Friday, August 8, 2008

AMCAS Research essay

Five days before Christmas 2007, I woke up wishing for a stellar final day of my semester abroad in Dublin, Ireland, but I was not expecting the highlight to be waiting in my inbox. When I logged into my email account, I found that I had been selected for an internship with Global Service Corps sponsored by the Helen Kellogg Institute for International Studies at the University of Notre Dame. I sprang out of bed and danced across the hall to my neighbor's room, blissfully singing "I am going to Tanzania!"

From May 29 to August 1 of 2008, I lived in Arusha, Tanzania, interning with the international nonprofit volunteer organization Global Service Corps (GSC). For nine weeks, I worked in GSC's HIV/AIDS education and prevention programs as a teacher for secondary school students and community groups of older Tanzanians. I was especially attracted to this internship due to its relevance to both of my undergraduate majors, biology and anthropology. After participating in immunology research and taking anthropology courses concerning African cultures and varied medical understandings, I was eager to meaningfully combine my dual fields of study by volunteering in HIV/AIDS programming in Tanzania.

Upon notification of my internship, I immediately realized that my time in Arusha was a prime opportunity to undertake research in medical anthropology. As an undergraduate student, I had been attempting to orchestrate research that would synthesize my interests in anthropology and medicine into a single senior thesis project. By volunteering in an HIV/AIDS education program abroad, I would be in the midst of a critical field within medical anthropology, allowing me to not only witness but participate in the response to the HIV epidemic in Tanzania.

While none of the current anthropology faculty members at Notre Dame has HIV/AIDS as his or her particular focus, I took my idea to Professor Daniel Lende, an assistant professor in the Department of Anthropology. Professor Lende's research in medical anthropology focuses on behavioral health, particularly compulsive and addictive behaviors. While his research does not address my specific area of interest, I knew from a previous conversation that his experience and knowledge in medical anthropology are extensive and he is exceptionally familiar with current anthropological discussions of HIV/AIDS in sub-Saharan Africa. I also presented my research proposal to the Glynn Family Honors Program at Notre Dame. While the Kellogg Institute funded my trip to Tanzania and internship with GSC, the Glynn Family Honors Program provided an undergraduate research grant to finance my independent project.

Under Professor Lende's guidance, I began my examination of sub-Saharan HIV/AIDS literature in the spring of 2008. While it is well-known that the global HIV/AIDS epidemic has struck sub-Saharan Africa the hardest (over two-thirds of all HIV-positive people reside in this area and it was the site of more than three-quarters of all AIDS-related deaths in 2007), it is less understood that a significant majority of those living with HIV in this region are women. Throughout sub-Saharan Africa, 61% of infected individuals are women. In Tanzania, an apparent disparity also exists between young men and young women's understanding of HIV/AIDS and engagement in prevention behaviors. A recent study showed that significantly more young males than females could correctly identify and had engaged in HIV prevention methods.

In the past, many studies have examined the personal risk behaviors associated with HIV infection, but the cultural and socioeconomic contexts of the virus have been increasingly cited as crucial factors in addressing prevention. Many investigators have correlated high HIV prevalence in females of sub-Saharan Africa to gender-based inequality and violence. A joint study by UNAIDS and UNFPA cites three key factors as contributing to the escalating HIV epidemic in sub-Saharan African women: a culture of silence surrounding sexuality, the prevalence of exploitative transactional relationships and intergenerational sex, and violence against women within relationships. Young women are especially vulnerable to the impacts of gender socialization on HIV prevention, as gendered power imbalances tend to limit their autonomous control over sexual health.

While youth HIV/AIDS education has been a focal point of many prevention programs throughout sub-Saharan Africa, a range of factors (such as low levels of perceived threat of infection, social norms concerning sexuality and condom use, gender inequalities, and economic constraints) challenge the effectiveness of such programming. Another key problem at every level of HIV prevention is a tendency among all people to conceptualize HIV/AIDS as someone else's problem. Although community education is typically held as a pillar of HIV prevention, researchers have pointed to the need to examine the disconnect between rhetoric and the realities of attempting to change behaviors within particular social contexts. Also, the impacts of sociocultural gender inequalities on HIV prevalence in young women and men require much further characterization. Therefore, I decided to direct my research in Arusha, Tanzania toward answering the following inquiry: how do young women's understandings of gender roles and sexuality influence their engagement in HIV/AIDS education and prevention?

