Private & Social - The Local Health System

This week has been a little slower than the first two weeks here. Juventas was moving offices this week so I helped a lot with that and it took some time to sort through all the papers and material and organize them in the new office. It was interesting though to see how many brochures and other promotional materials they had made. I read through many of their brochures on topics such as contraception, HIV, Hepatitis, drug addiction, and many others and I was personally very impressed by the material presented and the manner in which it was written. These brochures are especially well tailored for young people and one of their major projects for which high school students volunteer is helping distribute the educational material to schools throughout Montenegro.

This week I did finish making a list of possible donors for the drop-in center and I found an especially good website of grant listings that was helpful in finding some very good grant possibilities. I also really want to talk with the Juventas staff about looking more into local companies and corporations for donations for the projects. They told me that that doesn't work here but it was very hard to find outside funding sources that include non-profit organizations in Montengro in their eligibility. I may look into talking with people I know who work in local banks and such to see what their thoughts are on the matter as well. Since I didn't have much work at Juventas, I organized a trip to a microbiology lab here that does all the testing for HIV, Hepatitis, and lots of other diseases. There, one of the microbiologists showed me around the lab and talked with me about all their protocols and procedures. It was really interesting seeing and learning about everything as what they do is actually quite similar to what is done in the US. They, for example, have all the necessary equipment to do ELISA tests for various viruses and they do confirm all positive HIV cases with a western blot. Basically, beside the older equipment and the fewer amounts of it, they are able to do any test that may be needed by a patient. It was fun to see my microbiology class pay off as I had done some of the tests she was showing me and it felt good to be able to ask her more detailed questions about everything and to be able to understand

alot of the science she was talking about. For HIV in Montenegro there have currently been about 70 cases of which I think about 46 are currently alive. It is very interesting that there is only one doctor here who works with each HIV patient in Montenegro. He knows every patient really well and follows them throughout their life. I hope to be able to meet with him while here. All his patients are on antiretrovirals which are paid for by the national health plan. Every three months they have their CD4 count and viral load checked which is done at this microbiology lab. In general, there are fairly good health care options for those with HIV although some do have to travel several hours by car to see the one doctor. Just another interesting fact from the lab is that they were very excited to show me their new PCR machine. They had just recently bought it and it is I think one of the only ones in Montenegro!

Also, from my experiences thus far, I am very confused by the healthcare system here. It seems to be something in between a socialist and private system. I guess Montenegro is in the process of privitizing lots of things and health care is one of them. So right now there is both a social system where everyone gets some type of health care but then there are also private hospitals and labs where people with good jobs and health care insurance can go. These private clinics have better equipment and resources and patients don't have to wait as long to get seen and to receive test results but they do have to pay more. The woman I met with at the microbiology lab worked during the day in this non-private lab and then worked afternoons in a private lab which provided slightly better pay. I don't really understand why if the socialist health care system has worked so well in England and France and the private system is so terrible in the US that Montenegro would want to go towards privitizing health care but that is what is happening. Also, last week lots of doctors and nurses were on strike because of the super low pay they receive for the long hours they work. Imagine being a doctor and not having a salary big enough to buy an apartment. It is really strange how little they make here. It was a big mess though because lots of patients couldn't be seen as most doctors weren't working. The politicians are still discussing how to resolve all this and a big issue is under the counter payments patients have to give lots of doctors to be seen.

For next week, one of my biggest goals is to really work out a long-term plan with Juventas so I can better understand what to expect for the next two months. Even now, I don't know exactly what I will be doing next week so it is hard to set goals and make plans. I will most likely be doing work on the report on sexual health workers which I have started but am currently waiting for a response from the police department for more specific data. Also, the research study will be done next week so there will most likely be lots of work in analyzing the data obtained and organizing and writing up all the results. I will also be battling the heat as the temperature here is really starting to rise now. It is consistently over 100 degrees and I have been told that throughout July it is commonly in the 110-120 range. My 20 minute walks to the office and back are definitely getting harder.

