I finally managed to pry the clinic's door open and enter the St. Rodrigue Health Center. I saw a nun, who I presumed to be Sr. Benedicta, the head nurse, sitting at the front desk with no patients in sight. Suddenly, I felt nervous and excited. This was my fourth trip to the clinic in only a matter of days since my arrival in Lesotho, and I had never found the clinic unlocked and Sr. Benedicta free. I really wanted to volunteer there, but I was afraid that Sr. Benedicta might not need or want any help. I hurriedly introduced myself and held my breath for her response. She gave me a wide grin, exposing the gap in her teeth, and told me she would call me to the clinic once school started. I was relieved but I headed home that day worried that "I'll call you," meaning having a girl or someone come get me, was the Basotho equivalent of "thanks for your interest, but no thanks."
Much to my surprise and delight, she did call me back to the clinic, and it was official. I could come to the clinic whenever I was free, and I was given a Sesotho name, Nthabi (happiness). My year-long journey working at the clinic was underway.
I'm not sure I really started off with a bang. For the first couple of weeks, I got in the way just as much as I helped. Sr. Benedicta was away often, attending workshops and taking care of the clinic's business matters in Maseru. The other two nurses at the time didn't really know what to do with me. I couldn't speak Sesotho at all. I was just learning the greetings and the cultural etiquette that dictated that no matter how much of a hurry I, or whoever I saw, was in, I had to greet them slowly and with patience, and I had to greet everyone, every time I entered a room, even if I was just grabbing something and leaving instantly. I also wasn't yet familiar with the nurses' shorthand in the patients' health books. All patients in Lesotho carry a bukana, a small green book for adults and a larger yellow book for children and infants. The nurses record the patients' symptoms and prescriptions in them. To make things more confusing for me, the nurses often used generic and several different brand names interchangeably depending on their mood. I occasionally wasted time looking for something such as 'cotrimox' only to find that we had 'doctrim,' which clearly is the same thing.
My job initially was just to fill pill bags for a select few medications such as paracetamol or PCM, which was dispensed to just about everyone who entered the clinic. The pills were not given in little bottles with patients' names on them, but rather in small, white plastic pill bags that had both Sesotho and English on them. The bags had boxes in which we indicated how many pills the patients were to take and how many times a day. Patients were not told to take pills every 4 or 6 hours but rather 2 or 3 times a day. During my first semester at St. Rods, I was also responsible for filling the patients' prescriptions when the clinic was busy, but a nurse always gave the instructions to the patients. Because I didn't want to bother the nurses any more than I had to and my lack of proficiency in Sesotho did create a barrier at times (luckily for me, all the nurses spoke English and wrote in the patients' health books in English), I did not receive a lot of direct instruction. I figured things out as I went along, including the lay out of the clinic which was not immediately obvious to me at first.
It is divided into two sections, one for HIV/AIDS and tuberculosis (TB) patients and one for general problems. In addition, the clinic has a separate maternity ward that houses a labor ward (with no pain meds), postpartum ward, a kitchen, and the storeroom. The St. Rodrigue Health Center works in collaboration with Mйdecins San Frontiиres (MSF), and when I first arrived, MSF was sponsoring all of the medications for HIV/AIDS and TB patients ranging from the antiretroviral drugs (ARVs) and TB regimens to multivitamins and basic antibiotics. At first I thought the two sides of the clinic were separated to help reduce the spread of TB, but later I learned that it wasn't merely an issue of passing germs but so that the HIV positive patients did not have to wait in long lines during their frequent visits to the clinic. In addition to these services, the clinic also had weekly "baby clinics" in which parents-almost exclusively mothers-brought their infants, toddlers, or children to be weighed and vaccinated. Nurses travelled to "clinic outposts" in small villages about two hours' drive over rough terrain from St. Rodrigue.
