Noel

It’s not as if I grew up with white Christmases, but this year, I discovered that without a need for at least a light sweater, it doesn’t feel like Christmas at all. Ultimately, I think this was good for me because I wasn’t too homesick. Decorations around the convent helped too – if you will notice, featured below is a blow-up morning star hanging next to Santa. I’m not sure where the nuns got their hands on blow up medieval weapons, but it certainly added something to the birth of Christ.



On Christmas Eve, I went to Midnight Mass (held at 8 pm), and afterwards, we all reconvened in the refectory for midnight snacks and girltalk. Below is a group picture from that evening.

And what exactly ARE your goals for the future?

I have gotten this question a couple of times since I have started work, and apparently I need to come up with some stock answer, because people seem to be dissatisfied with mine. Of course, "I don't know" is not a very professional answer, but as someone who went straight from college to grad school and is only now working at her first, real full-time job, I think it's completely normal that I don't know exactly what I want to do for the rest of my life. (Okay, I don't actually say I don't know, but I do qualify and prevaricate more than I should).

I have general goals, obviously. I want a career that creates and upholds social justice; I want a career that lets me change venues and programs and grow as a person and as a professional; I want a career that is intellectually and ethically challenging; I want to not want to retire; I want to live abroad; I want to eventually be the boss; I want to be involved in new research; I want to help translate research to practice and vice versa; I want to be an expert in something.

But specifically, who knows? For my fellowship, I am supposed to come up with a career statement that describes where I am in 5 years. Last year, let alone 5 years ago, I could not have predicted that this year, I'd be living in Kinshasa, so I'm not exactly sure what to say.

Part of it might come from the generational difference in work culture. People born in the 40s and 50s probably assumed that they would find a job with a company and stick with it for the long haul. The familiarity with the organizational structure gave you a limited number of options with which to set goals. If you worked for the government, you could start at a low GS number and work your way up to a high GS number. You could go from assembly line to management. You could go from teacher to principal. Doctor to hospital administrator.

International or global public health, like a lot of emerging or recently emerged fields, is so dynamic that I think it's foolish to try and give yourself the type of long-term career plan that your parents gave themselves.

• First, you can't depend on program or project longevity. Almost everything is dependent on funding that could disappear next year. Sometimes these changes in direction are guided by research findings, sometimes by the rise and fall of an issue's sex appeal, and sometimes by the arbitrary decisions of someone who has neither expertise nor data to make an informed decision about what programs need funding or not, but in the end, even though you might not want to switch jobs, but you might have to.
• Second, although I am no pension expert, it seems that unless you work for the government, most NGOs don't give great retirement or pension benefits to people who only stuck around for a handful of years. This is a big problem considering point 1 and also removes the incentive to remain loyal to a company for decades even if you don't like your job or your boss or where you live that much .
• Third, the scope of global or international public health. The various systems at work that shape the state of public health on the ground are so complex that it truly is ridiculous to try to predict them in the long-term.
• Fourth, in a field where one of the commitments is social justice, is it appropriate to base your long-term goals on your individual interests? This is a very personal question, but for me, when my boss says think about your personal interests and we'll find a project that suits them, I feel confused. What if my interests do not reflect current needs?
• Fifth, there are endless endpoints in public health. I could be Surgeon General or head of a program or director of a state agency or director of a nonprofit or a researcher or write policy for the WHO or work in the private sector or in a think tank or stay in the field or a million other things. If what I want is to be Ban ki Moon, then I certainly shouldn't give that goal up just because I haven't yet managed to be hired by the UN.

Thanksgiving at post

Thanksgiving kicked off what is to be my first holiday season overseas (at least that I can remember). And of course, all efforts have been made to celebrate as we would in America, complete with reminders to order turkeys in October to ensure delivery before Thanksgiving and almost no mention of Native Americans (hey, we had a flag and they didn't).

But luckily I have a very considerate boss, who even though neither he nor his wife are American, dragged me around with them to several Thanksgiving celebrations, so that I didn't get too homesick.

