the moodle is trying to kill me, or "what i did on my summer vacation"

Studying the trials and tribulations of underdevelopment is all well and good, but I never understood the importance of practice as much as when I had to use the moodle (the internal website for my graduate program) on a low-speed internet connection. 

The impatience I felt last fall for the global classroom (connecting the entire network of MDP programs around the world) from a Columbia user point-of-view is nothing compared to what it feels like to try to open a single page on the moodle from anywhere that doesn't have high-speed internet--even using the "low bandwidth" setting is not enough to keep my blood pressure from soaring and the vein on my forehead from popping out a little more. My sympathies go out to all those who were connecting with us during the global classroom.

Nonetheless, in terms of getting through the day, the Internet and its connection speed are the least of our worries, as rationing water and power come before we even begin to think about how painfully long it takes and how many tedious steps are involved in accessing the moodle.

The four of us working for Millennium Villages in Rwanda this summer opted to live in Nyamata, the "biggest" town near the actual MV village, Mayange, and where the MV Rwanda office is located. In the seven weeks since we arrived, the dry season has progressed and we are feeling it at home. 

We are supposed to have piped water at the house every Tuesday and Wednesday morning and every Friday evening—though I found out today that this has been cut to twice per week. For the last four weeks, we've had problems of not being able to fill the house's water tank because the water pressure was too low, or the water that was supposed to arrive on Tuesday morning at 7am didn't start until 5pm or 10pm or even 4am the next morning, which means Daniel, our house guardian, has to stay awake until the water is on so he can fill the assortment of jerry cans, 5-liter water bottles, plastic buckets, and cooking pots we’ve assembled to store extra water. We've had to buy extra jerry cans of water (at 150 RWF a pop) to carry us through to the next time the piped water came on.

I taught Le, one of my housemates, the phrase "if it's yellow, let it mellow," and we've all become very strategic about trying to use the toilet somewhere besides home as much as possible in order to avoid running out of water for things like washing dishes, flushing the toilets, and performing our own limited ablutions.

(Having grown up in Southern California during a looooong drought, I'm no stranger to water conservation behavior change campaigns and I'm pulling out all the stops in our house this summer. So, yeah, like thanks, California Board of Education, I, like, totally learned something, I guess.)

The sink in my bathroom is like the canary in the mine—each time I turn the knob is like a check on the gauge, I can tell by the water pressure how much is left in the tank and the smaller the trickle, the closer we are to running out; I’m always anxious that this turn will be the one that releases only a gurgle of air and perhaps a melodramatic final drop or two. 

This week we ran out of our last jerry can on Monday morning and the tank was completely empty by the next morning. The water came at 3am and today we woke to a full tank, a platoon of water containers at the ready, and Daniel fast asleep despite the late hour because he’d been up all night first waiting for the water to come on and then filling the containers.

Also, I don't know how or if this is related to the water problem, but for the last few weeks, nearly every night we have had a power outage that lasted anywhere from 2 to 4 hours. This is only inconvenient in that it usually happens right in the middle of our dinner preparations, so we've become connoisseurs of half-cooked pasta topped with olive oil and soy sauce (75% of us are East Asians, after all). When it happens in the afternoon and the back-up generator is out of gas, the office empties, and work grinds to a halt.

Bitch, moan, rinse, repeat. 

As annoying as the water and electricity problems we're having are, they are not really much more than that—simple (temporary--for us) annoyances. I remind myself that even complaining about these problems is a sign of the relative luxury we are living in compared to most of the people in the community we serve and the neighborhood we live in.

Every day, we see kids and adults pushing bicycles heavy-laden with full jerry cans up and down the inclines that give Rwanda its "Land of A Thousand Hills" namesake. Electric wires and poles crisscross the Rwandan countryside, but at night, houses are as likely to be lit by kerosene lamps as electricity as “cash-power” is too expensive for most despite their technically being “on the grid.”

All this has made me wonder, at the end of this summer, are these three months much more than just adult camping? Are we the ultimate summer poverty tourists,“slumming it” for the novelty of seeing development in action? I'd like to think not and I'd like to think that, just like with what CA’s Board of Ed taught me about water conservation, I'm, like, totally learning something along the way.

While the three months of summer initially seemed like they would stretch lazily across twelve long weeks, I can’t believe we’re already more than half-way through. It seems like we’re only now getting settled and it’s already time to start preparing for our goodbyes.

Professionally, admittedly, I’m not making a lot of progress. I've come to realize that given the language barriers and the heavy involvement that the CHW program has with the Rwandan Ministry of Health (read: bureaucracy moves slooooowwww) and the hesitation (read: we are explicitly forbidden) I have to "go rogue" at the Mayange site (read: strike out on my own with an interpreter in tow), I'm probably not going to get very much accomplished with my project this summer. 

To make up for that, I’m trying to learn as much as I can about Rwanda's culture and society (with some very interesting observations! More to come on that in a later post.) and how these influence the country’s development challenges. I do this by tagging along for site visits even for sectors that aren't explicitly under the health sector purview, talking to people I meet on the bus to and from Kigali, and asking people why they think things are the way are or work the way the work or what they would keep or what they would change about Rwanda’s development progress.

I still have hope that, ultimately, I’ll be able to produce and deliver something that the MV health office here will find useful, but, so far that seems as likely as a full tank of water on a Tuesday.

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

clinic office visitors

Now we know, the answer is the chicken came first.

p.s. Her name is Ange (angel in French) and she was a total adventuress... on the move the entire morning, but always making sure her mom was nearby.