The clinic was staffed by three nurses, including Sr. Benedicta, when I first arrived and two lay councilors. Over the course of the year, one nurse left and two new ones were hired, giving the clinic a full workforce with four nurses (plus me). The two lay councilors are employed by MSF and, at least in Lesotho, are HIV positive people who test and council others, as well as assisting the nurses in dispensing medications to patients on the HIV/AIDS side. Once a week, MSF also sent a doctor to treat special cases and to treat many of the HIV positive patients.
Even though I didn't do any earth shattering work at the clinic, I was happy to work there. Our director, Doug Cutchins, told us during orientation that it was important to "recharge" our batteries-to do something that made us happy and better able to deal with any frustrations and hardships that came our way. I did bring my iPod and DVD player with me to Lesotho for that purpose but the generator died right before I arrived. Even though I couldn't listen to my tunes, I only needed to go to the clinic to boost my spirits. No matter how frustrated I got my first semester dealing with troublesome girls who couldn't have cared less about their studies, I just walked into the clinic, and my day instantly got better. I felt I was "doing something." At school, the girls in my classes were failing left and right, and I never seemed to be able to teach my form B2s how to manipulate negative numbers despite teaching and re-teaching the topic the entire semester. At the clinic, I knew that I was helping to save the nurses' time and energy, vaccinate and draw blood from little kids (I was in charge of holding them down), get HIV positive and non HIV positive patients their medications, and to ensure that our clinic's statistics were complete and accurate. I'd also like to think I contributed to helping decrease the stigma of HIV/AIDS in a rural village. I managed to secure a MSF shirt that is almost exclusively given to people who get tested at the MSF clinics. It says in very big letters, "HIV positive," with, "Get tested. Get treatment," underneath in much smaller letters. The back of the shirt says that medicine should be free and accessible to all in Lesotho in Sesotho. It was the unofficial uniform of the nurses and lay councilors, and I wore mine proudly. A few of my students thought that the shirt meant I was HIV positive which provided an excellent opportunity to discuss HIV/AIDS with them. (Adam and I integrated HIV/AIDS education into our English composition classes and many other teachers, especially science teachers, taught about HIV/AIDS. Many of the books provided by the government, including maths textbooks, included problems that referred to the HIV epidemic.)
Then in mid January 2008, Lesotho's Ministry of Health announced free medicine to all, including free ARVs and antenatal care. The free medicine announcement was made on Radio Lesotho in Sesotho so I only became hip to this change when I asked why the number of patients coming to the clinic suddenly skyrocketed. We started having between 80-100 patients a day on the general side of the clinic. The introduction of free medicine coincided perfectly a new semester and an increase in the number of Basotho teachers at the high school. This gave me very few classes and lots of time to devote to working at the clinic. My role expanded. I had to prepackage entire bottles' worth of all the medications we had in stock in pill bags or 50 ml or 100 ml bottles so that when I was not there, the nurses could simply grab the pill bags or syrups they needed without wasting any time counting or pouring. Also, by that point, I had learned how to explain to patients how to take their various medications by listening to the other nurses' instructions. I began to work independently as the "pharmacist" on the general side of the clinic, and I eventually gained access to the clinic's storeroom which was important because we were constantly running out of supplies.
While I had seen people adjust, adapt and make due with whatever materials were available in all aspects of Basotho life, it seemed to me that this skill was especially vital at the clinic. We were constantly running out of pills, syrups, ointments, pill bags, and bottles. We always managed to find some way around the problem or invented new ways to address it. In fact, I stopped trying to figure out how every detail worked at the clinic because once I learned one way of doing something, it would be different the next time I came in. I just adapted and adjusted like everyone else, and the patients never seemed to mind.
It was our forever adapting to chronic shortages that resulted in my only run-in with a patient. We had run out of 50 ml bottles that were used for children's and infants' medications. Since we still had 100 ml bottles for the adults' medicine, it was a no-brainer that I should use those and fill them halfway. As I was doing so, a woman started complaining in Sesotho that the aussie lekhuoa (white girl) was cheating her and everyone else. She angrily told me to fill them up to the top. One of the lay councilors stepped in to try to convince her that we were giving them the correct amount. The woman refused to listen to him and continued to argue that I was cheating her and giving everyone less because it was free. Luckily, she gave in before the nurse in the examination room had to come out to deal with her.
