external monologue

hello everyone,

I am presently at work today, my first day here at the CDC. Tim is supposed to find an internet cafe and say hello, but i will write too b/c 1) the first day is always a bit slower than others and 2) africa is always a bit slower than everyone else. For some updates:

we have a cell phone!!!! so if you would like to call us, here is the procedure. We have two numbers, one for Uganda and one for Kenya. We think that we are 6-7hrs ahead in uganda and 7-8hrs ahead in kenya. it used to be the latter in both before spring forward, but i had not called africa since then. Contact my mom and she should be able to tell you how to get a cheap calling card in the states to call us over here. we are borrowing the missionary's visitor phone and can only make limited calls from it. it seems to be very expensive to call the states from it, but costs us nothing if you call us. If you are able, try and think of a day and time to call (parents, maybe every week?) and we will make sure to turn it on and be close to the phone at those times. the first time might be a learning experience seeing how we have never received a call from it. we will leave it on tonight (tuesday) just in case you figure this out today and want to give it a try).

Kenya dial...
Uganda dial...
(email andy-ta@loapher.com for these numbers)

so, now for updates. please keep sending the e-mails, it is nice to know what is going on in america. i'm afraid that before i got to read all of these i have been enjoying myself a lot. it has been a very interesting place, but since i have read your e-mails, i am now a little sad.

so, we touched down in entebbe last wed morning and spent the day in kampala with Al (the new Karamojan pastor). it was a nice day full of new experiences of Africa driving, which is horrible, even by the new missionary. They think in cms not in inches. Everything (bikes, people, motorcycles, cars) can drive at 30km and come within cms to something else. you usually sit with your mouth and eyes opened wide fearing they will hit someone (in africa, to be a afraid to scared is said, ''they fearing''). We picked up a girl Haden from the airport that night and drove up to Karamoja the next day. Jim, david (jim's friend), tim and i ate dinner at a restuarant in kampala (khana khazana....the best indian i have ever had).

The road to karamoja is beautiful. (we passed the nile on the way. also mom, if you are trying to track our journey....karamoja will not be on the map, but if you follow the ugandan eastern boarder north there will be a game reserve on the left and a district called k...piripiri, i forget what comes after the k), it is maybe about 100 miles north of Mbale. there was such a change going from the big city kampala to the little town of karamoja. The karamojan are these beautiful, yet sickly looking people. In contrast to the rest of the country they dress in bright beautiful colors with these colorful pleated skirts and bright beads on both men, women, and children. The babies are rapped on the backs of the women with multiple layers of shawls, they look like they will sufficate fromthe heat, but this is considered their winter here. because they usually are poor and starving the shade and rain seems to keep them very cold. you should have seen jim working at the clinic. it was like he came to life. here, he is so relaxed and patient with the karamojan. they love him and he loves them. he will definitely be back. worship was beautiful there on sunday. it was a new experience worshipping with a translator, dogs running around under foot, and people coming and going (karamojan are often late). A karamojan nurse sat next to me and tim and lead the singing....that was amazing.

we tried writing from karamoja but it seemed difficult to have the radio e-mail working, too much trouble. i'm not sure how jim wrote so often last year. Hopefully we will be able to write more now, probably me here at the CDC....but the phone will help in communicating with tim.

We then headed to Mbale to stay a night with the proctors before using a Matatu (the common people's taxi) to get from Mbale to Kisumu. The proctors were very hospitable and helped us in many ways (including the cell phone). Yesterday on the Matatu we passed the equator and saw lake victoria. After ariving in Kisumu we were very very tired. White people are Mazungu. This word becomes your name which is yelled at you continuously. we have gotten used to that, but are a little thrown off by being bumbarded by people wanting to carry your luggage or take you in a taxi to your hotel. it is as if all they see is money with the Mazungu. we took a Boda Boda, a bike which carries the passengers on the back...men forward and women sitting properly to the side (i'm not so good at balancing). It was fun, but these boys work very hard for their 10cents they are getting. i think the excitment about traveling and trying to keep our wits about us for the entire time wore us out. we slept for a very long time yesterday (from 7pm-10am), i wanted to start the day off right at the CDC.

no one has gotten sick (yet). sorry megan and andy for making your stories a little less interesting, no deficating in the bushes. in africa, ironically, they know all of these big words with their broken english and often use the word deficate. they would say to the missionary teacher amy, 'miss amy, you not teach here, we have deficated here.'' Malaria is prevalent but we have not gotten it yet. ALL of the missionary kids had it when we were up there. it's like a minor flu or the common cold here. but we continue to take our antimalaria prophalysis, vitamin B complex, and garlic pills. tim is being very very good about taking all the vitamins i have us taking 3x a day.

Today is my first day in the office. tim is doing something, getting water groceries, we'll see. Andy, to inform you of what i am doing with the CDC.... with a translator we will be interviewing 30 women who are either pregnant of just delivered a baby. These women are HIV+ and use a MEMS cap (Medication Events Monitorying System) which records the date and time the vial is opened by the women. The MEMS cap then gives a % adhernece, which is compared against their viral loads (the gold standard in measuring adherence...if they take their drugs, their VL will go down) and their self reports (which sometimes might over report b/c they want to please the interviewer....making their adherence look a little better than it really is). These MEMS cap using women, however, have some protential barriers in using it and might have some benefits to its use. this is what i am finding out. barriers might include that the vial is large and everytime they are to take their medication they are to open the vial. however, sometimes husbands to not know they are HIV+ or that they are in the study. in this case women would open the vial once in the morning, take out three drugs for the day, and take them on time. however, the MEMS bottle will only say they are 30% adherent. this is a problem of using MEMS. The good part about them is that at each visit the mother's MEMS adherence graphs are charted and they with the pharmacist talk about why the medication was not taken at certain times. These women know that someone is checking their adherence (non blinded study) and may adhere more b/c they know someone is checking on them. my part of the study is to do an interview of them women trying to ascertain what barriers the women find in using the MEMScaps and if they find it embarrasing or helpful to talk with the pharmacist. Then i will use the VL, self reports, MEMS adherence leves, ect to see if there is any difference b/t those who use MEMS and those who do not.

today i have spent the day collecting a list of women who are currently using MEMS (only 18...i need 30, but we ca'n't put anyone new in the study until the CDC in US gives us approval). Yes, this means that right now i cannot start my study until they are given approval. isn't it wonderful to be here in kenya and not be able to start the study :). oh well, that's africa. my translators are Anne and Lillian (these are their baptismal names, no one gives Mazungus their african names b/c we can't remember them). they are getting a kick out of the fact that i want to also know thier african names. They have translated the interview and concent form into Duluo and next we'll do Kiswahili. they will also need to be back translated into english to see if they are correct translations and then piloted on a few women. that's what is happening here.

ok, so this is very long. i feel like if i have the opportunity to write i should write a lot, b/c it seemed like before it was difficult to get to an internet.

let us know about the phone calls. we love you and look forward to talking to you. sorry if this message has many spelling errors and sounds rough. i have noticed that we talk more like african english here than i can help (forgetting the is, a, the, etc).

love you all,