Reaching Out

I had a great time spending the four-day weekend in Zabljak. I haven't been there since I was a baby so it was great to see where my great grandparents house used to be and to hike and see all the beautiful lakes. I wore long-sleeve stuff almost all the time and it was nice to be cold for a change. Zabljak really epitomized for me the transition that Montenegro is undergoing. There is a booming tourist industry in Zabljak so in the main town there are new hotels and a new ski resort and in the fields you can see newly built, large vacation houses. All this is being built right in the vicinity of the old, run-down houses and barns in which the families that live year-round in Zabljak and whose whole family history is centered around those fields and mountains live. They live of what they can produce and it is often a very poor lifestyle. As my mom spent most of her childhood in Zabljak, we know many of the families there and I went to visit one of the families. They live and sleep in a barn house with a dirt floor that is filled with flies. None of the elders have any teeth and the kids (a 4-year-old and a 6-year-old boy) have teeth that are already rotting. There is only an elementary school and most kids from the area don't get past 8th grade. They barely get by on what they produce in the warmer months which they have to use during the winter-time and they mostly live of bread and dairy products. Among families such as this where kids have almost no opportunity to obtain an education come thousands of tourists year-round from Serbia, Montenegro, and the rest of Europe and their presence seems to almost swallow all the native inhabitants and the history of the location. The country is doing everything in its power to promote this tourism and to build new, giant, impressive hotels, etc.

In general, Montenegro seems to have forgotten about maintaining and improving the old and is just focused on building as many new things as possible. There are so many new, beautiful bridges, apartment buildings, restaurants, and hotels, but they are all being built right next to 60-year-old, run-down buildings which have never been painted or renovated. The city is the strangest mix of brand new buildings with peeling, broken, and falling apart buildings. They seem to be trying so hard to catch up to the rest of Western Europe that they have skipped key steps in the development process. I went to see the university my parents attended and the inside has not changed one bit since they went there twenty years ago. Every street is thus an example here of the transition this country is undergoing and it is perfectly clear what was the old and what is the new.

I took the time to try and develop some new forms for the outreach work that I think will be
more efficient so I can show them to the director when she gets back from the seminar on Monday. I already showed them to one of the outreach staff and he seemed excited about them. I think they will be much easier to fill out quickly when doing the outreach work and so it will help them keep more accurate records of everything they give out and all their contacts rather than counting on memory of who was seen on a certain night several weeks ago. I also went out to do outreach work two nights this week and helped with filling out the forms to test my new layout. I did not have trouble getting everything down even on one of the more busy nights we had. That night was a really tough outreach night for me as many of the clients were really under the influence of drugs and many could barely talk or walk when we saw them. Interacting with them was just a completely new experience for me and, at times, I was scared that something would happen to them medically. We had a client who had completely destroyed his legs from injecting as that area is extremely sensitive and one has to go really slowly and accurately or else the site of injection swells up. Both his legs were completely swollen and he told us that he had begun to inject in the veins in his groin area. I could no longer see a single vein in his arms and he really looked like he was in a critical state. We spent a while trying to talk
with him and convince him to stay clean for at least several days while the swelling calms down.

That same night, another girl got really mad at us as we would not give her a ride somewhere and none of us had 1 euro to give her so she refused any help and stumbled away. In that one night, I saw so many things that were new to me that it was a little overwhelming. I am still having a hard time understanding why and how people get involved in such things and how they can do so much harm to themselves. I guess it mostly comes from the influences one has growing up and, if you are surrounded by family or friends who are all involved in such things, it is difficult to escape it. And once you start, it becomes a vicious cycle that only a few can get out off. I just really feel helpless sometimes during the outreach work as there is nothing you can really do to stop the problem at the core and all you can do is minimize the risk but it just doesn't seem like that is enough. Hopefully, our work at least makes them think about the health effects of what they are doing and hopefully in at least a few cases that brings some motivation to think about and commit to stopping. I have finished all my work with the data gathering and designing
the new forms. I will definitely show her my ideas and, if she likes them, work on finalizing versions of the forms and preparing them to be used for the outreach work. In addition, I really want to work with her to set up a meeting with the HIV doctor in the near future which I still haven't been able to do.

On Monday or Tuesday, I plan on going again to the Voluntary Counseling and Testing Center to see if I can observe some of their counseling sessions. I will also continue going out to the outreach work. Finally, I will definitely try and see with the director if there are any trends in which they would specifically be interested for me to look into. There are some I would be
particularly interested to explore so I will see with her if that would be helpful for them for me to do.