The first was at the ambassador's residence, and wow, our tax dollars are certainly being well spent on that establishment - the inside of the house has an incredible art collection while the back terrace looks out on the Congo River (the peaceful, not crowded or dirty part) to a part of the Republic of Congo that has no buildings so it's just a bank of green. I also finally realized that anyone is allowed to go over and use their pool (and tennis courts) so I think that will become a Saturday morning routine - I'm barely any tanner now than I was when I got here - mainly because the nuns would consider sunbathing a little too immodest, so it's time to remedy that so that I can live up to everyone's expectations.

Friday, I went to another (and quite frankly more delicious) Thanksgiving party where there were sweet potatoes with marshmallow topping. Apparently there was also orange added in the mix, and I highly recommend this to anyone who ever makes sweet potatoes in the future. The hosts apparently have a pet duiker (tiny antelope-ish thing), but it was dark and rainy so I didn't get to see it, or ride it, or put jingle bells on it - although if they want to become somewhat of a legend around here, they should definitely do that for Christmas.

The only weird part of the party is that I was one of the only people without children, definitely the youngest by quite a bit, and seemingly one of the few women with a job, so often my small talk was extremely lacking. I'm thinking about making it one of my personal development fellowship goals. Others' main attempt at small talk with me was, "how do you like it here so far?" I have discovered that this is a trick question.

Kinshasa is a "hardship post." Now, it certainly is an inconvenient and expensive place to live, but to me, the words "hardship post" evoke thoughts of Somalia and southern Sudan, where you cannot bring your family and you live with a packed bag in case of evacuation or potentially a place without electricity or running water and no servants to haul your water or start your fires for you.

The acceptable answer to this question ranges from a half-hearted smile, a little shrug, and a sentence like "agh, it's okaaay" but in a way that implies that it's really not okay but you're just being polite to "yeah this sucks and I can't wait to leave." The less acceptable answer is mine - "oh I like it fine" or "I've found a lot of things I like about living here." These types of answers are generally scoffed or laughed at, being something only a nube would say, and generally end the conversation because people don't seem to know what to say next.

At one particular point of the Thanksgiving dinner (Thanksgiving, being a time to be thankful for things about your life that are good), as people are bitching and moaning about living here, I am sitting next to someone who has been born and raised in Kinshasa, and although having left during the Civil War, has been back and intends to stay (I think) - I'm guessing that to him, and other Congolese people who have to endure all the jibes about their country and city, many Americans are a little ugly.

But I don't want to end this on such a sour note - people didn't whine that much during dinner about Kinshasa - and considering this is just a bunch of people thrown together by chance, they might not have much else in common to talk about - in general, Thanksgiving was fantastic. There were adorable children running around laughing, babies (that generally at least one of the partners in a couple tried to hold while the other tried to discourage them from holding lest they get any ideas), as I mentioned the absolutely delicious sweet potatoes, and a chance to meet some of the other expats who live here too.

Probably the best thing about Thanksgiving though, is that even if maybe people forgot about the being thankful part sometimes, everyone made such an effort to welcome me and make me feel at home at a time when nobody is really at home. That community spirit, which I like to associate with barn raisings and the entire Little House on the Prairie series, hopefully makes more of an impression when Americans are overseas.

Office politics

Pretty much any job I've ever looked at wants to know that you can work well with others, and I figured that that was just something they tacked on at the bottom so that they could reject someone on some sort of vague basis and be able to cover themselves. This actually still might be true of the motivation behind putting this phrase in job descriptions, but I am really surprised at the size of the role that interagency politics plays in this particular country team.



As far as I can tell, this is for several reasons:



1) PEPFAR made no effort to deal with the reality that although each agency (CDC, USAID, DoD and PD) are part of PEPFAR, they all adhere to their agency-specific deadlines and policies first and foremost. This is a big problem when it comes to capacity-building for example - apparently based on some past happenings where USAID was caught with it's pants down, they aren't allowed to give money directly to governments of other countries. CDC has never had this problem, and quite honestly according to our specialties (lab and strategic information), it makes the most sense to partner directly with governments.



