6 months on

A mere six months have passed since I graduated from Princeton University as a molecular biology degree holder. I left so much behind me, including my wish to enter the world of laboratory research in the field of microbiology, biophysics and transient dreams of studying medicine. I returned to Namibia to do some job in public health and here I am writing this after the end of my job on the Namibia Health Facility Census. “If you had not been here, God only knows what would have happened to this census” said Jeanne, the data entry manager and programmer I trained under. I was her employee and also her student. “You have done an incredible job and I want you to know that” she has repeated in the last few days of finalizing the computerized data for the census. Apparently, I did work hard for this census, making sure the health facility data was entered correctly by data clerks which meant rectifying errors, clarifying ambiguities and making sense out of inconsistencies (when possible). Yet I still missed something that would have greatly enhanced the quality of the data collected. I did not realize we missed 9 of the 13 prison clinics in Namibia until the fieldwork was over.

The irony! Here I was really eager to do some public health project in the prisons, whether it be molecular epidemiological (HIV drug resistance) or more medical anthropological (qualitative study on HIV), but I did not immediately seek the questionnaires that evaluated services in our prisons. During September 2008, at the start of my senior year, I was gripped by this idea – the idea that doing a study in Namibian prisons would be something worthwhile. It was a specific aspect of transmission between men who have sex with men, a group that is often overlooked in Namibia. Why did I not look for those prisons earlier? In any case, there is a small chance the clinics within each of these prisons will be surveyed and they will be added to the data set. I hope this is the case.

In any case, however, I was challenged today about the worth of the whole exercise. Today, after a talk on HIV, AIDS and human rights, a local gynecologist said: “There are just too few prisoners compared to the total number of people infected with HIV in this country, they are just not epidemiologically significant”. I spoke to him when we snacking on the free food after the end of the talk and told him that I certainly disagreed To me, the problem is of significance since the inconsistent access to antiretrovirals in the prisons coupled with unprotected sex suits the emergence of HIV drug resistance. Perhaps I should have gone deeper and spoken about how antiretrovirals prevent HIV from reproducing in cells, but when the drugs disappears, mutants that can replicate and increase in number, which increases the chance of a drug resistant mutant arising. I figured that since he was a doctor, he already knew all this. Did I need to tell him the repeated infection with HIV leads to inter strain recombination, increased genetic diversity and thus greater chances of drug resistance? I guess not, but, he just seemed to shrug off the whole resistance thing as a non-issue.

The indifference of the doctor towards the plight of the prisoners coupled with the exclusion of most prisons from the Health Facility Census echoes what anthropologist Joao Biehl calls “apparent invisibility” of the most marginalized AIDS victims. Biehl wrote about how doctors in the Caridade Hospital in Salvador, Brazil felt “poor and marginalized patients were not considered worth treating”. Located in the epicenter of the AIDS epidemic of Brazil, the Cardidade Hospital could not accommodate the numerous patients, from the streets, that needed hospitalization and treatment for opportunistic infections (Will To Live, Biehl). I wonder whether a similar system of biomedical ethics operates in Namibia, whereby the men and women of the prisons are just not important to the government which must cater for the HIV treatment of hundreds of thousands of free men, women and children. Moreover, prevention programs assume people can choose to use a condom and be faithful to one partner, while inmates are often coerced into sex. A hopeless case, one where prisoners will never be able to protect themselves is probably what the government thinks when the thought of prisoner ever crosses their mind. But prisoners include juveniles, including those held a juvenile detention center in the north of Namibia that was not included in the health facility census.

To be taken seriously, any grant advocating for research to be done in the prisons will require me to do back it up with the primary literature. I need to assess to what extent the movement of people to and from prisons constitutes a bridge for HIV drug resistant strains. Luckily, there is a place underneath the central hospital, in the basement, where I can access a world of journals. It is called TICP and is run by an organization called “Management Sciences for Health” which is part of a whole slew of American know-how groups that help fight AIDS in Namibia. Which leads me to ask the question: How do I position myself as a future public health student who is a local Namibian, but who also graduated from an esteemed university in the United States? I believe I am in a good position, for I can empathize with the Namibians while at the same time claiming some sort of “American” expertise, way of thinking and doing. However, the danger is that Namibians, especially those in government, will see me as a one who merely seeks to advance a foreign, “imperialist”, American agenda, one that is counter all that is Namibian. I am counting on that not happening. So when I discuss issues of the prisons, I must bear in mind how I handle the issue men who have sex with men, which the government of Namibia just does not want to acknowledge.

For the coming year, I excited about the masters in public health program and the possibilities of thesis research, including a topic related to prisons, is alluring.