Progress & Note on HIV/AIDS Stigma

I have had a very productive week here especially in terms of organizing and completing all the data summations for the 2008 year for my partner organization's outreach work. I added all the necessary missing forms and compiled all the summed data for each month into an excel file. Now they have ready data which they can present concerning the amount of materials distributed and the number of field visits done and clients seen. I also compiled all the data for new clients who have to fill out a longer form. Some interesting trends I have seen that I believe are very positive is that almost half of the people have been tested for HIV and about 70% of sex workers have been tested for various STDs. However, for intravenous drug users, a large portion (close to 90%) have shared their equipment with others in the past. In addition to organizing the data, we spent a whole day preparing materials for the EXIT show which is a four day music festival with multiple stages in whichbands from all over the world play held in Serbia over this weekend. They saythat during the event there is a lot of drug use, especially ecstasy, and an increased engagement in risky sexual behavior. Each year Juventas has a booth there at which high school students volunteer to distribute condoms and educational materials. Therefore, we spent a whole day packing condoms into custom made boxes which have quotes on them such as "reduce the risk" and counting and packaging brochures into boxes so they can be transported to

Serbia.

In addition to office work, I have gotten much more involved in the outreach work this week. I went out 3 nights this week and have started leaving the van more often to interact with and meet the clients. I have also learned how to put together the packages of needles, syringes, condoms, etc. that we give to the clients and am learning what specific things known clients typically ask for. It has been great getting to hear the client's stories as we distribute the materials. There is really no set profile for either intravenous drug users or commercial sex workers. They all come from so many different backgrounds and each has a unique life story. In one night, we met with 15-16 year old boys who just started experimenting with drugs most likely because they were bored, with a guy in his twenties who had finished his second year of law school and is very intelligent and well- spoken, and with an older man who has been using

heroine for a long time and started because all his brothers had been doing it. They come from both families who are well off with regard to this area and from poor families who are refugees from areas such as Kosovo. The sex workers are mostly younger women and they say that 90% of them come from Serbia. Initially, it was very hard for me to talk with them as I just did not know what to say or what I could ask and what I couldn't. The commercial sex workers especially are very open about everything they say and they often make statements I just do not know how to respond to especially in Serbo-Croatian. They definitely talk about a world with which I have had very little experience so it is hard for me to relate and to find things to talk about. However, I have seen that they are all actually very open about their experiences and are willing to talk about themselves and their lives more so than I expected. Each time I become more relaxed and find it easier to talk with them. Also, I am starting to see the same clients over again so it makes it easier. Also, for the first time I saw one client ask the doctor we have go with us about Hepatitis C symptoms and such and then ask for which doctor he could visit to set up a treatment for quitting. It was interesting to see how she advised him on everything and we gave him the phone number of the doctor with which Juventas collaborates. They say that it is an extremely positive sign when they even begin to talk about quitting as they do not typically do this unless they are seriously considering it.

As for the data collection during the outreach work, I have been observing how they fill out the forms during the night to see what would be the best areas for improvement. I really think that there is a way to change the form a little to make it much easier to fill out in a uniform manner and to make the final summations much easier to do. This I believe would solve many of the problems in the most efficient way. Next week a lot of the Juventas staff will be gone for a seminar so the one outreach group will have to go out each night. As they are going to be very busy, I offered to go along and to help with recording the data. I will then try to set up the form in the way I envision and take down the data in that manner and then I will see what they think. I believe it is going to help a lot with making it easier to quickly record the necessary information in a way that will be easily accessible for calculating total sums and finding the necessary information for the data organization I have been doing this week.

I was also able to set up a visit to the voluntary counseling and testing center here in Podgorica and met with one of their counselors this week. The center opened about five years ago and early on very few people visited but now there are about 3 visits per work day. They are open Mondays and Tuesdays from 4-8pm and patients can pick up their test results on Wednesdays. However, the counselor I met with is a doctor who works in the clinic every day so she usually will also take clients in on other days if they can not come in. Also, since this clinic opened, 4 others have opened in Montenegro, most of which are in coastline cities that have large tourist industries. She explained how a typical counseling session goes during which she discusses their engagement in risky behavior, assesses how much they know about HIV, Hepatitis, STDs, and any other disease at which they may be at risk of contracting, and discusses with them what would happen if they were positive and who they would have to go to for support. This last part she says is most important as many come without having considered this at all and really become

reflective during such questions. At the end of the session she asks them if they would like to be tested and they can get tested right there for HIV and Hepatitis. Throughout this counseling and testing process, the patients can remain anonymous and they need not give their name or reveal any personal data. However, here, once a patient has been found to be positive for HIV, their name must be put in the registry and revealed. They are then sent to various doctors in infective disease and such and thus those doctors plus all the nurses that work in those units know the name of the positive patient. As this is in general a small town which is known for gossiping, it does not take much for the information that so and so is positive to get out. Unfortunately, with a