2) People of several nationalities and backgrounds serve on PEPFAR teams. I actually heard some office gossip that at one meeting not too long ago, but before I got here, someone walked out of a meeting crying. And now this person is very unsupportive of CDC activities because she thinks that someone in the office thinks she is a racist. Now quite honestly, from what I've seen, we don't tend to send the best of the best abroad. Well, maybe they're the best in terms of their technical expertise, but they certainly tend to represent the America that has been brought up like an only child, completely obtuse and unaware that other people and countries in the world exist beyond the role they play in our own contrived universe (sorry only children). So maybe she's racist, maybe she's not, maybe she doesn't know she is - if you've ever read Blink by Malcolm Gladwell, I'm sure you're familiar with the appalling feeling that you actually identified the black man with the negative words. But at any rate, she's going to hold that against the agency until she leaves, and probably carry it with her to other posts.



3) Some people think PEPFAR is a waste of time. Some of these people are on the PEPFAR team. Consequently, these people drag their feet and avoid doing what we're required to do by PEPFAR. I would think that any adult would have learned to suck it up and do what needs to be done, especially any adult who has worked for the federal government for more than 2 seconds.



These interagency politics get even weirder when you see these people outside of the work context, in the embassy community (like at Thanksgiving this Thursday), and they are totally nice and friendly. For me, it's difficult to tell what their character is exactly.



The problem is, I'm not sure how to make this any better, as I am only a fellow. It's very weird to know that you are at the bottom of the pile and people from other agencies don't really care what you think, especially coming from the academic environment where the tone was more collegial.



This expose on interagency politics isn't very exciting I know, but one component of working for the government is that I'm not supposed to talk about stuff I do at work - which is hard when this blog is supposed to help students interested in global public health figure out what working for the government is like. I suppose that in itself is a little insight.

Technical Work

Before I started this job, I really shied away from any job description with the word "technical" in it. For some reason, I have never identified public health as technical, which is a horrible sin considering how offended I am when people ask me whether public health involves science or not.

Now that I am here, I have realized that if you are a student who will be looking for a job and one of your destinations is the federal government, always ask about the amount of "technical" work you will be doing, because the secret is that "technical work" actually means work that you went to grad school to learn how to do.

And now, the 1,000,000th presentation on how poverty constrains behavior

(I went to APHA and got new soapboxes)

I'm not sure when we can stop presenting on this. I get that in every situation, you do want to be sure that you double-checked your assumptions, but I really wish someone would do research on the level of general poverty in a population at which you are very safe to assume that when you ask people:

Why didn't you come back for your follow-up appointment?
Why didn't you deliver in the hospital?
Why didn't you take your meds like I told you?

The most likely answer will have something to do with poverty:

I didn't have money to pay for transport
I didn't have money to pay for delivery services
I don't have money to buy food and I feel terrible when I take those meds without eating.

The other thing I find frustrating and slightly racist or insulting is the extent to which we present basic customer service principles as new finds in international health. For example, on PlusNews.org, there is a report about how rude health professionals are a barrier to accessing healthcare (http://www.plusnews.org/Report.aspx?ReportId=86289). To me, this is a no brainer. Who would want to go to to receive healthcare services from an institution like the one described there? Now you might say, well someone who's really poor probably doesn't think it's that big a deal or that it's an acceptable cost to receive services, which I think has been the attitude of a lot of public health professionals (yeah the doctor thinks you're a whore, but at least you get ARVs!) - but that's wrong. Just because you're poor doesn't mean you don't have feelings.

If you saw the Surgeon General speak at APHA (which I didn't and don't want to talk about how bummed I am to have missed that), apparently she told a story kind of like this one:

Once, when she was a practicing physician, a patient called in over a weekend or early in the week to ask for a prescription for pain to be called in. The woman was doubled over, unable to function (it seems), and so the SG says yeah of course, done. The woman shows up for her appointment on Thursday, obviously without having picked up the script, in horrible pain, and the SG says my god what are you doing why didn't you pick up your prescription? The woman says well payday isn't until Friday and I didn't have the money for it. So the SG goes over to the pharmacy, picks them up herself. The woman is extremely embarassed about this whole situation - she doesn't want to take the script - she's upset. The SG smoothes it over by saying after payday she can come back and donate to the pot of money that the office uses to help people out, but the damage is done, the woman was embarassed and perhaps a little insulted. Again, I don't even know if this woman was poor or simply underinsured or uninsured or had some sort of other expense she had to attend to first that week, but just because you don't have money to do what you need or want doesn't mean you don't have feelings.

