It was October of 2012. I was a few months into my EIS experience at CDC and visiting Namibia for the first time. Strolling around downtown in the capital city of Windhoek, I was a bit surprised. German stores and signs were everywhere. Had I arrived in Berlin or Sub-Saharan Africa? It was a national holiday, so the city center was deserted. In the summer heat I had walked around a large public mall searching for food and hadn’t found much that was palatable. I had ended up drinking a Windhoek Lager and eating a panini wrap at the Windhoek Square Cafe.
The next day I flew up to the northern border region with Angola, to a place called Engela. It was a funny place. The war between Angola and South Africa had gone along for two decades and had been devastating. Yet it didn’t seem to be talked about much, at least with us, the visitors. Because of the border with Angola, there was a constant flow of people each direction. The CDC director Dr. Thomas Frieden had visited Engela State Hospital 5 months before us and had found a large number of drug-resistant tuberculosis cases there because TB infection control measures were lacking. We spoke with staff, toured the hospital, and inspected their TB treatment logbooks. It was obvious that Dr. Frieden had been correct. Engela State Hospital was very under-resourced and several health workers had acquired DR-TB. Yet it was unclear what had been done since Dr. Frieden’s visit to make the facility safer (or if they had received any additional resources from PEPFAR or the Namibia government to help make that happen). After returning to Windhoek, we made recommendations to the Namibia PEPFAR team and Ministry of Health and Social Services (MOHSS) but ultimately I have no idea if Engela received the help it needed.
Flying Home to Hartsfield-Jackson International Airport
On Delta Flight 201 home from Johannesburg to Atlanta, I was hopeful. Soon I would see my wife Kristen. I thought my work in Namibia would come to something tangible over the next two years, because there seemed to be commitment from the Namibia PEPFAR team and the MOHSS. PEPFAR had plans to hire a permanent TB/HIV Advisor (a CDC direct hire). Namibia was to receive 3-year central funding (from the Office of the Global AIDS Coordinator, OGAC) for a TB/HIV initiative that would focus on TB/HIV broadly, new lab diagnostics, and would have room for operational research. And PEPFAR had ample funding and MOHSS support in the areas of TB intensified case finding/IPT and TB/ART. The PEPFAR country staff told us that they wanted to develop some TB infection control program evaluations as well.
Yet few of those plans came to fruition during my two years at CDC. There were significant delays with the OGAC initiative in terms of finances and staff. I wrote a protocol and got IRB approval to execute a study of ART uptake in HIV-infected TB patients in several districts. However, because of delays, that study never came to fruition during my two years of CDC and I’ve felt guilty about it ever since. The guilt isn’t so much because I didn’t complete the study quickly and get a publication on my CV. Rather, I feel unhappy because those delays could have potentially lead to deaths, and I share some of the blame. The study has since been completed, however, and the data are currently being analyzed.
“The past is never dead. It’s not even past.” – William Faulkner, Requiem for a Nun.
Why am I writing about Namibia now? Not sure. I left the CDC in 2014 and went back to academia to do an ID fellowship. Now I am with the Brigham’s Division of Global Health Equity/ Partners in Health. Tomorrow I am flying to Lima, Peru for the first time. The purpose of this trip is to work on TB Infection control in a very different context. With Socios en Salud, we are planning a study to evaluate the impact of F-A-S-T on nosocomial TB transmission. It’s a short trip and there’s a lot to do. I hope to do a better job in Peru than I did in Namibia executing this study. But along with the study itself, what is very important is how I interact with local people (be a better listener). On my blog there was also an excellent recent exchange about “neocolonial medicine” (please read through the terrific comments by Gregg Gonsalves, Tim Lahey, Charles Van der Horst, Jonathan Colasanti, and others) which will hopefully inform my work. From Peru, I’m hoping to try to update you on what I see/learn, assuming we have a good internet connection.
When I was in Namibia in 2012, I would have never expected to end up traveling to Peru and blogging about Namibia several years later. When you work at the CDC you can’t just write about your travels. Everything published by CDC authors goes through government “clearance” which is reportedly done to ensure high quality scientific work, but could also be interpreted as censorship. In 2013 I did write a couple brief blog posts from Windhoek but they didn’t say anything about the work we were doing in there Namibia. I believe I can write about the CDC now since I left there over a year ago.
Life works in funny ways, though, and the connections we make and experiences we have are never wasted. Now it’s time for some action, to make health facilities safer from TB transmission.