Coming to America

I have managed to write nearly fifty blog posts about my experiences as an American in Senegal.  But what about the other side of the coin—a Senegalese’s experiences in America?  With as much as I’ve talked about the struggles and delights of cultural differences, what would those differences look like to a Senegalese person? Just over a year ago, representatives from the embassy, including the Ambassador, came to visit my site.  Afterwards, they asked the health district to select someone to go on an exchange trip to America with health care professionals around Africa.  Fatou Traore, the mid-wife who serves as the Reproductive Health coordinator for the district, was selected, largely for her work with Peace Corps volunteers.  The trip was three weeks, and they visited DC, New York, Atlanta, Little Rock, and Los Angeles.  I was so excited to see Fatou had returned this week and promptly peppered her with questions, which she agreed to let me share here.

Fatou in New York (photos courtesy of Leah Moriarty)

ANNĒ: What did you think of my country?

FATOU: I didn’t want to come back!

ANNĒ: What was your favorite place that you visited?

FATOU: Little Rock—the landscape reminded all of us of Africa, and we got to visit smaller villages.

ANNĒ: Was there anything that was hard for you about America?

FATOU: The situation with homeless people.  In Los Angeles we went to a soup kitchen and fed over 900 people.  They said that there are that many people to feed every day.  I couldn’t believe that America is the richest country in the world and that there are still homeless people.  Also, the AIDS situation was surprising.  I had thought AIDS was just in Africa.  But it’s so different there.  Here, nearly all of the transmission is from unprotected heterosexual sex.  But there it primarily is injection drug users and MSM.  In the US, even though medication isn’t free, almost everyone who is HIV positive is on ARVs.  Here, the government pays for it, and we can’t get people to get on treatment.

ANNĒ: What else did you do?

FATOU: [Grinning] We went to Disney Land, the Bill Clinton Museum, the Jimmy Carter Museum, and the Native American Museum in Washington.  They organized lots of meetings for us and dinners.  We met people from Peace Corps administration (I told them I loved working with Peace Corps volunteers, that they were great people who have left their comfortable lives to come and do good in Africa), and we had dinner with several women who were over 60 who had done Peace Corps in Niger and Congo.  The woman who was in Congo still had not forgotten the language!  I saw New York with Leah [the volunteer who Pat and I replaced) and had dinner with Fode Mady’s [Ian’s] family in Atlanta. [Ian told me that it was so wonderful for his family (especially his sister who hadn’t been able to visit) to meet someone who had been part of his experience in Senegal.  As they were driving to drop her off, they passed a parking lot, and Fatou remarked, “Cars must be really cheap here.”  He had to figure out how to best explain that, no, they are the same price, people just have so much more money to spend on things like cars.]  We went to a small village outside of Little Rock, and they compared it to a Health Post, but it was a hospital.  It was better equipped than the new [and as of yet unopened] Saraya Hospital.

Fatou and Leah reunited.

ANNĒ: Was there any cultural differences you noticed?  When I first came to Senegal, I was quite struck by our cultural differences.

FATOU: Well, you know, here we are used to doing this in meetings. [Raises her hand and snaps her fingers repeatedly and aggressively.] You all don’t do that. 

ANNĒ: Yes! I was completely shocked the first time I ever walked into a classroom here!

FATOU:  But you know what really made an impression?  The hospitality. [It should be noted here that Senegal considers itself the country of Teranga, or hospitality.  For her to say this is a big deal.]  I thought that in developed countries I wouldn’t feel welcomed, but on the street, people greeted me.  I’ve heard that that doesn’t happen in the other countries, like France.  If we were lost, sometimes people would stop what they were doing and help us by looking up directions on their phones and steering us in the right direction.  And my veil.  I was very nervous about wearing my veil after everything that has happened in America with terrorism, and I thought that I would feel ill at ease and judged.  My younger brother actually told me that I shouldn’t wear it.  But I did, and it was fine.  I never felt uneasy and felt like people were just looking at me as a person.  No, everyone was very welcoming.  We were even met by a translator at the airport!  And hospitality was also shown to us at the dinners in families that were arranged.  I had dinner with a retired lawyer and social worker.  The other cultural thing is the volunteerism.  People give of their time and money to NGOs.  Here, the rich do not help the poor like that.  And everything was so clean!  The streets, the hospitals.  At the hospitals, people were always talking about hand washing.  You could be driving and not see a single piece of trash.  What else?  Obesity.  That was very shocking to see.  They say it is a public health problem in the US.  And diabetes too, it’s all caused by obesity. 

