the emotional ups and downs of working in health this summer

For any readers who normally work in the health sector, what I'll be describing here is probably old hat to you and you long ago learned how to deal with the emotional ups and downs of just another day at work.

I don't normally work in the medical field, so while my experience this summer fulfills a personal and academic interest of mine, it's my first time to have any practical experiences working with patients.

the ups

Yesterday I finally got to do my first "ride-along" with a CHW, Alphonsine--though it was more of a "walk-along," as her bicycle was stolen and regardless almost all of the households we visited were within walking distance of her home (CHWs are recruited from within the community they will work in).

We visited four households--all were very low-income, but some were definitely struggling more than others. The biggest determinant of this seemed to be the number of children in a family.

All of the families lived in houses built from hand-formed clay cinderblocks with metal window-casings and doors; however, the windows of poorest family's house were mostly filled with clay save for holes the size of grapefruits to let in light and allow air to pass through. They raised no animals, their youngest child (22 months) was moderately malnourished (an improvement from her previous diagnosis as severely malnourished), and even the older children and the mother were thin and small. They were using their malaria bed nets, but the mother declined to let us into the house, her face turned away from us as she turned down our request.

Her next door neighbor's family was fairing slightly better and they could boast a pig, several chickens, and there were piles of soybeans drying in their yard. Still, buying milk more than twice a month is too expensive for the family of 6 (four kids and two adults), even at only about 30 cents per liter. Both adults were very thin, though the father seemed hearty. Their 2-year old baby was gigantic compared to the neighbor's child and was able to very loudly voice his demand for mother's milk.

At the other end of the spectrum was the mother we met whose 4 year old son was big and tall for his age and walked around the dirt floor front room smiling with confidence and energy. This mother, now expecting her second child after several years using effective birth control to manage the size of her family, described her recent food purchases--eggplant, potatoes, sorghum--giving important diet diversity to her family and noting that she had closely followed Alphonsine's nutrition counseling both during and after her first pregnancy. Her son was also playing with a large avocado full of vitamins and healthy fats.

In this house, the 26-year old mother and her younger sister who also lived with the family, were healthy and full-faced, signs that everyone was getting good, nutritious food. The mother was also diligently attending her antenatal care (ANC) appointments and getting regular visits from both Alphonsie and the maternal and child health (MCH) specialist CHW.

I took no photos during the first part of the day because I wanted the community to just get used to me being there since my role was to just to observe and note the amount of time the various CHW activities take. In any case, every time any of us muzungus step foot in the village, it's like a one-man variety show, but I still wanted to attract the least amount of attention possible.

Again there were, seriously, babies everywhere, but I resisted the urge to photograph them. Alphonsine's 5-year-old son, Sentia, had a million dollar smile that charmed the pen off me--I'm now down to one pen this summer after giving away my other two, one to Daniel and the other to Sentia.

the downs

Later in the afternoon, I sat in on a verbal autopsy* for an 8-month old who died on Sunday. The discussion was conducted entirely in Kinyarwanda, so I could only catch a little of what was going on. I just watched. Maurice (the MV CHW manager) filled me in on what she'd said after we left the house.

I learned about verbal autopsies in my global health practice class this past spring, but we didn't go too far into it since most of the students will never participate in one.

Grief and sadness transcend language, however.

I sat silently in a wooden chair in the dirt-floored front room of a better-than-average house for the neighborhood and listened to the grief-stricken mother's barely audible account of how her baby had died two days before.

Her eyes glistened, but she shed no tears.

Eventually the father joined us. He spoke some, wiping at his eyes as though it was just the dust that was bothersome.

The CHW for that household had accompanied Maurice and I and both she and another young woman of the house held babies they nursed as the mother spoke.

The mother's shirt, clean and white when she sat down, slowly grew small wet dots where her milk was still coming. The only time she looked somewhere other than the ground or Maurice was to watch the CHW shift her now sleeping baby to bundle onto her back.

As the visit ended, I joined the procession of people exiting the house. As is custom, I grasped the mother's hand with one hand and my forearm with the other and said thank you in Kinyarwanda.

I wanted to say something more than a woefully inadequate "thank you for your time," to give her a hug, but the awkwardness of death and mourning is unavoidable in any language.

The most I could do was hold her hand a little longer than normal and give it an extra squeeze. She looked up at me then.

But I hope she forgets that I was there and that her memories of her child's passing aren't marred by the odd appearance of an unspeaking muzungu in her living room.

post-script

I realized while we waiting for the mother to join us in the front room that it was totally unnecessary for me to attend another verbal autopsy. That will likely be my one and only verbal autopsy in Rwanda. Until or unless I become fluent in Kinyarwanda within the next two months (highly unlikely), I can't imagine how my presence can help and can easily imagine how my being there can hurt.

I think it was useful for me to see how a verbal autopsy is conducted from an educational standpoint and I noticed some things that I might do differently if I were asked to give some kind of feedback, but I don't think the educational advantages outweigh the potential negatives for the family. In a setting where at least there isn't a language barrier, however, I could think of more justification for my presence.

*Despite the definition at this link, this family had sought out medical attention for their child several times.