American Samoa is actually made up of five islands; the largest, Tutuila, contains the majority of the population as well as the capital, Pago Pago, and the hospitals and clinics where I work. Aunu’u is Tutuila’s next-door neighbor. A few weeks ago my co-worker, her family, and I decided to take the trip over to Aunu’u to see what the rest of American Samoa has to offer.
Turns out, not much. There is clearly a reason why most people live on Tutuila. We drove to the wharf on the other side of Tutuila and I saw that it wasn’t so much of a boat ride over as it was some sort of motorized raft ride. We all climbed onto the boat and zoomed across the fifteen-minute stretch of Pacific Ocean between Tutuila and Aunu’u.
When we got there the first thing we had to do was announce our arrival at the island government building, which I’m pretty sure was just somebody’s house. The man we talked to offered to show us around the island, so we jumped in the back of his pick up truck and took a ten-minute drive around Aunu’u. During this entire time everyone was talking solely in Samoan, so I didn’t realize we were taking a tour until well into our drive. I clearly have not picked up any Samoan during my time here.
If someone thought Tutuila was unpopulated and rural, they clearly have not seen Aunu’u. It didn’t take long to see the entire island- most of it is farmland and very few people live there; however, the landscape of Aunu’u is slightly different from Tutuila. Apparently there are species of sea life found only around the island, and often residents of Tutuila go to Aunu’u for its beaches. We also found a lot of quicksand, which I hadn’t seen anywhere on Tutuila.
Our entire trip took about four hours, a lot of which was spent driving to and from the Tutuila wharf. I’m told the other islands of American Samoa are similarly unpopulated; however, they are a bit too far for me to check this for myself. Manu’a, possibly the next most populated island after Tutuila, is about an eight hour boat ride away- farther away than the country of Independent Samoa. While I may never go to Manu’a, the island is a source of pride for many American Samoans, since, as legend has it, this is where the first people of the world came from. Samoans who are from or who have family from Manu’a are quick to point out their direct ties with the island. Many Samoans also seem to have family in Independent Samoa, a former territory of New Zealand. Independent Samoa doesn’t seem to receive the same love as Manu’a; in fact, many people I’ve met are quite antagonistic to the country. In several weeks when I get the chance to visit Independent Samoa we’ll see if the feelings are mutual.
“Kimberly…Kimberly…Kimberly!”…. It felt like I heard my name a million times; the patients were all calling me over wondering when would it would be their turn. I cringed as I informed some patients that they would have to wait up to 2 hours to get survey and/or interviewed. To my surprise they all said they would be willing to wait.
Today was a very hectic day in the clinic. Natalia, Dan and Sarah were each personally administering the survey to a patient. Many patients need one-on-one help due to reading and/or computer illiteracy. I was left all alone to recruit additional participants in the waiting room. I had about 5 lined up survey participants and about 6 pending interviews. Since each survey and interview can last up to an hour, some of our patients had to wait up to 4 hours for their turn. This is actually an improvement because during our piloting stage, surveys lasted about 2 hours and were very burdensome on the patients. We had to go back to the drawing board and delete about half our survey to ensure patient comfort and ease of completion.
Although the survey is shorter, our waiting times are sometimes pretty long. Today, we had one patient who decided to wait 4 hours for an interview because she had not eaten in over a day. All our patients are being compensated for their time with a supermarket gift card with 200 Cordobas (about 8 dollars). They can get up to two gift cards if they participate in both the survey and interview. This day was also difficult because one patient was also concerned about being seen by another patient who knew her. Luckily everything worked out for the best with our help and the assistance of the clinic’s psychologist. My experience with the qualitative interviews has so far been wonderful. It is amazing to listen to my patients’ stories of fear and pain because they always manage to find the hope and motivation to live their life to the fullest. My patients are the epitome of the strength and resilience that can emerge from even the most unfortunate circumstances. A prevalent theme I have noticed in the interviews is the presence of HIV stigma due to the general ignorance of methods of HIV transmission. I experienced this firsthand when I visited the local photocopy place. The middle-aged clerk asked what brought me to Nicaragua and I explained I was involved in a research project with HIV patients in the hospital. The clerk responded, “pero ellos no tienen a esa gente regadas con todas las otras personas?” (but they don’t have those people spilled among everyone else)? I simply responded, “why would they need to be contained, they are sick patients just like any other sick patient in the hospital”. He seemed very confused, so I proceeded to tell him that HIV could not be spread through a hug, kiss, a handshake, or through the air. I informed him that he could get HIV from unprotected sex or by sharing needles because HIV is found in blood, semen, and vaginal fluid. He seemed intrigued and thanked me for the information. Two weeks ago I had another teaching moment with the same clerk. Sarah and I were photocopying our materials for our “Drugs and Alcohol” workshop and he expressed confusion at our picture of a black lung. We informed him that lungs become black after smoking and he was so surprised. These experiences show that any moment can be a teaching moment in which we could possibly make a difference. In this situation we can only hope that this clerk takes this information and shares it with others. We can only battle stigma and misinformation one person at a time.
