The Things that are not Asked

This morning I arrived at the health centre and joined the staff for the biweekly prayer session. Once the preacher had finished, everyone brought their chairs into a smaller circle, and one of the older nursing sisters announced that a staff member, Baba’mkhulu (Grandpa), had died the previous day.

Just two days before, as I was visiting one of the satellite clinics, the same nursing sister told me that I must go and speak to this baba to learn about the history of the clinic. The old man had spent many years living and working in Pholela and he had seen many of its changes. Indeed, yesterday I went to look for baba, but he had not come to work.

For my research I am interested in placing today’s health and environment in a larger historical context that begins in 1940 with the opening of the original Pholela Community Health Centre. While as far as history is concerned, sixty-eight years may not be much, as far as living memory is concerned, sixty-eight (or fifty, or even thirty) years of experience is disappearing. I will never be able to ask Baba’mkhulu about his life and his time at the clinic. The questions I have for him will remain unasked and his answers will remain unspoken.

When I first thought about writing a post about the things that are not asked, Baba’mkhulu was still working at the help desk, and I was looking forward to the end of the month when I will finish at the clinic and begin my own, self-directed research. I had been thinking about all of the time I have been spending in the ARV clinic, with the mobile clinic, and at various home visits where I wonder about the life of this or that patient. I had begun to think more and more about the things that are not asked.

For example, in “lifestyle” diseases like Type II Diabetes which are common in Pholela, patients are rarely asked where their food comes from. True, patients are given education about limiting starch intake, boiling food, and eating more vegetables. But they are not asked what food comes from the garden and what food comes from a shop; who controls to purchase of food, or who controls its preparation. While talking to a gogo about what she should eat to control her diabetes is good in theory, if she does not decide what she eats, or if she has no control over how it is prepared, then she has no control over the very “lifestyle” that causes her disease. In the end this gogo will get pills that (may) control her diabetes, whether or not she has the means to or the knowledge to change her eating habits.

Perhaps this is the reason that so much is left unasked, and so much is left unsaid. Or perhaps it is because there are forty more patients waiting to talk to the nursing sister that afternoon and the mobile clinic only comes once a month.

Then there are the questions that are asked, but that people either don’t want to or don’t know how to answer. One sister noticed that a woman had bruising all over her face and asked what had happened. A smile, no answer. Then she asked how things were at home. Again, a smile and no answer.

Perhaps things aren’t asked because no one wants to answer them or because the answers are too long and too complicated and there is a line of people still waiting for their diabetes medication.

The nursing sisters are not the only people who leave questions unasked. A woman of child bearing age arrives at the mobile clinic complaining of flu. The sister takes the opportunity not only to treat the woman for flu, but also to encourage her to go onto “the injection” (a contraceptive administered intravenously by the sisters once every three months). The sister asks if the woman agrees. She says yes. And family planning is achieved. But this woman does not ask if there are other options; if she could take birth control pills rather than the injection or if there are condoms available. She doesn’t ask how it will affect her menstruation cycle, what happens if she happens to be away the day the mobile clinic comes to her area in three months, or how long it will take for her to become pregnant once she stops. And no one asks about the implication of a public health service encouraging its poorest and most disempowered citizens to use birth control.

AIDS is different, or so they say.

In order to be tested one has to go to pre and post-test counseling. If a person is negative he is counseled about how to stay negative. If a person is positive, she learns about how to prevent the spread of HIV and how to begin the process of “getting onto treatment.” This HIV+ person will be advised to have her CD4 count checked and if it is at or below 200 she enters a series of three counseling or education sessions about HIV, the progression of the disease, the treatment regimen, potential side effects, and how to find support. In some ways this system works and both the medical professionals and the patients have the space and the time to ask question.

When the patients come to the ARV clinic the nursing sisters and the doctor ask them about contraception, pregnancy, intimate relationships, TB history and other serious illnesses, if she has ever taken treatment for HIV before, and if she has declared her status to her family. And patients answer these questions (though how representative the answers are of reality is, of course, open to interpretation). Further, within this structure built around AIDS patients are empowered to both see the doctor and to question their treatment. One man today asked the doctor if he should be taking one regimen because in his classes he learned that people who work the night shift should be put on a different regimen. He had the knowledge and the power to ask about his own treatment. Another woman came in to ask to for medication to control her epilepsy. She explained that from 2004 until she started ARVs she had been taking a traditional medicine to control her epileptic fits. She was at the clinic today because she had learned in her classes not to mix traditional medicines with ARVs; since she had stopped taking the traditional medicine her fits had returned. Like the man before her, she was empowered to ask questions.

And yet, there are things that are not asked. What was the traditional medicine that had controlled her epilepsy? Would it really interfere with ARVs? There are more general questions as well. What treatments are patients seeking outside of the clinic system? Why have they decided to test? How supportive is their family? How as this changed? How did they get to the clinic? How much did the transport cost? What do they eat everyday? Where does their food come from?

While the medical system has come to understand HIV/AIDS as a social disease, it is only a particular kind of social. It is about sexual relationships and changing family structures. It is not about different healing systems, transportation networks, or the combination of climate, ecology, knowledge, and political-economy that determines what people eat, where it comes from, and when they go hungry.

But there are many patients waiting, the sisters and the doctor are busy, and people want to finish early so they have enough time walk home before dark or so they can catch the erratic transportation available in this rural area. And so there are things that will remain unasked.

As I leave the health centre and venture out on my own I am eager to begin asking about some of these things that are not asked. I will ask questions about transportation, food, understandings, and history. These questions will lead to different ideas and to more questions. And while I know that there will continue to be things that go unasked and others that go unanswered, I am still eager to begin. For as Baba’mkhulu reminds us, if we don’t ask about things today we may never get to hear the answers.