Based on my review of recent literature and considering Tanzania's typical socioeconomic structures and cultural norms, I hypothesized that gender inequalities may hinder young women's active participation in community HIV/AIDS education programs and young women may lack the perception or reality of sexual autonomy needed to effectively implement HIV prevention methods. Additionally, I hypothesized that young women in Tanzania may not have a sense of ownership of the HIV/AIDS epidemic, making them further unlikely to engage in HIV prevention.

In order to examine the influence of female conceptions of sexuality on HIV/AIDS education and prevention in Tanzania, I utilized qualitative methods in a dynamic observational multimethod assessment process, including participant observation, interviews, and archive collection. Qualitative methods were particularly useful in my study as this was my first trip to Tanzania, and the active nature of this paradigm allowed me to tweak the project as my research progressed.

During my first three weeks in Tanzania, I taught at a day camp for secondary school students in Arusha. In this time, I focused on participant observation, in particular examining power dynamics and participation differentials between males and females, as well as students' feelings surrounding gender roles and sexuality. I recorded my observations in structured observational checklists and unstructured field notes. I also began my archive collection, seeking out and gathering materials concerning HIV education and prevention in the Arusha area.

Once day camp was completed, I began facilitating GSC's HIV trainings for community groups throughout Arusha. I continued participant observation and also began conducting key informant and semi-structured interviews. Key informants included GSC staff and other youth educators in Arusha, selected for their principle roles in HIV/AIDS education and prevention in the community. Fellow GSC volunteers and, most importantly, young Tanzanian females and males (between 18 and 30 years old) participated in semi-structured interviews.

As my field research advanced, new themes emerged as crucial to the treatment of HIV in Arusha. Specifically, current changes in gender roles and potential shifts in ideas about female sexuality were repeatedly mentioned by Tanzanians in both day camp and community trainings. Interviews highlighted an apparent problem that had not emerged regularly in current literature: a lack of familial ownership of the HIV epidemic. With the family as a key social unit in Tanzania, and youth education crucial to decreasing infection rates, the majority of Tanzanian parents' unwillingness or inability to discuss relationships, sexuality, and HIV with their children leads to a large gap in HIV prevention. I added my observations to interview scripts and observational checklists, making sure to follow the data and include topics that Tanzanians themselves emphasized as important.

Now, upon my recent homecoming to the United States, I am beginning to code field notes, transcribe and code interviews, and organize and code my archive collection. Additionally, I am returning to the literature to further explore shifts in gender roles and conceptions of female sexuality, as well as family dynamics in Tanzania and impacts for HIV/AIDS education. This process will continue into the fall semester of 2008, when I will finish my senior thesis on this research. After its completion, I will present my research at several meetings and will submit my paper for publication to an appropriate anthropological journal. My research should have practical implications for improving HIV/AIDS education in Tanzania, potentially playing a part in alleviating the current crisis. In the future, as a physician and social scientist, I will be able to conduct research in medical anthropology while practicing medicine, enhancing both the immediate and long-term health of communities. My interest in the integration of biomedicine into other traditional conceptions of health plays an important role in the study of sub-Saharan Africa's HIV epidemic, as real change will not be affected until education and prevention programs adequately consider unique cultural contexts.

Re-entry, real life

I spent my final few days in Arusha scrambling to buy gifts, finishing interviews, spending time with friends, and figuring out how to get to the airport. The last one turned out to be a bust, as I lined up a shuttle that I was going to ride there, only to check back early Thursday morning to find out it had been canceled. I ran around Arusha for an hour or two looking for another shuttle, but apparently there were no others that day that would get me to the airport in time to make my flight (at least none that I could find). I eventually admitted defeat and decided that spending $40 on a taxi for the hour-long ride to the airport was probably worth it to ensure that I actually did make it onto the airplane home. It actually turned out nicely, because my mama knew a taxi driver who let my dada Rachel and cousin Erick make the trip to the airport with me, so we got to say goodbye at the very end. Saying goodbye was awful...Rachel and Erick were both crying, and I was tearing up. I felt guilty too, because while I was very sad to be leaving I also had things and people to look forward to in the states, so I definitely had some positive emotions mixed in with my sadness. But for them, it was just me leaving - nothing particularly good about it. When I got here, there was already an email from Erick making sure that I got home safely. I will miss all of them very much, and hopefully will get to see them again in the future.

The trip home was long: Kilimanjaro to Nairobi, Nairobi to London, London to Detroit = 27 hours total. Plane rides do not really bother me though, and I was especially content because both long flights had personal TVs for each passenger and an array of movies to watch. I arrived in Detroit on Friday afternoon to discover my luggage was missing, which did not surprise me too much. My dad and sister Sarah were waiting for me, and even though I was kind of self-conscious about looking like some dirty wild jungle-woman, I was happy to be home.