ANNĒ: Speaking of obesity, what did you think of the food? What did you really like?

FATOU: Mexican food [which happens to be the food that is generally agreed upon to be the most missed amongst volunteers].

ANNĒ: Anything you didn’t like?

FATOU: What was it called? Oh I don’t know…usually we asked the waiter what everything was on the menu, so I always got something I liked.

I guess that means she liked this ice cream!

I have to say, I was surprised about some of her answers, particularly because of the questions that people ask me based on their impressions of the differences between Senegal and America gleaned from TV.  I was so glad to hear her impressions of American hospitality, because it is commonly believed that we are completely inhospitable to each other in the Western World.  It’s so great that the Embassy provides this kind of program.  People often ask me why I can just come here to Senegal like it’s nothing, and it’s next to impossible for them to get a visa to see America.  I typically say something about how long and hard the Peace Corps application process is, but really, that’s just an easy answer.  It’s not the same, and I have not only access to a super easy American life but the opportunity to up and visit places where life is not easy.  It’s a tough question to grapple with, like so many other questions of inequality that I constantly encounter. Giving someone like Fatou a chance to visit the US and have an overwhelmingly positive experience there, however, is a great diplomacy tool, and I hope more programs like it emerge. 

It also made me even more excited for our upcoming trip home.  Just two months to go until we get to stuff our faces with MacKenzie River pizza and salads, drink Montana micro-brews, hike in the Bridgers, go to a movie, sit out on my parents deck and watch the Alpen Glow, chat with family and friends without having most of the conversation be “Can you hear me now?”, dance and be merry at two weddings of dear friends, celebrate 30^th and 91^st birthdays.  Oh, America.

I'm just in it for the t-shirt

May 15^th marked one year spent in our site.  I’ve been told that you have to live four seasons in a place to really know it (although the four seasons was referring to Montana weather, and there are really just three here).  We have come full circle and are starting up again with weather, the pests that come in short-lived plagues, and the agricultural season.  But we have also seen and participated in a year of public health activities directed by the health center in our site.  In addition to working on our own projects, we help out at the health center whenever we can.  Not being practitioners ourselves, that usually ends up being helping out with public health activities that typically come in the form of centrally organized campaigns or events mandated by the Ministry of Health.  You always know when a campaign has just happened, because all of a sudden everyone that is even remotely related to the health is sporting the same t-shirt.  

I now present to you a year of health district activities through the lens of the t-shirts we have collected, which are a big deal in the eyes of our community.

Vitamin A and De-worming

In real life, the baby on this shirt is super creepy.

One of the first activities we were invited to participate in was the distribution of Vitamin A capsules and mebendazole, a de-worming medication to children under 5.  This happens every six months.  It’s hard to know how old anyone is, so the under/over 5 cutoff is determined by whether a child can reach their ear by extending their opposite hand over their head.  While most people here get enough to eat, they are not necessarily eating well.  Micronutrient malnutrition is a big issue, with deficiencies in Vitamin A, iron, and iodine being common in the developing world generally.  De-worming children has also found to be one of the best interventions for increasing education rates.  This was a great opportunity to go to every single family compound in town (there are about 5000 people in our site, so we definitely hadn’t met everyone).  It maybe wasn’t so great for the kids, who had to take medicine and come into close contact with a scary white person.  It was the first time I realized just how terrifying my skin color can be, and I made a lot of kids cry. 

