First Day at Rakai

February 25, 2010
Kalisizo, Rakai District, Uganda

First Day at Rakai
I must admit I was nervous for our first day at the Rakai Health Sciences Program. It has been 8 years since I was last here and, while many things about me have changed, I am still the overly anxious, totally self-conscious, pathologically insecure person that I was when I was doing research here in college……

[A little background on Rakai for those of you who are reading who are unfamiliar with the Program (http://www.jhsph.edu/rakai/). In 2005, the Rakai Health Sciences Program opened a new complex, which is a state-of-the-art research center with extensive space for laboratories, data management, and data storage, as well as clinical facilities, training facilities, and offices for scientists. Funding for the building was received from the Doris Duke Charitable Foundation, the Bill & Melinda Gates Foundation, the Gates Institute for Population and Reproductive Health at Johns Hopkins University, and through University loans. A contract through NIH/NIAID International Center for Excellence in Research is equipping the laboratory. The laboratory is an air-conditioned, 3,600-square-foot, state-of–the-art facility. It includes rooms designated for lab accession, clinical microbiology, tissue culture, serology, nucleic acid amplification, and laboratory support. The clinical facility includes a patient waiting and reception area, an outpatient clinic, a pharmacy, an x-ray room, four examination rooms, two operating theaters, a sluice, an autoclave, and storage, as well as patient changing rooms and offices for surgical staff. The two theaters, designed for outpatient surgery, are mainly used for male circumcision at this time, but will provide facilities for colposcopy and other procedures. (all this descriptive information taken directly from http://www.jhsph.edu/rakai/about/where_we_work.html)%5D

Anyway……Jake and I walked down the hill on our first day—it is a nice walk through sleepy Kalisizo, much different than the walk to Mulago in Kampala. There is barely any traffic (human or machine), the surrounding matoke plantations are beautiful, and the air is easy to breathe……it is also the kind of place where little kids in brightly colored uniforms run after you in groups yelling “muzungu, muzungu”……

Upon arrival, we were given a tour of each department and orientation to each of the many research studies happening here (these include the Rakai Community Cohort Study; Male Circumcision for HIV Prevention; Randomized Trial of Male Circumcision, STD, HIV and Behavioral Effects in Men, Women and the Community; ARV Effects on HIV Epidemiology and Behaviors; Impact of Peer Educators and Mobile
Phones on HIV Care; and Assessing the Impact of a Community-Based Intervention Designed to Reduce Levels of Physical and Sexual Domestic Violence in Rakai District, Uganda). That is all that I want to say about each department and study for now—next week, we spend a day with each research study and I will write about them as I experience them….

After our introductions, we traveled to one of the local community clinics where the Rakai Project provides free ARV treatment. In comparison to the clinic in Kawaale, this was a quiet clinic with about 75 patients. The morning started with an education session, which happens before every clinic. The topic of discussion was prevention of maternal-child transmission—unfortunately, the education session was conducted in the local language and Jake and I just sat in front of the audience (after a big formal introduction) looking stupidly out across the faces trying not to stare or be stared at. There were flashes of the brilliant color of African fabric amidst the sounds of laughter, baby cries, silence, worry, impatience….I forgot how these experiences are both incredibly interesting and extraordinarily awkward at the same time. I had such a hard time not studying the faces of the patients in front of me as they listened intently to the health educator….the faces are old and young, all carved by experiences that I will never understand and never fully appreciate. We were then guided through the research paperwork that must completed during each patient encounter—pages of paperwork that condense the life histories of these patients into a series of boxes and codes. It is a meticulous, impressive, and I would argue somewhat dehumanizing process. We left as dark rainclouds began to gather, taking with us only passive observations of the surprisingly mundane nature of HIV care and research in action.

After lunch, we headed out in the field with the education/community organizing team for a community drama production focused on education around circumcision, voluntary HIV testing and counseling, ARV treatment, and getting involved in the Rakai Cohort study. Based on the groundbreaking results (from Rakai) showing the efficacy of circumcision on reducing HIV transmission, the Rakai Health Sciences Program now offers circumcision surgery and post-op care to all men in the region and the Program uses drama to educate communities on the health benefits of the procedure. When we arrived, there was a crowd of at least 100 villagers gathered under a tree in the center of the village. We were immediately greeted by the leader of the community and escorted to our seats on very small wooden benches in the very front of the crowd. Jake was seated next to a group of elders who all wanted to shake his hand—he looked totally bewildered (and it was really cute). The drumming started as children pushed their way to the front of the crowd and plopped themselves down timidly next to us. Everyone was, once again, staring at us (some with amusement, some with curiosity, and some with distrust). However, once the signing and dancing began, all eyes were fixated on the local group of actors. Although we could not understand a word of what was being said, the audience was captivated and engaged…apparently, the drama was hilarious. I wish I could have understood the messages that they were giving—especially about circumcision (I can imagine that it might be challenging to convince grown men to have a circumcision). I have always loved these moments in Uganda—the moments that are filled with energy and music and laughter, when people of all ages gather together for a collective human experience. Despite the fact that Ugandans are some of the most welcoming people I have ever encountered, these are also the moments that make me feel the most vulnerable and exposed—an outsider, an observer—disconnected and in disbelief of the reality around me. The drama lasted for hours and as the sun began to set, I must admit that I grew impatient and anxious to return home to my own reality—my own comfort zone where the people around me don’t stare and whisper and wonder and touch….In any case, it was an extraordinary way to begin this part of my last 2 weeks in Uganda.

Moving on to dinner, which was as surreal as the afternoon drama…..It was a dinner full of sexy science. The setting was the dining room at one of the Rakai Health Sciences Project guesthouses. The guests included a luminary in the field of HIV research—a lifetime NIH employee who has repeatedly revolutionized our understanding of HIV, a junior infectious disease physician-researcher, a public health worker, a young Canadian PhD candidate, and Jake and I. The meal was traditional Uganda with a splash of red South African wine, a homemade tossed green salad (rare in Uganda) and dark almond chocolate. The conversation covered the scientific history of the discovery of HIV in Africa (firsthand account), followed by a debate surrounding the anatomy of the foreskin, the sharing of gorilla hike adventures, and the viewing of You Tube videos showing a new laboratory sequencing technique. The contrast between the afternoon and the evening was extraordinary and I found the juxtaposition between the grassroots community HIV prevention work and dangerous, exciting HIV laboratory science fascinating….both types of work are absolutely essential pieces in the history and future of HIV in Africa. Reflecting back on my experience with the clinic and the seemingly mundane nature of HIV research and clinical care in action, I realized that it was not mundane at all… all of these activities are, of course, part of a continuum of care and each part is equally important. The real question that I keep asking myself is where do I fit in this continuum or rather where do I want to fit in this continuum? I am not a lab scientist and have no desire to do lab science (although I immensely respect it). I am not a pure clinician and have no desire to limit myself just to clinical practice. At this point in life, I think I know who I am not—but I don’t yet know who I am…

This extraordinary first day was also the day that our rank order list was due for residency. I barely even remembered. On another personal note, I am sick. I have been for the past 5 days. And as I sign off for tonight (with a promise to write about our weekend trekking gorillas and stalking lions in queen Elizabeth national park), I am very much wishing I was home, curled up in bed, looking out over central park….