Health is Greater Focus of 2013 Peace & Reconciliation Conference in Uganda

13 01 2013

IMG_7739-croppedBy Caroline Hope Griffith
Research Analyst, Duke Global Health Institute

Hello from Uganda! I am here to attend the annual Great Lakes Leadership Institute organized by the Center for Reconciliation at the Duke Divinity School and its African partners. I will be blogging about the five-day conference, which brings together Christian leaders from East Africa (and a select few from the U.S.) working to promote peace and reconciliation in their communities. The week will be full of plenary sessions, discussion seminars, and time for worship and reflection.

I attended the 2012 Institute and came away inspired and awed by the work of these amazing leaders. (See last year’s blog posts compiled here.)

My three goals for this year’s Institute are to:
1. Learn,
2. Connect, and
3. Be present

Learn: This year, for the first time, we will have a seminar on reconciliation, trauma, and community health, which I helped to organize. In this seminar, we will hear directly from leaders working in the trenches about how they address health – physical, mental, and spiritual – in their communities and the role reconciliation plays in building healthy communities.

Connect: At Duke I manage research projects that connect faculty and students in global health, theology, business, and environmental studies to address difficult global health challenges. Over the next week, I will continue to serve as a bridge-builder, looking for ways to connect participants with each other (and possibly with my colleagues back at Duke) so they can support one another in their work.

Be present: One of the wonderful things about this Institute is that it takes the participants away from their daily routines and struggles. It is a place of rest, reflection, and rejuvenation and provides space to build and nurture relationships. I also plan to use this time to be present; to stop rushing from place to place and task to task and to focus on the conversations, the relationships, and the insights that the week is sure to bring.


My Visit to India as a DGHI Doctoral Scholar

19 12 2012

By Jie-Sheng Tan Soo
DGHI Doctoral Scholar

jie-sheng1I went to India for the first time last summer to learn and observe how fieldwork is conducted and to understand what life is like in a low- and middle-income country. It was my first time in India, and my first research trip as a DGHI Doctoral Scholar.

I’m a PhD student in the Nicholas School of the Environment working with my supervisor and mentor, DGHI faculty member Subhrendu Pattanayak, on research projects related to water and sanitation and improved cookstoves. I’m excited to be working with Dr. Pattanayak.

My first stop in India was the mountains of Uttarakhand, where I worked on the improved cookstoves project. To reach Uttarakhand from Delhi, we took a four-hour train ride and a three-hour car ride up winding, narrow and unpaved mountain roads. This long and at times dangerous journey was worth it as I could escape from the sweltering summer heat of the plains.

We were trying to determine the desired features of improved cookstoves and how to encourage usage of these cookstoves among rural households. For the ten days I was there, I helped with staff training and participated in household surveys. While I have worked with datasets collected by others, this was the first time I was part of the data collection process. This experience allowed me to put a ‘face’ to the datasets. It also gave me a new appreciation for the hard work that goes into data collection and for the time people give up in order to provide us with information.

jie-sheng2After a week and a half, I begrudgingly bade farewell to the mountains and their lovely people as I proceeded to the state of Orissa in the eastern part of India. This is one of the poorest states in India and signs of their relative poverty were obvious everywhere.

While in Bhadrak district, which is located at Orissa’s coastal area, I surveyed villagers involved in the 2005 sanitation evaluation study led by Dr. Pattanayak and others. This study was initially designed to examine whether subsidies and/or social pressure on open-defecation would lead to higher adoption of latrines. The team is following up to see if the adoption was sustained and, more importantly, if there were improved health impacts because of the use of latrines. During this particular visit, I met with rural villagers and gathered preliminary information on the sustainability of that project. Some villagers complained about the poor quality of the latrines while others seemed proud to have one. Regardless of their attitudes toward latrines, I was almost always invited for a cup of hot Chai. On a more somber note, I noticed animal feces in the village, possibly making it more challenging to quantify improvements in health from latrine use.

The highlight of my two weeks in Orissa was visiting and interviewing villagers. They welcomed me and treated me to many new and interesting sights. In Uttarakhand, I coordinated my visits with the help of a native, who happened to be a fellow Duke student. All these hands-on efforts made these visits more satisfying.

The last leg of my trip was in Maharashtra, where the financial capital Mumbai is located. Upon arriving in Mumbai, I was overwhelmed by a sense of familiarity as the high-rise buildings, luxury cars and well-paved roads reminded me of my native country of Singapore. At the same time, I was made painfully aware of the wide wealth disparity as Mumbai is home to some of the largest slums in Asia.