Vaccination Campaigns

Let's protect ourselves against Meningitis A

My first vaccination campaign happened after a measles outbreak in a neighboring village where every case was traced back to a gold mining site.  (People with gold fever apparently don’t have time to take their children to vaccination days.)  For the meningitis campaign, I was tasked with filling out people’s vaccination cards.  This was no problem until we went to a Pulaar village and I couldn’t even ask people what their name was.  At first there was a guy helping me and standing who would yell their names etc. to me, but when he was called away, I was stuck.  Fortunately, I had benefited from his assistance for enough time to realize that over half of the men were named Mamadou Diallo (and being a major mining site, it was predominantly men).  I decided to just say, "Mamadou Diallo?” to every man who approached.  No one ever thought this was a strange tactic, and they would either matter of factly say “yes” or “No, it’s Mamadou Ba”. The age cutoff for this campaign was 29 years old, and if you were to look at age data in Senegal purely based on the formation from this vaccination campaign, you would be led to think that there were a hugely disproportionate number of people born in 1984—you can’t tell the chief he can’t get vaccinated, or anyone else really, while supplies last.

World AIDS Day 

For World AIDS Day, my job was taking pictures and setting up what, in my opinion, is a terribly dangerous game that involves giving blindfolded children scissors and having them walk forward to a string laden with dangling prizes that they have to cut off in one snip.  T-shirts were given out as prizes to people who either correctly answered HIV/AIDS trivia or won dance competitions.  As I was walking home, my teenage neighbor yelled out “Sadio, I didn’t get a t-shirt!”  I said, “Well, Bintou, you didn’t answer any of the questions.”  “That stuff is not in my head,” she protested (direct translation from Malinke).  “Well how are you going to protect yourself from HIV then?  You should come over to my hut sometime and we’ll talk so that stuff is in your head.”  I expected her to scoff at this idea, but instead she said, “When, tomorrow?”  The next day, I had seven teenage girls in my hut that came with the explicit purpose to learn about HIV.  I felt like such a legit Peace Corps volunteer!  It was really a turning point in my relationship with the teenage girl community in my neighborhood, and I became someone they could come talk to about anything.  While this has been overwhelming sometimes, because there are situations that I do not feel prepared to counsel them about, I am so touched that they feel that they can come to me.  This is the power of a t-shirt in Senegal.

Schistosomiasis and De-worming

You may notice that there is no picture accompanying this section.  That’s because they don’t give a t-shirt for the schisto campaign for school children.  Schistosomiasis is known as a neglected tropical disease, and I guess that this is one way it’s neglected.  It is caused by a parasite that lives in snails that are found in freshwater.  All volunteers in Kedougou are presumptively treated for it when we leave.  The meds are no fun to take, and school children are not happy to take them.  I think they ask me to come along to make it seem more cool to take your schisto meds (I am also a member of the high school Spanish/Portuguese club for presumably the same reason).   

I’ve already written blog posts about the events accompanying our other t-shirts, but they have to be displayed here to show you our full collection. (You'll notice that volunteers have taken the t-shirt hint for our programs.)

http://lineoverthee.blogspot.com/2012/09/camp-la-senegalaise.html

http://lineoverthee.blogspot.com/2012/10/peacecare-and-disease-that-sits-in.html

http://lineoverthee.blogspot.com/2013/04/2013-kedougou-youth-leadership-camp.html

http://lineoverthee.blogspot.com/2013/05/be-cool-stay-in-school.html

A Whirlwind Month

While I typically avoid "this is what I did" blog posts and try to write about specific topics, the month of May has been such a whirlwind of experiences that could be blog posts in their own, that I have decided to condense it all into a series of mini posts in this one, to best capture the many goings-on of the hottest month of the year.

Bassari Initiations 

Each year, a group of 12-15 year old Bassari boys are initiated into manhood, and, this year, we were fortunate enough to participate in the celebrations.  The Bassaris are a minority ethnic group who live in Southwestern Kedougou (quite far from where we live).  They are distinguished from most of the other ethnic groups in the region due to their Christian/Animist traditions.  Their distinctive culture is appreciated around Senegal, and people from far and wide come to observe the initiations.  