Generating Trust, Understanding the Needs of a Population, Outreach

My second week here in Podgorica has been very exciting. I am continuing to grow accustomed to the work atmosphere here and have been fitting in well with Juventas. The research I needed to do for the report on the current status of commercial sex workers in Montenegro has been somewhat difficult to do as there is very little information available. It has been a little frustrating trying to find the necessary information as I do not know exactly who needs to be contacted to obtain the needed data and the people I am working with inJuventas have been very busy and unavailable this week. We have managed to sendan email to the police headquarters and they should be able to provide us with much of the data we need at least in terms of the current numbers they have of current sex workers, arrest rate, etc. I hope to receive a reply from them at least by Monday although I am not completely optimistic about this.

In addition to this, I have been working in the office on helping Juventas initiate a new project. They would like to build a drop-in center for individuals with HIV/AIDS or Hepatitis B and C or individuals at risk, such as those who are injection drug users, commercial sex workers, or the MSM population. Here, people would be able to obtain needed information, receive counseling, seek help, and possibly get tested for the various diseases. I have spent much of this week looking for possible donors for this project and editting and helping write-up a letter of interest for the project. It is interesting to be able to participate in projects at various levels of their

implementation.

The research study they are conducting at the hospital has been going fairly well although fewer and fewer people are coming for the study. They are really scared as several of the people who previously went to the study have recently been arrested for possession of drugs so they think there might be police spies around the hospital. Nevertheless, I am learning a lot from the staff at the microbiology clinic and from the Juventas staff about the three diseases, their treatment, the different effects of various drugs, and the current available rehabilition options. Just recently, a drug rehabilitation center has been opened in Podgorica and I have heard that it is very nice with fairly good health care and lots of different opportunities for patients to engage in

athletic and social activities that will help them with their recovery. This is one of the first such centers in Montenegro and I really hope I will be able to visit it soon. An alarming fact from the study that I have come across is the number individuals affected with Hepatitis C. From the current data and the patients I have seen thus far, I think it is estimated that about 80% of

injection drug users are Hepatitis C positive!

I have also been out with Juventas to do outreach work this week. This has been a very interesting experience. Many of the people we see during the outreach work are long-time clients of Juventas and are either injection drug users, commercial sex workers, or both. They actually have the phone numbers of several of the Juventas staff and thus whenever they need clean needles or condoms or just someone to talk to, they can call the staff and we visit them

in their homes during the outreach period. For all new clients, we advice them to come to the clinic during the study period so that they can get information and counselling so that most of the people we eventually see have all the needed information on drug addiction, the various diseases, safe behavior, etc. I am very impressed with the relationship Juventas has built with its clients

and the trust that has been formed between them. For the outreach work, we basically drive around Porgorica in a van, first making all the planned stops to visit the clients that have called us earlier that day. They either come to the van or we go up to their apartment and give them clean needles, syringes, and condoms. We also have a doctor with us who works in an emergency room and she can provide them with any medical care or advice they may need. I am currently in charge of writing down everything we give each client for that night. I have met a few of the clients although I do not go out to each visit as I am new and the people are often scared of new members as they do not yet trust that I am not with the police. After going out several times and having them see me around for a while without any negative consequences for them, then I will be able to interact with them a little more.

After making the planned visits, we drive around some of the areas in Podgorica known to have hang-out spots for drug users or sex workers. Two nights ago, we visited an area called Konik which I never knew existed in Montenegro until this year. It is basically an area in which all the refugees from Bosnia, Kosovo, and other war zones, the roma population, and many delinquints live. It is an extremely poor area and many of the houses are barely standing upright, there is a lot of trash everywhere, and it just looks very run-down and scary in general. I was shocked that I had never seen or heard of this area before and it is very strange that some of the most marginalized populations in Montenegro all live in one location. The outreach work is really making me aware of how hurt this country has been by the war. It has also showed me how widespread the drug problem is here and how it affects individuals from some of the most diverse backgrounds.