This cliché is used to describe everything from the taste of food to that feeling when you finally get to pee after holding it for two hours.
The phrase has never been more applicable than to Tuvalu though.
When I first arrived, high off the prospect of my upcoming six week adventure, Tuvalu was paradise. Snorkeling and exploring the novelty of everything in front of me only intensified my excitement.
But the truth quickly set in. Tuvalu has no reliable internet (and the poor internet that is available costs around $40-$60 per week), no immediately drinkable water, showers are frigid, the days are scorching, most items are vastly more expensive than elsewhere, almost all the food tastes bad, and there is very little access to fresh vegetables.
I’m not going to lie, there was one week, which just happened to be the week I had Dengue, that I was counting the seconds until I could leave this god-forsaken island. All I could see were the negative attributes of this country. Learning that there is no Tuvaluan translation for the word “flavor” didn’t help my feelings about the food. I was also angry about being all alone with basically nobody to talk to. I, for the first time in my life became homesick. I didn’t like that I always felt the need to be on the (very poor) internet, but it was truly my only form of social interaction. I admire the Tuvaluan’s lack of cellphone and internet dependence that has come to define the very nature of our generation in the states. But everyone here has family and friends with whom they can talk and play for hours. I have nobody. Even on the occasions that I engaged with locals, I still clearly remained the outsider.
But even more frustrating than the actual negative attributes of the country was the fact that these detriments disturbed me so. I’ve always considered myself to be a very independent and adaptable person, especially when it comes to travel. My inability to fit into this country was the most frustrating of all. I was actually afraid to put up blog posts for fear of only complaining about the conditions here.
But it was actually one Skype conversation with my girlfriend Nina that changed everything. She reminded me that I should still take the time to enjoy the place and to take lots of pictures. It then occurred to me that I had not used my camera in two weeks.
I had vastly underestimated how important photography is in my life. One beautiful sunset and portrait at a time, I once again found the positive side of Tuvalu: the little things.
I used my creative outlet to capture the beautiful faces of Tuvaluan children in the golden setting sunlight. My resentment dissolved as I marveled again at the daily painted skies of dusk, casting orange and pink glows through a deep blue backdrop. I smiled at the simple act of riding my motor bike the short distance between my home and the hospital, waving at locals and being inspired by the adjacent views of the glowing teal water of the lagoon. I began to wear my Tuvaluan name, Palagi (which means white person, pronounced ‘palangi’), with pride. I cherished the moments when rainstorms unleashed their fury for mere minutes only to be followed again by the glowing sun. I gazed nightly at the glory of our universe in the vast starlight above.
Steadily, the relative importance of the negatives in my experience began to dissipate. The little things overcame it all. The hot weather made me even more appreciative of shade and the rare air conditioning. I began to actually enjoy the cold showers for how much they refreshed me after a day of sweating. The lack of vegetables was still a burden but let’s be real, everyone needs a little bit more ice cream now and then. I have even now started feeling a sense of belonging in the community.
Yesterday was the most stressful day of my life but by some miracle, we finished 40 interviews in one day thus completing an anxious but fun two week interview blitz.
As my time in Tuvalu winds to a close, I am happy to say that my reflection on my experience is positive. Although Tuvalu may have several negative attributes, the beauty of the people, the nature, and the culture of this country more than make up for the flaws.
My mood towards my departure can best be described as a really spicy burrito. When you finish it, you’re ready to quench the fire in your mouth with a cool horchata and return to normal. But a little part of you still wishes you had more delicious burrito to eat. I am excited to be reunited with my community and enjoy some real food again (namely California Burritos). However, Tuvalu is filled with so many more little things that I will never have the opportunity to enjoy and to photograph. I wish I had one or two more weeks to spend here without any work so that I could continue exploring the enormous beauty of this place. But I really do want a burrito.