The Kedougou Peace Corps volunteers (and a few friends from other regions) rented out a car to take us to Egath, the village where the initiations were held this year. 

We had a few too many people than would fit in the mini-bus, so I got  to ride to Egath on top.  It was exhilarating, and I only got a little sunburned (though very dirty).

Things got going on Saturday evening with the sounds of whistles and coming from the forest.  Then this procession emerged with ornately beaded costumes, goat hair ankle, and each with a scarf from the first woman he had slept with.  These were not the initiates but the older warriors.  This parade of whistling and marching continued with no breaks until about 1 am, when they retreated back into the forest.

Eventually, the initiates joined in the parade with their red and white outfits.  Most Senegalese boys and men shave their heads, and it was so different to see these boys with their braids.  Families choose the initiation dates for their boys up to three years in advance in order to prepare.

As the parade continued on into the evening, we set up camp and partook in the festivities, which included palm wine, honey wine, and millet beer.  It was so different to see alcohol consumed in a village setting.  You take a cup and go from house to house, and your cup will be filled.  Senegalese hospitality a la Bassari.

The next morning, the whistling came from a different direction of the forest surrounding the village.  The warriors emerged with their masks, their bodies covered with clay.  This parade didn't last nearly as long, and was merely a procession to the area designated for the actual initiation: the fights.

Women aren't allowed to watch the fights, but Pat was able to describe it to me.  (Children aren't allowed to watch either, but every ten minutes or so kids would come sprinting away from the fighting area, chased by a figure covered in clay brandishing a big stick.)  Each initiate is armed with a bow that serves as a shield, and a long wooden sword.  The initiate runs forward and hits the older warrior, and after a few hits, weapons are dropped, and it turns into wrestling.  In all but two cases, the older warrior won easily.  After a few hours, all of the men emerged back into the village where the women (the female Peace Corps volunteers in particular) were busy buying beautiful Bassari jewelry.  The new health volunteers were arriving in Kedougou that afternoon, so we had to hustle back to welcome them.  We are now the senior health volunteers, which is nuts.

Fighting Malaria in Paradise
Peace Corps Senegal has a great relationship with the President's Malaria Initiative, which has two resident advisors who work with the Senegalese National Malaria Control Program.  Because of this relationship, another volunteer (who also is a Masters International Student at Tulane) and I were invited to participate in a 4 day workshop regarding the roll out of an exciting new piece of the arsenal in the fight against malaria.  Seasonal Malaria Chemoprophylaxis is the provision of monthly malaria prophylaxis (like what travellers take) to kids in zones where malaria transmission is highly seasonal.  It is being rolled out in the four southern regions of Senegal this rainy season and is expected to reduce cases of malaria in the target age group (kids under 10) by 75%.  This workshop was for the National Malaria Control Program and partners to take the World Health Organization recommendations and turn them into an action plan for operations in Senegal.  Technical guidelines and tools for communication and monitoring and evaluation were created, and it was really cool to be able to help with that.  I have to say, I don't think I've ever learned so much in any other four day period.  After a year working at the district level of the health pyramid, it was fascinating to see how things work at the national level.  
 

Added bonus: the workshop was held in Saly, a beach paradise.  Pat was doing his mid-service health exams in Dakar for the first three days but was able to join me on the last day.  It was an all inclusive hotel, and the buffet of Western food was a great break...I had hit a brick wall the food at site and really felt like I needed a good break to be able to endure it for another year.

Festival du Jazz
We scheduled our mid-service health appointments in Dakar around the Jazz Festival in Saint Louis (it's such a trek from Kedougou to the coast that you have to make it count).  It was a great weekend in a really cool city.  Saint Louis' architecture really reminds me of New Orleans, so it was fitting to hear jazz music there (although nothing can ever compare to JazzFest in New Orleans).