I saw quite a few presentations at public health who presented both of these theses as research of interest - I would say they are of very little interest. I could care less whether after 100 in-depth interviews you discovered poor people do not like their privacy or their humanity devalued and that if you don't have money you can't do stuff you want or need to. Paul Farmer alone has beat this point to death (and I won't believe you if you say you've never read Paul Farmer and are in global/international health).

But what's more disturbing is that we seem to feel comfortable identifying this as a finding, as research worthy of presentation. What does that say about our assumptions about people who are poor, like many people living in low income countries, or people who just don't have the money right then, like lots of Americans who can't afford healthcare costs?

The Real World of Work

To give all of you out there a taste of what work is like after grad school, here are some examples of what other fellows from my batch are up to from some emails we have all been sending back and forth. While it seems about half of us are still waiting to use our public health degree, the other half have jumped right in. The main lesson seems to be that the smaller the office, the more hats everyone wears, including management and budget hats. I am most jealous of Rwanda.

“ . . . it (H1N1) broke in Rwanda the day after I got here and I got detailed to the MOH (Ministry of Health) and put in charge of surveillance. I'm not sure how that happened either.” – Rwanda

“I constantly feel like I am begging to go to meetings or to have some work to do but so far, not getting anywhere. Everybody seems to have their own little niche and carving out my own has proved to be slow going.” – Cambodia

“I haven't done a single piece of technical work the whole time I've been here. I don't think I even need a Public Health degree to do this stuff. In fact, the PEPFAR coordinator here has an MSW. Probably, an MBA would be even better.” – Nigeria

“my life in short: work on needs assessment protocol week one. turn it in. revisions. turn it in . revisions. turn it in. new stuff like editing and updating manuals. turn it in . revisions. turn it in . revisions.” – Atlanta

“I'll be compiling data, policies, and other info on TB's target countries for TB/HIV to prepare our team for TA (technical assistance) assignments in-country (maybe I'll get to tag along?). And I've been tagged to help in a TB outbreak investigation in Topeka, Kansas. The outbreak seems to be occurring among a population prone to homelessness and substance abuse, so I've been informed much of our case-contact investigation will be occurring in Topeka bars. I'm also going to drafting a policy paper re: government/private incentives for development of second-line antiobics. ” – Atlanta

“I'll start a new evaluation project this next week at an area hospital. A Prevention with Positives (PwP) research study was pilot tested here. The actual PwP study will start here and in a few other PEPFAR countries in December (I think that's the right month). Anyway, I'll be going to the hospital to extract records to see how the intervention has been working. Not sure if we'll do focus groups or not yet. I am also hoping to sit down with the Technical Prevention Advisor and Country Director to get a grasp on how they see my role.” – Namibia

“I've been spending most days at work developing a protocol for a Cochrane Review of mass drug administration that we are considering pursuing. While, perhaps not as exciting as some other projects, I think it's a good beginning. I'm learning a lot about a subject matter I'm not too familiar with and about the Cochrane review process, which will surely help me develop skills that will be extremely useful later on.” - Atlanta

As for my part, I tend to agree so far with the fellow in Nigeria who mentioned how apt an MBA seemed for this job. My office is in the middle of doing the various reportings that the US government requires, such as country operational plans, grant announcements, and the implementation plan for the all important partnership framework (as you might recall, the motto of PEPFAR II is capacity building and as part of that, we have to write a report in collaboration with all relevant partners and the government of DRC that proves we have a capacity building plan and a way to implement it). This is what I do with most of my day, with the caveat that I am learning everything I never learned about public health politics in grad school.

Once you have developed yourself into a good scientist, I think that the next two skills that anyone who wants to be in a leadership position in public health should pick up are: 1) managing people and 2) working well with politicians.