Since college, I’ve felt like I have no geographic identity. In the US, I constantly feel like I am too ‘West Coast’ for the East and too ‘East Coast’ for the West. But I also sometimes feel I would be better suited with my Jewish roots in Israel or my adopted ethnicity somewhere in South America. Some days, I reflect on this multi-faceted sense of self negatively: a man without a home. But most of the time, I cherish this global citizenship. I am perpetually eager to find the next place to call home.
Although I likely will never have the opportunity to return, I know that for the rest of my life, a little part of me is now Tuvaluan as well.
“Woah, slow your roll, bro. Aref…I thought you were in Botswana.”
This may be what you are currently thinking and you would be correct. Except, I spent the past week (I am a week behind) in Uganda.
“Woah, but you don’t have money. How did you get all the way to Uganda?”
Correct again! But, I am working for an awesome company that flew me there and put me up in a five star hotel. But I will get to that soon enough. While I was in Uganda I got to explore some of “Real Africa”. The country is completely different than Botswana. I would almost say that Botswana is closer to the United States than it is to Uganda. The people are louder and more vibrant, their homes are made of tin sheeting, and the number of people on the streets is shocking considering the quiet life I have had in Gabs. My opportunity to explore Kampala was all thanks to everybody’s favorite court case: Roh v. Wade. Michelle Roh that is!
We met in the capital and began a makeshift tour, directed by Abullah the taxi driver. Oh, we saw the sights! Uganda is a largely Christian country and therefore has many religious sites that are quite interesting. Turns out that the first Christians to enter Uganda were, quite violently, burned to death. Nowadays they run the show, so that’s a change of heart. We also got to visit the only Baha’i temple in Africa. I have now seen two of the eight temples as I live next to the one in North America—how serendipitous!
We also visited the huts where the royal family of Uganda have lived for the past century or two. It turns out that the original huts were blessed with the blood of several men. They soaked the cords in blood which is why they are black in color. I asked if they were volunteers; the guide said they were likely not. Rough.
That night I went to bed soundly only to be woken up by the thrilling pains of death. Turns out I got food poisoning somewhere between Gabs and Kampala. I laid in bed for around 30 hours, but made a full recovery. Michelle was an absolute dear. Later that week I met up with THE power couple of YSPH. They somehow managed to both get their summer internships in Kampala. Bert and Sarah came over to celebrate the 4th of July, have a shot of Jack Daniels (The most American thing we could find), and watch Germany triumph over France. No fireworks, but still a great celebration!
So, what was I doing in Uganda? Well, my company has a grant to increase capacity in 5 African countries in the area of HIV health economics. The idea is to teach private companies, economists, the MOH, and international agencies (WHO, UNAIDS) in these countries about basic economic research principles, how to use economic tools, how to write a research proposal, and inform them of gaps in knowledge that could be addressed. I got to meet with the head of UNAIDS for Uganda, professors at Makerere University, members of the MOH, and other key players.
The program was highly instructive for me as well as the participants. I learned about economic analyses, costing, cost efficiency, and the Spectrum suite of models which was developed by my company and is used by the UNAIDS and MOHs all over the world. By the end of the program, the contingency of HIV economists had come up with two proposals that would be developed further for $50,000 total. I was there to listen, observe, learn, and in the end provide a final report of everything that occurred.
But, the hotel! Oh, my. I don’t think I will ever stay at a hotel as nice. It overlooked Lake Victoria, had an Olympic sized swimming pool, and had quite the fountain collection. I also stuffed my face every day. But alas, back to baloney and cheese sandwiches…
I took a picture of this officer holding an AK-47, because it struck me as interesting. Guns are illegal in Botswana, but prolific in Uganda. He proceeded to tell me that I could be arrested for taking pictures without permission. I could handle Ugandan prison.
Last night I decided to return back to my favorite photo spots to take advantage of the full moon for some long exposure shots in Tuvalu. The results surprised even me. Even though many of these photos are bright as day, all of them were taken between midnight and 2am using a 30 second exposure for each. Enjoy!
Walking through the street right at sunset three weeks ago, I spotted an elderly man sitting shirtless in a plastic chair; in his hand was a small fan made from woven straw. The many frayed edges were covered in a brown-grey layer of dirt from the years of use during sweltering Tuvalu days.