Saint Louis--colonial city about as far as you can get from Kedougou within Senegal, in terms of geography, climate, and appearance.

Dakar

All volunteers are required to do mid-service health check ups in Dakar. Over the past year, between the two of us, Pat and I have experienced giardia, worms, skin infection, and typhoid fever.  Our mid-service check up was basically just a brief physical, a TB test, and a trip to the dentist.  It did provide a good excuse to explore Dakar while waiting for the 48 hours for my TB test to be read and then waiting a few more days in order to get a ride down to Kedougou in a Peace Corps car.

The first few days in Dakar were spent soaking up every last minute with our dear friend Ian before he left us for America.

Last blast on Ngor Island

Pat and I found these traditional Malinke mudcloth boubous in Saint Louis (we haven't been able to  find them anywhere in Malinke land, and the salesman was so stoked to meet us and told Pat that he was a real Malian (most Malinkes are from Mali and Guinea).  We got Ian a matching one as a farewell gift, which ended up being hillarious because he was given three other boubous within his last few days in Senegal.

A few girls from my training group were also in Dakar for mid-service, and we decided to go on an adventure to the Ile de Madeleine.  It involved negotiating with fishermen to get a boat out, but  all the sketchiness we encountered in that phase of the adventure paid off.  The island was beautiful, and we had a blast.

Now, after two and a half weeks out of site, it's time to hit the ground running with projects.  Pat says that rainy season started with a vengeance a few days ago, tearing apart the grounds at the Kedougou regional house.  Rainy season means malaria season, and there is a lot of work to be done to get ready for all of the interventions that are being rolled out in the next few months.  Good thing this whirlwind of a working vacation has us rested up and ready to go!

Be Cool, Stay in School

If I sit on the sidewalk in the morning to eat a bean sandwich these days, as I often do, I will see at least five cars stuffed with people on the inside and loaded down with coolers and building materials for temporary huts.  I will be surrounded by people trying to get on one of these cars.  Nearly every other sentence would contain the word “Kharakhena”.

The gold rush in southeastern Senegal has been a large part of my Peace Corps experience, but when the mining destination and boomtown changed from Sambrambougou, which is in the middle of nowhere and hard to access, to Kharakhena, a village 30 kilometers away from us on the beautifully paved road to Mali, it become a part of my daily life on a whole new level.  It is no longer inconvenient to get to the gold.  My host family is mining now.  The neighboring compound seems like a ghost town—they’re almost all in the djouras.  It is nearly impossible to buy ice or building materials here in Saraya—everything goes to Kharakhena where it will sell at between two and eight times the Saraya price.  The population of Kharakhena went from 78 to at least 5000 in two months.

Losing students to the djouras has been a big problem at the middle school/high school in town for a while, and now that things are blowing up just down the road, the problem is greatly exacerbated.  One of the first people who sought us out when we arrived last May was the former school director, who wanted to work with Peace Corps on a campaign to encourage kids to stay in school instead of going to the djouras. 

In July and August, we worked on a mural to kick off the campaign, which we called “My Future Shines Brighter than Gold.” 

"My future shines brighter than gold.  I don't leave school to go to the djouras.  To safeguard a job, a house, a family, my future, I stay in school.

Then, at our health summit last fall, our boss in Dakar approached Marielle, our former sitemate about working with Pat on a Jeune Relais (youth peer educator) project with the goal of keeping kids in school.  (Marielle and our other friend Ian had done a Jeune Relais in her former village that focused on family planning.)  We thought this was a great idea: it was a great project model and something that was really needed here, plus Pat had acquired a gang of teenage boy groupies, some of whom would make great peer educators.

Pat wrote a grant for funding from VAST, a PEPFAR funding source for small Peace Corps projects, and we planned to roll out the project in April, during the last three days of the students’ Spring Break.  We had no idea how timely the project was going to end up being. 

We developed a curriculum for a three day training for 12 kids from three middle school grades—the grades that the school administration thought were the most vulnerable for dropping out (although there was one week a few months ago where they lost 7 kids in Terminale—the last grade of high school.)  The curriculum focused both on the value of staying in school plus the dangers of the djouras.  

