous food booths. I ended up being somewhat adventurous and having a kudu burger for lunch – very good, though I think I still like buffalo burgers better. We relaxed at the festival all day and then had a nice dinner in downtown Stellenbosch before heading home. Needless to say, it was a lovely day.

On Sunday Byron, Wenli, and I explored the nearby suburb of Constantia. Byron and I went running through some amazing neighborhoods (truly, it felt as if we were running through Beverly Hills or the Hamptons) and also found some nice trails to run on in the foothills of the mountains. Both the wealth and the scenery were breathtaking. While we ran, Wenli practiced driving. So now with two down in terms of driving, that leaves, well, me…

NPI Conference

Last Friday for work I had the opportunity to attend a New Partners Initiative (NPI) conference on behalf of m2m. I felt a little lost since I was only showing up on the last day of the conference, but it was still very interesting to be there. As part of the new Monitoring and Evaluation team at m2m, I went to the conference to take notes on a lecture about M&E under the new PEPFAR guidelines.

The New Partners Initiative is part of PEPFAR (the U.S. President’s Emergency Plan for AIDS Relief) and is designed to help expand more community-based and some faith-based organizations serving in the HIV/AIDS prevention and care field. Essentially, this is part of plan for the USG (United States Government) to enhance HIV/AIDS work and strengthen community-based projects by working within existing local frameworks. m2m has been awarded an NPI grant to partner with organizations in Kenya (Catholic Medical Mission Board), Rwanda (Imbuto Foundation), and Zambia (Development Aid from People to People) to expand its PMTCT work to these new countries with the help of organizations that already work there.

This week the NPI State of the Art Technical Meeting was held in Cape Town, a meeting designed to provide the NPI grantees technical assistance for better grant implementation. Of course I missed most of the meeting (similar to the IAS conference, the m2m office was rotating a few meeting spots throughout the week), but it was really interesting even just to gain minimal exposure to some of the issues that organizations face as they work within the USG grant regulations. The M&E talk I went to was focused on the changes in the new PEPFAR (the new PEPFAR being the president’s HIV/AIDS policies based on Obama’s administration, as opposed to Bush who started PEPFAR) and what it meant for M&E teams. To be frank, I left the meeting feeling fairly overwhelmed. Listening to how extensive M&E data should be, how organizations should integrate their M&E into other local organizations and tailor it to each host government, and how organizations like m2m need to comprehensively train and rely on their peer educators in order to actually collect much of the M&E data – well, it became very clear just how hard it is to actually implement a strong M&E program, especially in resource poor, often rural areas. I certainly advocate holding grantees accountable and want to see data on the number of people reached, the effectiveness and quality of the programs, etc., but when you get down to actually collecting that data, it’s a very daunting task. I’m glad I’m getting to see first hand some aspects of the USG grant world and learn about the practicalities of reporting on NGO work. There is a big difference between having the heart and desire to get something done (e.g. providing PMTCT counseling to women in sub-Saharan Africa) and actually succeeding in doing so. It really makes me admire and respect the m2m founders who have worked so hard to bring an idea into practice – expanding this program from 3 sites in Cape Town to hundreds of sites in seven countries is nothing short of amazing.