Through all this work, I have been making a ton of friends here at Juventas. I really like that I get to work on so many different projects and get to see how this organization runs as a whole. I have been pleasantly surprised with how well everything is organized here and the work they are doing is, I believe, very effective. The only thing that is missing is support for organizations

such as Juventas from the general public, and especially from local cooperations and the government here in Montenegro. There are very few donors within Montenegro and Juventas is really having a hard time finding funding for its projects. I also had the opportunity to attend a press conference held by Juventas this Wednesday during which it announced all its upcoming projects and work to the media. I have attached some pictures from this conference so you can

meet the three main people I'm working with here.

For next week, I plan to continue my work searching for donors and hope to have a list ready for Juventas by the end of the week. I will also continue going to the research study and outreach work. I hope to make some progress with the outreach work so that I can communicate more with the clients and begin making more of the visits with the other Juventas staff. While I am having a hard time with the fact that most of what I am going to be doing each day here is not

planned and organized in advance, I am learning to adjust to this cultural difference here and am beginning to trust that even though I might not have every detail of my project planned, I am still getting interesting and new experiences each day and am able to contribute to Juventas' projects.

Relaxed Work Culture, Significant Progress

Overall, my first impression is that there will be some very interesting things for me to do and see while I am here and I am really enjoying getting to know all the staff here. They are very friendly and easy to work with and have been very good about teaching me and explaining everything to me. The workday here has been slightly strange for me even though I am from here. We all get to work at 9am but this does not mean that we start working at 9am. First, everyone gets together to drink coffee and just chat for about 45 minutes and then we start working. After a few hours, we all go out again together to get something to eat and then sit down at a café for coffee again and take another hour or so break. Throughout the day, they take these coffee breaks and the general work atmosphere is very relaxed and laid back.

It is a little strange for me as I am always used to working and getting things done and taking short breaks, but it is really interesting to have time to talk with them and get to know them outside the work setting. I feel that I will really gain a lot from this experience not only in learning how to work with injection drug users and commercial sex workers and seeing their status in Montenegro, but also in observing and being a part of a completely different work culture. Also, I am very pleased to see the relationship this organization has built with the populations they serve. They know many of their clients for a long time and have built very strong bonds with them. I feel that the clients really trust this organization which not only helps in promoting the safe preventive behavior but also serves as a gateway through which Juventas can work with their clients to help them stop using drugs or to get them away from sex work.

The first week here has been great. I met with Senad and started working at Juventas on Monday. I have spent most of this week getting to know the Juventas staff, their programs, and how they are organized. My projects have slightly changed due to last minute changes in what Juventas will be doing in the summer but the overall project is similar. I will mostly be working with them on one of their bio-behavioral study that looks at the incidence and prevalence of HIV, Hepatitis B, and Hepatitis C among injection drug users and commercial sex workers. Furthermore, it looks, through a survey, at the general behavior of these populations in terms of reproductive health and general safety.

In addition to some office work during the day, I have been going in to the clinic from 5-9pm three times a week. Here, test subjects can come and have their blood drawn. The blood is then tested for the three diseases. After, we go through the survey with them and, if needed, give them clean needles, syringes, and condoms. Also, I will be going 2-3 times a week to do outreach work on the streets from about 9-12am where we talk with injection drug users or sex workers doing some counseling and distributing again clean needles, syringes, and condoms. I am in the office from about 9-3pm each day and this includes entering fieldwork data into the computer, attending meetings to discuss project difficulties and ideas or how to improve the work, and working on several reports with which I will be helping this summer. Right now I am helping them to write a report on the current status of commercial sex workers in Montenegro, including an analysis of their rights, their health status, and their behavior. As this needs to be written in English, I will be writing most of the report and will be working together with several of the staff to conduct the research. Research will include visiting the epidemiology and infectious disease clinics to speak with doctors and obtain data and internet research.