On the first day of the training, 5 kids showed up instead of the 12 we had planned for.  I’ve been here for long enough at this point that this was not heartbreaking to me, I would have been stunned if they all showed up (advanced planning is not a strong point of this culture, and we had invited them before they started their two week break.)  We sent the five kids back out into the community with a description of the kind of kids we were looking for (students that expressed themselves well, did well in school, and would be listened to by their peers).  They came back with 5 more, some of whom ended up being better than the students chosen by the school.

We opened with a discussion of school abandonment—why is it happening and why do we care?  It all comes down to money.  Almost everyone in the school comes from a family of subsistence farmers—money isn’t plentiful.  And then students see their friends who have dropped out zooming around on motorcycles.  It isn’t hard to imagine why the djouras seem attractive.  But when we turned the discussion from the positives of the djouras to the dangers, this is the list the students came up with:

·         -Accidents

·         -Fires

·         -Bandits

·         -Alcohol and drugs

·         -Dirty water

·         -Diseases (HIV, STIs, Tuberculosis)

·         -Toxic chemicals

-     - Violence

People are very aware of these dangers.   As much as people talk about the people who have made millionaires (which in dollars translates to having at least two thousand dollars), they talk about the highway banditry, the makeshift shantytowns made entirely of thatch and bamboo that burn down in minutes, and especially the giant fight that broke out in Diyabougou between men from Mali and Burkina Faso, killing at least five and hospitalizing about 20.  We asked the students, if you know how terrible these places are, why is everyone going there?  For them, they said it came down to the inability to get past the immediate interest of the possibilities of money to look forward to the future.  They see their friends with their motorcycles and are able to forget the risks.

Pointing to the list they had created, we told them the curriculum for the training.  In order to have credibility when talking to their peers, they had to really understand these dangers.  In this training, we focused on HIV and mercury toxicity.  We also added in a module on family planning.  For girls, although they do leave school to go to the djouras, early pregnancy is the largest factor in leaving school, as is the case just this past week with my sixteen year old next door neighbor and her fifteen year old best friend.   On the pre-test we gave them before starting, their knowledge of family planning was essentially zero.

 To balance the training on the dangers of the djouras, we had a career panel to talk about the positives of staying in school, plus a session on money management.  For the money management session, we wanted to show the advantages of studying to the point where you could have a salaried job over a gamble like gold mining.  It is also a phenomenon here that the villages that make people rich do not actually develop in any way that is sustained after the boom, so we talked about saving and investing in the community.   How bank accounts worked was a totally new concept (the fact that no one else could get to your money was received with both excitement and mild distrust), and we ended up spending quite a bit of time on that.  We also had a session on interpersonal communication to help them figure out how to express themselves when talking about these difficult subjects.

Midwife Fatou Traore explains the basics of HIV transmission and prevention

Fancy lunch from Saraya's own restaurant

·     

Interpersonal communication lessons with Sidy Lamine Traore from Catholic Relief Services

Mr. Cisse, who works for the local government under the title of "Responsible of Local Development" helped us do the honor of handing out certificates after his session on good money management.

Career panel with the assistant mayor and radio station manager (both from this area originally), a teacher (the original teacher we invited didn't show up--we found out later he had gone to the djouras), a police officer, and a nurse.  They talked about the triumphs and struggles in their careers and the importance of education in achieving career objectives.

Playing Jeopardy to review and catch gaps in their knowledge about HIV and family planning

Here's a video Pat took of me re-explaining the effectiveness of different family planning methods during Jeopardy (notice how my French has become totally Senegalesified).

In the Mystery category, one of the questions was "Name an American dish."  This was difficult, as you can see in this video.

They loved Jeopardy so much that they would play during breaks.    This particular  round was Saraya trivia.