Similar to my time in Orissa, I visited areas like the rural district of Nashik to interview villagers about their water practices and health needs. The top health concern for this community is water availability. Due to the scarcity of this natural resource, the community wanted a more reliable source of water. The more fortunate ones had water tanks to store excess water. However, during the long dry season, the water in the tank is used up quickly. I asked whether having water tanks in their village helped to reduce cases of diarrhea. Their answers seemed to be inconsistent — everyone had a different idea of what diarrhea meant to them. This is a good reminder that anthropometric health measurements are needed in addition to self-reported health status.

Since making the decision to work on health issues in the developing world, I have the nagging thought of whether this city-dweller can fully understand the daily challenges the locals face and if I have ability to make a difference. My trip to India has made me realize that I still have a long way to go, but I have taken that important first step. I look forward to returning to India soon to continue this important research.

Engagement Through a Common Language Goes a Long Way

10 11 2012

By Jen Rackliff, MSc-GH student
from her fieldwork location in Rwanda

jen-rwanda2012Every morning, I come to the porch, also known as my “office”, and sit perched atop the hill overlooking the beautiful hills of Rwanda (pictured here). It’s a painting-worthy view and one I never tire of, but it is not quite how I envisioned my fieldwork to be.

For my self-designed internship, I am helping an international global health organization move its community health research agenda forward – both in supporting their current research and through my own research project. I envisioned regular field visits and closer interactions with community members and health care providers – seeing community health delivery firsthand. I quickly realized that was not quite how it would play out.

Though I learned in my first couple of days that I wouldn’t be so intricately involved with the surrounding communities, it still seemed as if I would be doing some incredible things, like helping identify study designs and methods for developing impact evaluations of community health programs. But, even this wasn’t quite as glamorous as I had envisioned. What it actually meant were days filled with conducting background research and literature reviews, which made my days a bit humdrum and unexciting. I knew I could not sustain a four-month internship this way – I needed to get more involved and be more active!

So, the first step was asking my Rwandan co-workers for ikinyarwanda lessons. Even just learning greetings and conversational phrases has helped me interact with local Rwandans, both at work and in the villages. I have developed closer relationships with my team and others throughout the organization that have opened doors for me to become more involved at both the organization level and the community level.

I now support my team on their current projects from back-translating study tools to conducting general research on current studies. I have been to the field to observe data collection and I regularly get invited to community health meetings held throughout the District. All of the field visits, data collection, and community meetings are in ikinyarwanda, which I don’t understand, but just attending is a learning experience! I’m thankful that I am able to properly address people and introduce myself.

Many places that MSc-GH fieldwork will take you will have difficult languages to learn, but the best lesson I have learned is how many doors can be opened by attempting to learn language – both professionally and socially! I often get laughed at when pronouncing (or, rather, mispronouncing) words and phrases and when I don’t understand the responses that people give me. But, my small arsenal of ikinyarwanda phrases and words is ever-growing, and the learning and laughter that comes from them, are what brings me closer to my friends and coworkers. It may be embarrassing at times, but I wouldn’t change it for anything!Many of my non-Rwandan coworkers and friends have commented about the things I have done and the opportunities I have had after having only been here for a month. I owe most of my experiences thus far to being able to engage, even if only superficially, through language.

Why Health Commodities Aren’t Reaching People Who Need Them in Laos

7 10 2012

By Madeline Boccuzzi, MSc-GH student

Spending a summer in Laos was a great way to complete my global health thesis research. Southeast Asia has much to offer including amazing food, kind people, glimmering Buddhist temples, and gorgeous landscapes. The work was fascinating and productive, and all in all, it was an incredible experience. I look forward to going back.

maddylaos1I knew very little about Laos before I started my fieldwork preparations, so a bit of a primer before I get into the meat of my work. Laos is a small, landlocked country sandwiched between Thailand (to the west) and Vietnam (to the east). It also shares borders with Myanmar (Burma) and China to the north and Cambodia to the south. The country is roughly shaped like a palm tree, and the capital city Vientiane sits on the western border where the trunk turns into fronds. The total population is just over 6 million people with about 700,000 people living in the capital. Laos is a communist country, but the government has allowed large-scale development projects in huge swaths of the country and is en route to losing its Least Developed Country status by 2020.

