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.

rwanda vs usa: rwanda FTW (in health)

one of our CHWs here at Mayange

I came across a great blog post on the NY Times about Rwanda's national health insurance system. It gives a great, succinct background of where the country was beginning from (basically, rubble) to where it is now with its VOLUNTARY (i.e., opt-in) national health insurance scheme (called mutuelle) that has had amazing health outcomes over the last 9 years, since it was launched nation-wide.

Malaria — a major killer of children — is also now treated. “People were waiting for a long time to go and access care because it was very expensive,” said Makaka. A clinic visit before was 5,000 francs — about $8.30. “By the time they accessed care malaria became so severe some lost their lives or became disabled.” Today, malaria is usually diagnosed by a community health worker. She can give the first dose of an effective medicine right away, then send the patient to a health clinic for a visit that will cost a maximum of 33 cents.

The increase in clients and the payments from Mutuelle they bring has transformed hospitals. Without income, hospitals couldn’t pay doctors or buy equipment. Now that hospitals can pay, doctors and nurses are moving from cities to the countryside. “Before there was a marked concentration in cities,” said Makaka. “Now there’s equitable distribution across the nation.”

an (un)showered summary of community health, millennium villages, and "pasta mush"

Editor's Note: As part of my summer field assignment, I am required to submit a minimum of 6 posts to a class blog, so some of the posts on my personal blog may sound a bit technical or more formal in tone if they are one of those posts that is serving double duty. This will be one of those posts...

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life so far

I'm near the end of my second week in Rwanda. 

With three other MDP girls (Le, Janice, and Malak), I'm spending the summer in Nyamata, about 40km south of the country's capital, Kigali. We're living in a 5-bedroom, 5-bath house (6, if you count the squat toilet in the back of the house!), on a huge lot with lots of grass, a couple trees, and swimming pool! Okay, the swimming pool is actually just behind our house at the hotel that is both our neighbor and our nightly DJ--we drift to sleep each night around 10 or 11, tucked into our little country beds (complete w/ mosquito nets), to the dulcet sounds of Rihanna, Andrea Bocelli, Eminem, Celine Dion, Beyonce, and the odd old chanson a la francaise.

And the 5-bedroom, 5-bath deal probably sounds pretty luxe, but notice that I mentioned nothing about a kitchen... or hot water... or even regularly available running cold water. We've all become very good at sponge-bathing Monday through Friday, though last night we finished negotiating a deal with the hotel to combine our pool subscription with access to hot showers so we don't have to worry about coming to blows every weekend when we finally arrive at a place with hot water showers. One of our (regularly showered) friends in Kigali has assured us that we don't smell, but there's a good chance he's just trying to be nice. I don't think anyone in my office will ever see me with my hair down as it's safe to say that my weekday look would not be out of style in a production of The Sound of Music.

the hiiiiiiills are aliiiiiiive...

with summer hair

Despite the minor disruptions to our regular bathing schedule, we're all still glad to have elected to live in Nyamata rather than deal with the hour "bus" commute each way from Kigali. The inside of the "bus" looks like this:

And that was after we'd let out a bunch of people along the way. Before that, I couldn't move my arms to get my camera out of my bag. The guy on the right with the hat had to have been over 2 meters tall and was pretty muscular, yet he was able to squeeze into a flip down side seat, with his knees pressed up into his chest.

Our house is a couple minutes walk down the same clay dirt road that the Millennium Villages office sits on. We have begun to meet our immediate neighbors, which include so far a home for the physically disabled that is run by 5 nuns; an orphanage full of sweet, runny-nosed toddlers and children under-5; and the Palast Rock Hotel (of Eminem and Celine Dion-playing fame). This afternoon we are planning to visit the orphanage and the nuns to get to know them better--the hotel knows us pretty well considering we ate there for dinner almost every night when we first arrived thanks to various mishaps with our attempts at fixing our own meals (those stories will come in another post).

pasta mush

The other night we finally remembered to take a photo of dinner. We invited Daniel to eat with us since he'd been around while we were cooking. 

family dinner in our living room (that's pasta mush in the bowls)

Our dinner consisted of everything but the kitchen sink... and the only reason that wasn't included is because we don't have one! We had to be creative with what were able to put together for dinner and made use of all the food we had left from our weekend shopping--we've learned that we need to start buying more food for our family of four. We combined eggplant, tomato pasta sauce, onions, 2 eggs, honey, curry powder, salt, water, oil, and vermicelli pasta to create what Janice not-so-ceremoniously called "pasta mush."

We tried to fancy up the marketing of this dish and renamed it an Asian-Italian fusion dish since it reminded me of almost every Chinese dish I ever tried in France AND every pasta dish I ever tried in Southeast Asia. Unfortunately for Daniel, this was his introduction to American cooking. We ate our cucumber, almond, and egg white salad out of plastic mugs. We stressed over and over that this is not the normal way that Americans (or Chinese) eat, but who knows what he really thought of our muzungu (foreigner/white person) eating habits.

Another funny "muzungus have weird habits" story: The first night we moved into the house, we decided it was best to put the trash outside so we didn't get ants in the house. We didn't yet have any trash cans, so Le put her paper bag full of cookie crumbs in the middle of the lawn so it was well away from the house and we would remember to throw it out in the morning. About an hour after she put the bag out, I went outside and noticed it was gone. Daniel had picked it up to throw out and I can only imagine he thought muzungus put their trash in strange places.

mayange

This summer I'm working in one of Millennium Promise's Millennium Villages (MV). The one in Rwanda is called Mayange and it's located about 15 minutes' drive from our office in Nyamata. I'll be focusing on assessing various aspects of the community health worker (CHW) program. I'm still finalizing my Terms of Reference (TOR), but I'll mostly be focusing on an assessment of the operational gaps of the CHW program, especially looking at their post-2015 sustainability/longevity, when the MV offices will shut down and the management of the MVs will be turned over to the communities themselves. I'll also be working with the Health team here to determine whether it would be useful to run a Senior/Lead/Supervising CHW training program here this summer. Basically, I'm going to be walking around the community doing household visits with CHWs, interviewing members

Last Friday, at the monthly Morbidity and Mortality Round (MMR) with the CHWs, my big boss, Dr. Felicien (the Health Coordinator for the site), and my CHW boss, Maurice (the CHW Manager) introduced me to all the CHWs and Senior CHWs in the community. They gave me a little welcome chant--it was pretty cool, but I didn't have my camera in my hand when it happened. :(

Maurice (left) and Felicien (right) discussing the new renumation program for CHWs -- their individual earnings will now go toward saving for a cow... see next pic for the CHWs' reactions to that news

Actually, I have no idea what the CHWs are talking about in these photos... but it makes for a dramatic photo story, right?

future CHWs

in the village

We arrived in the village yesterday and moved into our house. We met most of our colleagues at the Millennium Village office.

Our first sunset in Nyamata, with a cute little boy who wanted to be in the shot.

Our first house guest--I let him sleep in my room, though, sadly, he didn't make it through the night (Malak offered that he might still be sleeping, but I think she was just trying to make me feel better).

Le asked for chopsticks at the local hotel restaurant. They very sweetly brought her bamboo skewers to improvise with.

Photos to come of our house, our office, our neighborhood, our community, and our work.

Today I'm off to the field to meet the community health workers (CHWs) that I'll be working with this summer.