Being back in the U.S. is still strange...it has not been especially hard for me to pick back up with my normal way of life, but it makes Tanzania seem surreal, like an elaborate dream. I am having some food issues - not stomach problems, but taste bud problems. It is super weird, they are all ragged and you can tell by looking at them that something is seriously wrong. I think the fact that I ate mostly tasteless ugali, rice, etc. for two months made them hyper-sensitive to more flavorful foods? And I have been eating a lot of textured and seasoned foods that I could not get in Tanzania...now it hurts to eat a lot of things so I am regressing back to bread, cheese, and apples for a few days, hopefully they heal soon.

Meanwhile, I finally submitted my AMCAS application for medical school yesterday! Overall, I am pleased with it and I think it represents my collegiate career well. Now I am studying for the MCAT again, which I am re-taking on August 22 (two days before returning to Notre Dame for my senior year). My first batch of MCAT scores were not awful, but I feel that I can do a lot better so I decided to take the test again. The only downside is that I now do not have much time to spend outside, so my current extremely pale state is probably not going to significantly change. People find it hilarious that I came back from Africa paler than I left. Explaining that it was winter in Tanzania does not seem to help much; after all, it was AFRICA.

As part of my AMCAS application, I had to submit an essay describing my significant research experience for MD/PhD (in anthropology) programs that I am applying to. I am going to post that essay in this blog (see above post) in case anyone who read this over the summer is interested in the specifics of my medical anthropology research that I conducted in Tanzania. Otherwise, feel free to skip it :)

Back-entry...Maasai village!

This post is a little late, but visiting my friend Isaya's village was an amazing experience that I want to share.

The last weekend before I left Tanzania, I went with some of the other volunteers to Isaya’s Maasai village (Isaya works for GSC, see previous post for more info). After a Friday night of fun with our whole volunteer group and an interesting breakfast at a local restaurant where we were gratuitously overcharged, refused to pay extra and walked out, and then returned and forked over the extra cash because some of us lived in the neighborhood and did not want to be mugged, we were finally ready to meet Isaya on Saturday morning to make the trek out to the village. This began with a packed hour long dala ride to the nearest town where we stopped and got some food – I had chai and a donut for 50 cents. Over lunch, Isaya taught us some basics of Maa, the Maasai language which is still spoken in Tanzania today. The Maasai are one of the tribes that still use their own tongue instead of Kiswhili, which many Maasai people do not speak at all. After he was satisfied with our attempts at Maa, Isaya then led us to a pick-up truck, the bed of which was already full of Maasai of various ages. In Tanzania there is always room for more when it comes to vehicles, so nine more of us piled into the truck. Isaya sat on the roof while we braved the crowded bed. Claustrophobia ended up being the least of our worries, as the lack of personal space and bumpy road provided perfect excuses for some molestation by the men on board…luckily I was surrounded by our group, but those on the fringe had an interesting experience. Forty-five minutes up the steep dirt road, we came to a large village…where we were surprised to see two small children of obvious mixed ethnicity. Their light skin confused us until we were approached by a white British woman, who apparently was married to one of the Maasai men in the village and was currently teaching a group of American students studying there. We did not press her for details, but I suppose she was an anthropologist? At any rate, very cool.

Our journey continued for 20 more minutes up the hill, where thorny trees suddenly began encroaching on the road and we had to regularly duck to avoid be pricked. Finally, we arrived at Isaya’s boma (cluster of huts) and were greeted by his mother and younger siblings. He led us into the hut where we would stay that night, and began to give us a lesson on Maasai culture. I was familiar with the majority of it from my anthropology coursework, but it was fascinating to hear it from a Maasai warrior himself. During the course of the discussion, as he is talking about traditions and the importance of preserving culture…his cell phone goes off and he answers it and talks for 10 minutes! Nice, haha.

Later, we went outside and Isaya and his fellow warriors danced for us. Usually they dance at night, but since there is awesome jumping involved that cannot be fully appreciated in the dark, they decided to give us a preview while the sun was still up. And it was STELLAR! If you are not familiar with the type of dancing done by Maasai warriors, watch the youtube video at the end of this post to get a general idea. But to see it in person was so great, and some of them were jumping significantly higher than the warriors in the youtube video. Also, the singing/chanting that they do is so cool! Everyone has different parts and they glide seamlessly from one type of song to another, with specific people playing different roles in each one.