In addition to working at the clinic in St. Rodrigue, I also had the wonderful opportunity to visit many other health centers around Lesotho and one in South Africa. I was able to visit the Maphephetheni clinic in a rural Zulu village outside of Durban, the Baylor University Pediatrics HIV/AIDS clinic, the military hospital on the Makoeyane infantry base in Maseru, and Queen II, the main hospital in downtown Maseru. These different clinics gave me a broader sense of what health care is like in the Mountain Kingdom.
Indeed, Lesotho is a pretty exciting place to be to learn about international health. Its health care system has received a lot of international attention recently. With an approximate adult HIV/AIDS rate of 30% and a subsequently high rate of TB infection, the fourth highest in the world (HIV and TB tend to go together), many international organizations like MSF and Partners in Health (PIH) have come to bring accessible medical care to the Basotho. MSF works in collaboration with 14 clinics in the Maseru and Mafeteng districts, and PIH has moved quite quickly to establish four clinics in the most remote regions of Lesotho's Maluti mountains and hopes to continue to add to that number. Baylor University runs the pediatrics HIV/AIDS clinic in Maseru and is also in the process of opening more satellite sites throughout the country. The Seventh Day Adventist church runs the Maluti Adventist hospital in Mapoteng and faculty, residents, and students from Boston University Medical Center carry out rotations at Maluti hospital as well.
Bringing accessible medical care to Lesotho is no easy task. Very few roads dot the mountainous regions of the country and most transport is done by horseback or donkey or foot. St. Rodrigue is located in the lowlands and is only 98 km from the capital but it can take up to 4 hours to travel there due to the roads. Almost all of our patients walked an hour or more to reach our clinic and often they waited all day to be seen. PIH, the organization tackling the most remote regions in the mountains, has to airlift all personnel and supplies to their sites.
An issue for clinics in the capital is that while their services are free, transportation is not. Buses and minitaxis are often too expensive for many patients, and the fares are climbing as the cost of petrol increases. For Basotho living in rural areas, traveling to Maseru is very costly (from St. Rodrigue it costs roughly $6 roundtrip, a huge sum for people who often make less than a $1 a day).
Then of course, there is the question that many are asking: Can the Ministry of Health afford to provide free medicine for everyone? As the winter cold set in as I was leaving, the numbers at the St. Rodrigue clinic were down to pre-free medicine levels. I think everyone anticipates the number of patients to increase as the weather gets warmer, and only time will if the government will/can keep its promise.
Problems aside, as I look back on my year, I am so thankful to the nurses and the patients at the clinic for enriching my experience in Lesotho. When I first signed up for Grinnell Corps Lesotho, I had no idea how it would turn out. I didn't even know that there was a clinic in St. Rods until mid-way through my interview. I thought the fellowship would be purely a teaching fellowship as it had been for so many Lesotho fellows. When I first stumbled up to the clinic to meet Sr. Benedicta, I was considering going to medical school, and I thought volunteering at the clinic might be fun and help me decide whether I was heading in the right direction. Now, I want to pursue a career as a physician and work in clinics, like the St. Rodrigue Health Center, and hospitals in developing countries around the world. I've had the incredible opportunity to live and work alongside HIV positive people who are not only surviving, but also thriving with the disease, and I have seen how much of a difference a clinic staffed by dedicated nurses can impact their community. I hope, someday, that I can come back to the St. Rodrigue Health Center and serve in a more integral and crucial role. Sr. Benedicta told me she'll probably be retired by then-she's 59 and nuns retire at 65-but she told me that I should be able to find her looking after the sick sisters in Maseru, and somehow, I think it'll take me four trips to the hospital to find her free then too.