My fieldwork project evaluated Laos’ HIV and malaria procurement and supply chain processes. Supply chain and procurement challenges have a direct impact on health outcomes in Laos. Working through the World Health Organization (WHO) country office in Vientiane Capital, I was integrated into the Lao Ministry of Health’s (MoH) national HIV and malaria units in an effort to identify why health commodities do not reach the people who need them most. The WHO works intimately with the MoH, and both entities have identified procurement and supply chain management of health commodities a major public health concern in Laos.

Procurement and supply chain management can mean different things in different contexts, but my research is limited to what happens once commodities arrive in country and the process they go through to get to patients throughout Laos. I focused on HIV test kits, malaria test kits, and Artemisinin-based combination therapy (ACT) tablets to treat malaria in an effort to map the supply chain and procurement processes in Laos. These three commodities are particularly relevant in the Laotian context because of rampant HIV test kit stock outs and a three-fold increase in malaria incidence rates in 2012.

Laos does not have one single factor that would yield a challenging supply chain situation – HIV prevalence rates are low (0.2% in 2011), malaria has been controlled (3,837 cases; 17 deaths in 2011), there is decent infrastructure in place to reach the provinces, the government acknowledges weaknesses in procurement and supply chain management, and the Global Fund for AIDS, Tuberculosis, and Malaria has ensured that there is not a dearth of funding for HIV and malaria programming. This makes the HIV and malaria supply chain failures in Laos perplexing – a small country, with a small population and relatively low rates of infection and disease should be able to test and treat its population accordingly. Unfortunately, this has not been the case in recent years. HIV test kits have been in low supply or stocked out countrywide, resulting in areas with selective testing or none at all. As one of my interviewees said, “Not having [HIV] test kits is the worst possible problem a [HIV] program can have.” The best-laid HIV program plans are useless if you cannot test people for HIV.

maddylaos2Unlike HIV, malaria in Laos is seasonal. Malaria transmission follows the rainy season, which is roughly early May through the end of September. Malaria commodities (insecticide treated bed nets, malaria test kits, and ACTs) must be delivered to at-risk areas prior to the rainy season for effective malaria prevention and treatment. Delays in receiving bed nets and delays in distributing them to the provinces have caused a significant malaria outbreak in the South. There have already been 11,221 malaria cases and 12 deaths from January –May 2012, a shocking three-fold increase from 2011 year end statistics.

My research interests in supply chain management aligned with a great need for clarity on the current health situation in Laos. The MoH and the WHO know all too well that supply chain failures negatively impact Laotian health, but where and why the supply chain fails had not previously been studied. I conducted 35 key informant interviews with health care workers at all levels of the supply chain in an effort to understand the barriers and bottlenecks they face. I spent a week in the southern province Savannakhet and met with people who are actually using health commodities at the point of care and must face patients who are unable to get the products they need. In addition, I sat in on almost all procurement-related meetings during my time in Laos, which allowed me to see firsthand how these issues are being handled. These data collection methods afforded me unprecedented access to what makes the supply chain tick and gave me the opportunity to work with key players to help solve problems.

While the data is still being analyzed, I can report that there is no one reason why commodities are not reaching patients, but rather a complex web of coordination and management issues that you might expect to find in any organization throughout the world. The issues fall on a continuum ranging from systematic challenges (i.e. the human resources available) to implementation/technical challenges (i.e. storage of goods). Although this seems daunting and there is not one magic bullet that can solve all of the supply chain challenges in Laos, there are intermediate steps that can help address specific problems, ultimately improving the system step by step. Seemingly small changes such as making reporting forms for village health workers easier to fill out would make a big difference all the way up the chain.

My Visit to DGHI’s Student Fieldwork Site in Tanzania

6 09 2012

By Melissa Watt, DGHI Assistant Professor

When you pull off the paved road toward the village of Mwika, the first thing you see is the Lutheran church nestled at the bottom of the hill among the groves of banana plants. The church serves as the center of the community, and we first paid a visit there to meet with the community’s leaders and the partners of DGHI’s Student Research Training (SRT) program.

It was serendipitous that I was in-country this week, since I recently agreed to serve as the new faculty mentor for the SRT site in Tanzania. Vera Mushi, the on-ground coordinator of the site, and Trish Bartlett, who has served as the mentor for the past several years, graciously accompanied me to the site to show me the setting and help facilitate the introductions.

The primary partners of the SRT program are the pastor, the staff of the Mwika clinic and Mama Nancy, who provides the homestay experience. These three partners work together to welcome and support the group of Duke students who go to the village each summer. Their summer experience includes cultural immersion, a clinic-based project and a household survey on the knowledge and needs of the community.