When I looked over at him and said hello, his face warmed. Through the parted lips of a huge smile, I could see only 10 teeth randomly dispersed in his mouth. The man’s name was Telaso.
He asked me where I was from. When I said the United States he promptly replied, “I like the US. The US saved us from the Japs.” I made a safe assumption he wasn’t talking about Jewish American Princesses and I ignored the derogative terminology.
Only nine years old at the start of World War 2, Telaso remembers the day that the Japanese bombed the church in Funafuti. I would expect him to remember an event that happened across the street from his home. He told me his house was very small back then and that the explosion damaged much of it.
We continued on to talk about more current issues such as global warming, a pretty ‘hot’ topic in Tuvalu, but his missing toothed smile never wavered.
It is really impossible to fully characterize a people. In one word though, I can describe the people of Tuvalu as ‘open’. Much like my interaction with Telaso, when you walk on the street, everyone says hello to you or at least gives a smile and a sup-nod. The only exception to this rule is the angsty teens who think they’re too cool for Tuv.
Tuvaluans meet. They spend time with each other. The lack of cell phones and internet means that people resort to the original social networking tool: food. And they will talk for hours on end. At the large public gatherings, such as at the Queen’s Birthday (that’s Queen Elizabeth 2 of the UK) celebrations a few weeks ago, families come together for the brunch and stay long past the final plate has been cleaned.
Tuvaluans are also open with other people. As a foreigner, I get a lot of looks. But nearly everyone with whom I have shared more than just a hello has opened their life to me and shared their stories.
The openness pervades creative life as well. Dancing is extremely popular and can be seen all around the island at various events. Just after my conversation with Telaso, he invited me to a dance competition for the 100th anniversary of the Funafuti church choir.
Admittedly, the dancing was a little repetitive. Nevertheless, it was fun. Gathered in the Funafuti community hall, bellies full of roasted chicken, lobster, and rice from the opening feast, four groups of dancers huddled close to one another. Each group was from a different island of Tuvalu. From right to left, the groups represented the islands of Vaitupu, Nui, Nukufetau, and Funafuti. After talking with one of the dancers, I found out that the members of the Funafuti group actually all live in New Zealand now. Their dancing reflected their new home. They had a certain flair for performance that the other groups lacked.
The performances consisted of high pitched singing accompanied by drum beats with a handful of dancers doing a hula type dance for around one minute. After each minute, all the members of the group would twirl and give out a Pocahontas call. Then the singing and dancing would repeat for 20 more cycles. Each group had a slightly different sound but the basic structure was the same. The groups rotated through their performances three times.
Some people, both men and women, dressed in palm leaf skirts. Others wore colorful flower dresses. Nearly everyone had handmade flower wreaths on their heads which filled the room with the sweet aroma of plumeria…or maybe it was the perfume.
Ah yes, the perfume. This was the strangest part of the ceremony. Throughout each group’s performance, women would go around with perfume bottles and spray the performers. On occasion they would come around and spray the audience members as well. I left the event smelling like potpourri. Originally I thought that the perfume was a way of showing that they liked the performance. But then it occurred to me that perhaps it serves a more practical purpose: all those sweaty people crammed into a hot room smell bad. I still cannot explain the one occasion that several women walked up to a very large male performer wearing only a skirt made of feather boas and stuck money onto his skin. I was under the impression that you only find such action in Las Vegas.
Although Tuvaluans might enjoy dancing, my experience is that they should steer clear of singing. Their complete lack of well-tuned pipes doesn’t stop them though from enjoying singing at school, in performances, and on the radio. The radio consistently features a playlist of four songs, all of which sound like small children in a chorus where everyone is singing a different song at a frequency fit for a dog whistle. I’m not sure if it is just the lack of other choices or if Tuvaluans genuinely enjoy this din but the radio always remains on in our office. Tuvaluans may be blessed with many skills, but singing is not one of them. I won’t lie though, it is pretty entertaining to be watching the World Cup while various Tuvaluans attempt Abba and Katy Perry on the karaoke machine behind you with the accent of a Polynesian and the melodic grace of Ethyl Merman.
