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.

i was theeeeeeees close

It's a little difficult to see, but in this picture all three gorillas that we hung out with are there, including the silver back who is hiding in the bushes, sort of toward the upper right corner.

also this moment was right before...

I took this picture:

gorillas

For as long as I've known her (and I've known her since her beginning), my sister Emi has been obsessed with primates. When I told her I last week that I was going to Uganda to see the gorillas, she told me I was living one of her lifelong dreams.

For Emi

silverback traveling

lunch time

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.

no electricy, no problem (ok, a little problem)

Last week, I learned the word ntakibazou, which means "no problem."

The most common response I get to almost any request I make is "no problem" and now that I've learned how to say it in Kinyarwanda, as Janice pointed out, I'll probably start hearing it everywhere in conversations around me.

We had no electricity at the office last week from Tuesday afternoon until Friday morning. Little mini-shutdowns that last for a couple minutes aren't uncommon at the Millennium Villages office, but usually either the generator kicks in pretty quickly or the breaker is fixed and we're back in business in no time.

But since Tuesday, we were out of "cash power," the prepaid system Rwanda uses for electric and water utilities. Wednesday morning we were running on the generator, but by the afternoon, the generator was out of battery too.

Most of the office was in Kigali last week for the Millennium Villages annual meeting/retreat, so the power outage wasn't too disruptive. Those of us left at the office already had a lot of downloaded research to go through anyway, but no electricity meant no wifi and no wifi meant no blogging and no blogging meant... lots of picture taking and processing.

Thursday morning, we had a surprise site visit from Jeff Sachs (of MDG fame), Sonia Sachs (health director for the MV project and J-dog's wife), and their family, so there was a bit of scrambling in the morning to get ourselves set up for their tour.

the agriculture info sign drew the attention of both young...

and old co-op members

me and the president!!! chantal is the president of the basket-weaving co-op board

this other president is popular here too

yes you can... be ready for your close-up

Once we had everything set up at the cooperative, we were able to socialize a bit with the women and men working there and worked more on our Kinyarwanda fluency and basketweaving skills.

"how's it going?"
"amakuru"

"good morning!"
"mwaramutse"

(photo taken by Malak Yusuf)

(photo taken by Malak Yusuf)

 

the co-op president formally welcomes jeff sachs

I talked to Sonia for a long time about the health system in Rwanda and at the site. I told her that overall I'm pretty impressed with how things are working here. I'm very interested in how the mutuelle de sante (national health insurance) system is working here and how that is incorporated in the community health system/policy that Rwanda's Ministry of Health has made the core of its national health policy.

can i help you? baboon etiquette

We visited Nyungwe National Park this past weekend and were greeted by a pack of baboons not long after entering the park. This guy was the last in the pack that we came upon.

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.”

the little team that could(n't)

Yesterday, Rwanda faced off against Algeria in a FIFA World Cup qualifying match.

David organized us to go watch it and we invited along our fantastic colleague, Alain, to join us. Alain was of two minds about attending--on the one hand, it might be fun; on the other, as Alain, a Rwandan, assured us, it would be pointless to watch because Rwanda would surely lose. But the Rwandan fans wouldn't be deterred and showed up to support the home team.

They tried their hardest and put up a good fight--indeed, Algeria was not playing at its best--but, ultimately, their good fight wasn't enough. The game ended 0-1, Algeria. 

a daniel update

I tested Daniel's literacy level in English as well his numeracy level. He's actually pretty advanced when it comes to writing (he has great penmanship) and math (he can do basic quadratic equations). His listening comprehension needs to most improvement and he's getting that easily by just dealing with us every day. His reading comprehension needs to be improved--he's not at the level yet where I feel he can read a newspaper article without a lot of dictionary help.

But he likes getting homework and I think he'll be much more advanced by the end of the summer. I ended up spending about an hour with him on Wednesday night as well. The added difficulty that I think is common among all Rwandans above a certain age is that they have spent their education using three different languages as different stages--in primary school, it was all in Kinyarwanda, then in middle school, it was in French, then in 2008, all school switched to English, so some people went from the last year in middle school to the first year of high school and on in a totally different language.

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...

************************

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

seriously, there are babies everywhere

Another summer highlights album... please no comments about my ovaries, uterus, or biological clock.

photo reel

I'm posting highlights of the photos I'm taking over the summer on this web album:

play on words

This guy works for a gorilla conservation organization in Ruhengeri, near where a lot of the gorilla trekking areas are.

Muzungu means white person, but generally refers to all foreigners/non-black people in Kinyarwanda and the shirt refers to the movie Gorillas in the Mist, about Dian Fossey's gorilla conservation work. 

another office, another visitor

daniel, our man friday

Daniel is our house guardien (angel)--his duties include everything from keeping up the exterior grounds, to fixing toilets, to chasing out bats (which, as it turns out, means killing them...). He's super nice and takes good care of us and the house. 

He's 23 and, as he was quick to note, single! Actually, it turns out that telling your marital status is a pretty common part of the self-introduction process in Rwanda. 

Bit by bit, we are learning more about Daniel. As with so many people we've met in Rwanda, Daniel's life was deeply affected by the 1994 genocide (sometimes referred to as simply "1994"). He was left orphaned when his mother and father were killed. He worked hard at school and won a national scholarship to a technical high school nearby our house in Nyamata, where he studied carpentry. 

He's actually pretty decent with his conversational English and, like many young Rwandese, understands some French--I speak to him using mostly English (with the aim of improving his English skills by the end of the summer), a little bit of French, and a lot of miming, charades, and hand gestures. 

The Rwandan education system used to be conducted entirely in French, but in 2008, with the intention of modernizing and further advancing its development, Rwanda switched to an Anglophone-based system. So, for people like Daniel, their education is a mixture of French and English. For example, things that one might especially learn when in primary school, like numbers, are easier in French than in English.

Daniel and I have had a couple of long talks since we moved into the house. Last night's was a quietly epic one that began with us talking about instructions for the woman who comes on Tuesdays to clean and do laundry (her name is Chantal, more on her later this summer as I get to know her better) and ended with us agreeing to do an English study lesson once or twice per week. 

Tonight will be our first English lesson and I'm planning to do a general assessment of his literacy, writing skills, reading comprehension, and numeracy. I'll write up a follow up soon!

P.S. It turns out the other girls I live with want a little French lesson, so I'll be covering numbers and greetings with them in French tonight too!

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.

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.