Mwika partners shared with me how successful the student projects were this summer. Duke students completed two large projects. (READ THEIR BLOG.) They organized all of the patient files in the clinic to create an electronic database to link medical record numbers with patient names, and they completed a household survey on major health issues that culminated in a community workshop and a colorful brochure to share the findings. In addition to these accomplishments, the pastor praised the students for how enthusiastic and kind they were during their stay. Mama Nancy told us about how the students became part of her household during the two months they lived with her.

I feel grateful that I was able to visit Mwika during this trip, get to know the location where the Duke students live and work, and meet our kind and committed partners. I look forward to supporting Duke students in the years to come, in order to continue to build this relationship and build upon the very strong foundation that has been built. I hope to return to Mwika someday to breathe in the cool air and visit again with these warm people.

Working to Improve the Lives of Women With Obstetric Fistula

31 08 2012

By DGHI Assistant Professor Melissa Watt and DGHI Doctoral Scholar Sarah Wilson

We just hosted a workshop in Moshi, Tanzania on the psychological and social issues among women who have obstetric fistula. We sought to share our study findings with doctors, nurses, nongovernmental organizations (NGOs) and public health workers to facilitate discussion and action that can ultimately lead to improving how we care for these women.

The workshop was the culmination of a two-year study, funded by DGHI to examine the mental health of women with fistula who are receiving fistula repair at Kilimanjaro Medical Center (KCMC) in Moshi. KCMC is one of the few health care centers in Tanzania that has the capacity to repair obstetric fistula.

Obstetric fistula is a terrible condition and embodiment of disparities in society and health care. Women who develop a fistula often spend days in labor – either failing to get to a health care setting or being neglected by health care workers at a time when they desperately need a caesarean section. They often wait years with a fistula before they reach repair, due to poverty, lack of knowledge and poor access to health care.

A fistula develops when the fetus is stuck in the birth canal, eroding the vaginal tissue, and produces a hole between the vagina and bladder or rectum. A woman who has a fistula experiences uncontrollable leaking of urine and/or feces and a persistent bad odor. The psychological impact of their condition can also be devastating. Women are often isolated and stigmatized in their communities, and they may have severe pain and gynecological infections. In addition, they are dealing with the painful memories of the labor experience that led to the pregnancy, the loss of a child and the possibility of never being able to give birth to another child in a culture that highly values childbirth.

During the workshop, we shared our finding that – not surprisingly – women with obstetric fistula had higher levels of depression and more symptoms of post-traumatic stress disorder compared to women without fistula. We also found that they had lower social support, which may either be because they had low social support before the fistula or lost support due to the fistula. Quite interesting and unique to this study, we learned that women with fistula had high levels of shame. They felt worthless and unacceptable, and they commonly used negative coping strategies like self-criticism and giving up.

However, we were surprised to find that disclosure was a big issue in the study. Despite their obvious physical symptoms due to leaking, women spent years hiding their condition from others, keeping themselves sequestered in their homes and denying themselves food or water to try to prevent it. As we reflect on these findings, we can’t help but put ourselves in the shoes of these patients – to imagine what a terrible impact this must have on their lives.

As we shared these findings, workshop participants noted how this resonated with the experiences of fistula patients they care for at their health facilities. We talked about what it would mean to provide “holistic” care to these patients (taking care of the whole person, not just the hole in the vagina), and people had ideas about the need to address the multiple needs of these women in care. One suggestion was to collect information on the patient’s life history in addition to the physical and clinical history. Understanding the woman as a whole person would help to identify an individual care plan that includes mental health counseling, pastoral services, referral to other clinical services and linkages with relevant NGOs.

Of course, the glaring challenge is health care resources. Tanzania, like most African countries, experiences a severe shortage of health care workers. It makes the implementation of anything beyond the basic clinical services difficult to provide. However, participants kept coming back to the definition of a “cure” for fistula, and what “care” means. There seemed to be consensus that if the broader psychological and social needs of these women were not met during the time she was in care, then the health care setting was not providing the best care for the woman.

We spent the next few days at KCMC, working with the Department of Obstetrics and Gynecology to talk about how our study findings and the workshop discussion can inform both the provision of obstetric fistula care, as well as the next important research step.

It is wonderful to be here and humbling to work with people who have dedicated their careers to caring for this vulnerable population.