Tuvaluans have a way of giving directions that is indicative of their society. When you ask where something is, usually you get a response that sounds vaguely like: “Go down the main road until you get to the place that used to be a bar two years ago then turn right. The house is behind the Chinese shop on the corner.” Another frequent response is my personal favorite: “Go down the street until you get to where Toluka Selavai’s granddaughter lives then turn left.” As if the Selavais and I have been tight for years. When you offer up a suggestion of another landmark close by, if you’re correct you’ll get the Tuvaluan version of a yes-nod, a repeated raise of both eyebrows for a few seconds. I’m a little concerned to say that I think I’ve adopted this creepy behavior. This harkens back to one of my favorite podcast episodes of all time titled “UTBAPH” from 99% Invisible. You’ll definitely understand the directions after you give it a listen.
The volcanoes and mountains were the first things that surprised me. As a city girl, a familiar landscape has always consisted of tall skyscrapers and tons of cars and people. The sight of unfamiliar fields, greenery, and mountains certainly forced me to realize I was no longer in New York—-this is Nicaragua! For the next 10 weeks, my team and I will conduct a summer research project in León, Nicaragua. Our project will explore the barriers and facilitators to antiretroviral medication adherence in HIV patients. Our host institution is The National Autonomous University of Nicaragua—León (UNAN-León). We will also teach health education workshops to 12-18 year olds in the nearby town of Goyena, with the help of the New Haven-Leon Sister City Project.
My team and I met through a student group at Yale called “Student Partnerships in Global Health” (SPGH). SPGH is dedicated to sending interdisciplinary teams of students to work alongside in-country partner organizations on global health projects around the world (http://spglobalhealth.org/). SPGH previously focused their work on HIV in Ecuador, but this year they have expanded to Nicaragua. My team of Yale undergrads (Natalia Forbath YC’15, Sarah McAlister YC’16, and Daniel Michelson YC ’17) and I are looking forward to an amazing summer of cultural enrichment, wonderful memories, and avid learning! Before we can embark on our research we must obtain project approval from the following sources: The HIV clinic director, The director for the Center for Demographic Research UNAN-León, The hospital director, and the IRB bioethical committee. We plan on exploring our surroundings and becoming acquainted with León while we wait for approval. Walking around León has been a wonderful experience for me. I already have quite some interesting stories:
–There was the time that I gave a homeless man 50 cordobas (2 dollars) and he kept saying hi to me every time he saw me throughout León. He seemed extremely excited and kept wishing me a good day.
–The one time the hamburger guys were calling me over and saying “hi” to me. I usually ignore anyone who talks to me on the streets. I quickly realized that in Nicaragua it’s best to say hello to everyone! The hamburger guys got upset and said, “Wow she has no manners, you should steal her purse”. At first I got angry, but then I realized they were maybe really offended because I wasn’t friendly. I went back and said hello and we ended up having a nice convo. Now, I have learned to put aside my New Yorker mentality, which tends to ignore strangers, and embrace the opportunity to make new friends!
–I met a sweet, middle-aged woman who sold me some beautiful souvenirs. I learned that she used to be a public health worker who did outreach for HIV and cancer patients. After many years, she was forced to stop her outreach work when she was diagnosed with cancer. She is currently unable to attend her follow-up appointment because the clinic is in another city and she doesn’t have the $750 to cover the visit. She also told me about her other friend who has not received chemotherapy in over three months because the public clinic in Managua has run out of treatment. She cried as she described the daily pain she and her friend are experiencing.
She also spoke about her disappointing experiences as a researcher. Years ago, a non-profit in Europe paid for her to take classes to develop a recycling program in Nicaragua. The mayor’s office had asked her to share the curriculum and program development materials. She shared the information with them and two months later the mayor’s office launched the program without her! She also mentioned how there is often corruption when it comes to publishing the true findings of program evaluations. Negative findings are usually ignored or the data is manipulated to diminish the severity of any pressing issues. In all, the lady told me had lost her faith in non-profits and public health initiatives. However, it was interesting that she asked to introduce us to the HIV outreach organization she worked for. Perhaps not all hope has been lost after all.
In the intense Nicaragua heat, in the midst of tears and hugs with this wonderful lady, I had a very cold, rude awakening. Hearing her story allowed me to put my experience in perspective. We cannot only focus on the beauty of this country. We have to critically assess which areas are potential sources for improvement. This experience will motivate me to continue to seek out more Nicaraguan friends. Their stories will allow us to understand our patients’ hopes and fears.
Written by KV
The Yale School of Public Health Class of 2015 Summer Internship Diaspora