Then we got a surprise when Isaya told us that we had to try it out, so we each took a turn jumping with them, which clearly was quite hilarious. Some of the warriors were having trouble continuing their singing because they were laughing too hard! I already knew (from past experience taking jumping photos) that the key to maximizing your apparent height is to pick up your knees, so I looked like I was getting higher than the other volunteers. The warriors were doing the same thing though, so I was not really cheating, haha. Before going inside to dinner, I spent about 20 minutes talking with Isaya’s little brother, who I affectionately dubbed “Kaka” (brother in Kiswahili) since his Maa name was a bit too intimidating for me. He had some knowledge of English and Kiswahili, so we worked through a conversation which highlighted our running experiences (he also ran the London marathon with Isaya…and at first did not believe me when I told him that I had ran a marathon as well). The second jumping photo above features Kaka :)

Dinner that evening was beans with maize and some sort of porridge, which was actually surprisingly decent. Following dinner and socializing in the hut (with everyone – 8 warriors, 4 children, 3 mamas, and 8 volunteers – inside the tiny structure), we headed back outside where we started dancing again around the fire. The mamas taught us how Maasai girls dance, so at that point some of us started imitating them. My favorite part of the dancing was when the warrior who had just jumped would come up to one of us and offer his shoulder, which you would then turn and hit with yours. I am not sure exactly what it means, but for us it was a fun way to connect on some level with those warriors who did not speak any Kiswahili (or English, obviously).

Before bed, the warriors came into our hut again and did more singing, chanting, and some storytelling until around midnight. At that point, six of us volunteers crammed into one bed – granted, the bed was relatively large, but definitely NOT big enough for six people. We all had to sleep on our sides, and every few hours someone would announce that it was time to roll over so that one hip did not get too sore. Suffice it to say that none of us got much sleep that night, and we were up pretty early. That morning, the Maasai warriors slaughtered a goat for us to thank us for coming (we each donated $40 to their well project), so we had fresh goat for breakfast! And I really do mean fresh…

As a vegetarian, I had already warned Isaya that I would not be partaking in the goat. His first response was “Well, you can drink the blood though because that is not meat.” Haha, nope, sorry Isaya. After seeing the humane way in which they suffocated the goat, realizing that it had lived a full natural life, and noting the fact that the Maasai were going to use every single part of the goat (literally), I was very comfortable with the whole process. When the warriors started scooping out and drinking the still-warm blood from its carcass and then offered some to us, I made a game-time decision to go for it. After all, how many opportunities I am going to have to share blood with Maasai? It was pretty gross because there were organ chunks mixed in with my scoop of blood, but I managed to choke it down without gagging. Then Isaya offered us some of the raw liver, which after drinking blood was not that big of a deal – it just tasted kind of slimy. Finally, we had the meat roasted over an open fire, which was not bad.

[After this, I decided that I am going to be a full-fledged vegetarian (i.e. also give up chicken and fish) now. Seeing the sustainability of their meat usage, the respect and gratitude that they showed to the goat, and the humane way in which they slaughtered the goat, I really do not want to contribute to American meat consumption anymore. Also, I know I am over-romanticizing the experience, but it is pretty neat that the last meat I will eat is a goat I shared with Maasai warriors. My parents now think I am crazy for drinking blood but refusing to eat chicken legs.]

Unfortunately, Kaka decided it would be a good idea to share the goat’s intestines with me, which I graciously accepted. After I swallowed a large chunk, he informed me that they were “medicine”. What kind of medicine? Medicine for your stomach, to clean it out. Maybe it was just the fact that I ate meat for the first time in awhile, but maybe Kaka was right, as I definitely had some “stomach cleaning” going on for the rest of the day. It was pretty miserable actually…thank you, Kaka.

Meanwhile, we needed to return to Arusha relatively early because some of the girls had to make long journeys home to the hospitals that they were working at and wanted to get back before dark. So Isaya recruited Kaka to walk us back to the first village that we had encountered on our way up the hill, so that we could take the pick-up truck back down to the town from there. After a 45 minute walk, we arrived at the village…and the truck was nowhere to be found. Kaka talked with some people, and discovered that it was not coming. After an hour of scrambling and different arrangements being promised and then falling through, we eventually decided to just go down the mountain on foot. Long story short, after two hours of walking and talking with Kaka (and many bathroom stops for me in the bush), we made it down to the town and hopped on the dala dala back to Arusha. I held a little mtoto on my lap for the entirety of the ride, and I tried to stop her with limited success from playing with the fresh goat-skin bracelet that the Maasai warriors had made for me. While the pungent goat and smoke smell has finally been eradicated from my coat now that I am home, the time I spent in the Maasai village is definitely something I will remember for my entire life.