It’s Not Fair

29 07 2012

By Joy Liu

The past week marked the second week of our research. Six mornings a week, Sabrina, Daniel, and I go with our translator and a CRHP staff member to one or two of the twenty villages that have documented cases of neonatal mortality. Usually, we’re greeted by the village health worker. Based on our records, her records, and the government village health worker’s (called an Angan Wandi) records, we compile a list of neonatal mortality. Then, we follow the village health worker in search of the households so we can interview the mothers in order to better understand the causes of neonatal mortality.

To me, the interviews are perhaps the most interesting but discomforting part of the research process. Our NGO partner didn’t want English translation to be provided during the actual interview itself, so I have very little understanding about the actual conversation until much later. The interesting part comes from observing the body language, facial expressions, and mannerisms of both the mother and our translator. The discomforting part is more subtle, something I only pick up when I really take the time to look at the mother, her children, her husband, her in-laws, and her surroundings. In nearly every single interview, I’ve had a moment of clear realization, a moment when I’m singularly conscious of the fact that the only thing separating me and the woman I’m sitting less than a foot away from are the circumstances of birth.

Nowhere did this hit home for me more than one particular interview we did a few days ago. From the moment she first entered the room, I sensed something a little different about her. She looked very young for a mother, but carried herself with remarkable poise even though I sensed that she was shy. When she talked, her words were much softer than those of the other women we interviewed. She was at times drowned out by her more overbearing mother-in-law, sitting back as the elder chattered on. Out of the now over seventy mothers I’ve interviewed in Kenya and India, she was the first woman who cried. It was when she no longer had the power to control the tears welling up in her eyes that I realized why she stuck out to me, and it was a classic light bulb moment. When I looked up at her again, what I saw was a reflection of who I might have been. It was like having a mirror held up before me, only the person staring back wasn’t really me in the physical sense of the word. I saw so much of myself in her shyness, her hesitancy, her soft-spoken manner. I frowned a little when I saw her mother-in-law prattling away while she listened because that’s my position most nights at the dinner table with the rest of the CRHP group. When I saw her tears, I wanted to cry with her because I too, am a terrible actor and concealer of emotion. I respected her for not keeping the sari blouse piece we gave her at the end as a token, for tossing it aside to her mother-in-law like she couldn’t accept anything for the memory of her dead child. I smiled when I saw the way that her hair was arranged—the way she clipped it twice, but how the ends of her hair were still sticking up with a slight messy, pesky curl because it was at the awkward length between too short and too long. I thought about how many times I had tried to smooth my own hair in frustration when it peaked up like that. It was the small, unimportant details that made me blink back tears. It was the knowledge that even though we may be so similar, our lives couldn’t be more different. Then, I felt the guilt, a “Why was it me instead of her?” moment. Then came a new kind of sensation—anger. I had an indignant “This is not fair” hour or two.

It’s such a basic realization. I was fully aware that I sounded like a five-year-old pouting child when I kept on repeating “It’s not fair” in my head over and over again. If we were sharing this in class, I would sound stupid. But as I kept processing, I realized that there’s a lot of power in that simple statement. I could have been born here. I could have been her. BUT I WASN’T. For whatever reason (providence if you believe in God, chance if you don’t), I was born on April 2, 1992 in Jilin, China as the daughter of Fujun and Fenghua. I was given this particular lot in life. It’s not for me to question or feel guilty about why this is, because that’s of no use to anybody. It’s for me to decide what to do with what I’m given. Those three words, but I wasn’t, are what separates me from this woman, and that’s what is fundamentally not fair (and consequently probably the basis of social justice). There’s power in that basic complaint because it confers responsibility. That woman never once looked at me during the entire interview (I was sitting behind her). I’m not sure if she even knew I was there. I’m fairly certain that she’s already forgotten me. All of that doesn’t change the fact that I have a responsibility to her. I was given what she wasn’t, and I have to make it count.

I’m getting a little angrier just sitting here writing this, and I almost never feel angry (the consequence of inheriting an awful temper that I’ve worked very hard on suppressing for years). I remember sitting at a crowded table with Dr. Peter Drobac (PIH Rwanda Director), hearing him tell his life story. I remember very distinctively that he said that he felt angry when he first encountered injustice, and it’s the sentiment that has fueled so much of his motivation to work in global health. I didn’t understand it at the time, partly because I never really cared enough about anything to get very worked up and partly because I didn’t understand how anger could motivate something good. Eight months later, those words are starting to make a lot more sense. I feel a bit more angry, a bit more motivated, and a whole lot more sympathetic to the complaint “It’s not fair”.

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