small population, everyone knows each other so the information can quickly get to friends and family. While all the hospital staff is expected to follow a confidentiality code, miscommunications can happen. Therefore, she also discusses this with the patients before they get tested saying that they do everything possible to maintain confidentiality but that that can't be guaranteed at this time. Despite this problem, she also spoke with me about a very interesting phenomena that exists here in Montenegro but that she did not see in other areas of the world. When a family member is found to be positive for HIV, rather than throwing him/her out or isolating him/her,

the whole family (here, this includes a much more extended family than would be typical in the US) really sticks by him/her and goes out of their way to help him/her. She said that she observes this most when patients come for check ups during which she says almost always at least 5-6 people from the family call to see how they are doing and someone always accompanies them. While the patient will undoubtedly face stigma from the society here, it is interesting to see how much the family takes care of one of its members during a difficult time. This comes from the general culture here in which family is the most important thing and everyone is expected to do everything they can to help any family member no matter how distant. She said that she hoped research studies could be done to statistical show this as she believes it is something very different and positive that would be exciting to show the rest of the world. In general, the stigma here comes some from the belief that those infected with HIV must either be very promiscuous, involved with drugs, or must be homosexual all of which are things that the culture here looks down upon. However, she says that in general people know about the disease and its transmission and understand that it is a global epidemic. They are now looking at ways in which they can educate the incoming tourists and the tourist workers about safe behavior. Overall, it was a great experience being able to speak with her and see the center. I will hopefully be able to visit the center again during its working hours and get to sit in on some of the counseling sessions if the patients allow it.

For next week, Monday and Tuesday are holidays here (Independence Days) so there is no work. Thus, I am spending the four day weekend in Zabljak, a small town up in the mountains in which my family has a house. The nature there is beautiful with lots of open fields, beautiful lakes, and mountains and the weather is much cooler than here. Hopefully, with the cooler weather and the peaceful isolation I will be able to get a lot of work done on medical school secondary essays which have been piling up and which I have not been able to work on adequately yet. For the end of the week, I will be doing outreach work each day and will be in charge of recording the data. I am not yet sure what I will be doing in the office during the day but the director said she would email me with things to do over this weekend. Overall, I am learning more and more each week here and am really excited about my involvement in the outreach work.

Moving Along

I have had a much busier week here. I spoke with the director and she gave me an overview of the summer. They are going to spend much of the summer putting together all the data gathered from outreach work and the research study in order to prepare to start writing grant proposals and renewals in the following months. I will thus be involved in both helping sort and sum up data and in writing and editing some of the proposals and interest letters as many of these need to be written in English.

This week, I began to organize and sort much of their outreach work data. Each night when they go out to do outreach work, they record the nature of the contact with the client and the issues discussed, if any.

The forms are supposed to be filled out in a specific manner so that it is easy to see what was given out on each night and I was supposed to sum up everything for each night and then record the number of clients seen, resources given out, etc. for each month. I spent much of this week trying to organize all this data. I filled out missing forms to the best of my ability and tried to re-write the outreach work data in a more cohesive manner. I worked with a member of the staff, who has been doing outreach work for the longest time so he was able to help me sort through the paperwork. I have been able to get through a lot of it and have May and June left for next week. As I really like to organize things, this was a fun project for me. I definitely could see ways in which cooperation and guidelines on uniformly could really help make the process more efficient. This is something I would really like to help out with and it is something I believe will be very helpful in the future so we do not have to spend as much time later sorting through data. Also, I am thinking of ways in which we could make more of it computerized sooner.

In general, I want to get more involved with the outreach work as I feel I can contribute in that area and it is very interesting to go out at night and meet the clients and get to hear their stories. In speaking with the team, there are two other aspects of the outreach work that need improvement and in which I would like to get involved. One is that now they are starting to be spread out too much throughout Podgorica as they know more of their clients and where they live and each client expects them to come to their apartment or house to deliver the clean needles and other materials. Because of this, they have to do a lot of driving and are starting to find that they do not have time to visit everyone. Therefore, they want to try and institute several central areas as meeting places and have a set schedule of when they come to each place.

I am excited about getting involved in all these aspects of the outreach work and I will start this next week. My main goal for next week is to finish organizing the paper work and to have the final summed data ready. I want to go out for the outreach work as much as possible and to start working with the outreach team on alleviating some of these issues. They are also saying that it is supposed to cool down a bit here next week so I am excited about that. I have found a path home that has a lot of shade so the walk to work and back is not that bad. I am really looking forward to the following week!