For the most part, I was really happy to see how the training went.  It felt so good to be actually doing work in my site (working at the Health District level has meant that a lot of our projects have rolled out in surrounding villages).  Some of the girls who started with us didn't come back to finish, but the 7 that completed the entire training were fantastic.  They never wanted to end in the afternoon, and Pat and I would be exhausted and say that they had to stop practicing their causeries (the Senegalese expression for a talk about health or another subject in front of a group) and go home.

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We finished up the training by working with the kids to prepare a radio show.  They chose the themes of HIV and school retention, and we recorded them speaking in both French and Malinke about what they had learned and then aired it on the night of the last show.  It was a great way to conclude—we got to see how well they had mastered the material, and they got to start their peer education with a bang!

We plan to have mini-trainings with the kids every few months (they want to learn about malaria, first aid and tuberculosis), to maintain relationships with them and increase their capacity as peer educators. 

This continuity will be important.  The weeks that followed the training were a bit of an emotional roller coaster.

The evening after the training ended, I was sprawled out on my bed in my hut when three teenage faces appeared in the door.  “So the certificate we got, does that mean that we get to start sensitizing people about these issues now?”

“Yes!” I laughed.  “You are officially Jeunes Relais!”

 “Oh good, because we already talked to a bunch of people.”

I was so moved by their enthusiasm to make change in their community.  The day after the radio show, two of them told Pat that they were saving up their money to do another radio show (it costs about 4 dollars for someone to make announcements or do shows on air).  I told them I didn’t want them to spend their money and let them come and talk again the next time I did a radio show (Peace Corps has a free weekly slot). 

Three Jeune Relais doing a show they prepared, appealing to fellow students (and to teachers as well) to stay in school 

A few nights later, I was talking with Fatou, the midwife who led the HIV and Family Planning elements of the trainings.  “You know that before the training, Djiby was going to drop out.  He now told his mom that he wants to stay in school and become a doctor.”  I felt like I was walking on air.  It is not often that you get to see the results of something so drastically and immediately. 

But then, a week later, when we were going class to class introducing the Jeunes Relais to their peers, I was reading the list of names, and someone yelled out, “Djiby left school.”  He had done the supplementary radio show on staying in school just days prior.  It wasn’t gold fever, it was the opportunity to work on a car that goes back and forth to the mines, which is a respectable job.  But it did hurt.  When we saw him a few days later, he made excuses but then told us that he had been talking to people he encountered on the job about the issues we had covered in the trainings. 

You win some, you lose some.  You obviously can’t change an entire culture of early school abandonment in three days.  We will continue working with all of the Jeunes Relais, even the ones who have left school.  We designed the curriculum knowing that they would be equally talking to kids who were in school and kids who had dropped out and were encountering the djouras and their dangers.  Even if the training doesn’t keep kids away, I hope that the diffusion of information will help them to be safer, healthier and smarter while they are there.    

Ladies and gentlemen, the Jeunes Relais of the Lycee du Saraya

The Baby

When I walked I ducked into the shade structure behind the health center, it wasn’t the infant in the midwife’s arms that surprised me, it was the bottle.  Babies are omnipresent in this area that has a 1% prevalence of family planning utilization.  Bottles are not.  This was the first bottle I had seen in Senegal, while the number of breasts I have seen (breastfeeding or just hanging out) are countless.

“Who is this?” I asked Yvonne. 

“I don’t know,” she answered softly, gazing down at the baby.  That was clearly not the answer I expected, but she was too enthralled with the baby in her arms to want to engage in any kind of conversation that would give me any actual information.  My curiosity was piqued, and I went in search of someone who would fill me in.  Mr. Sy, the hospital social worker and my official counterpart, rounded the corner, and I rushed to ask him if he knew anything. 

He smiled sadly.  The baby was found in the woods outside of Koliya, a village with a big djoura (artisanal gold mining site) on the border of Mali, by a man who was looking for firewood.  She was in a hole, covered with rocks.  The man gave her to the village chief, and then somehow she was given to the Saraya Health Center.  They guessed she was about two days old.  “This is the kind of thing you might see in a big city, but never here,” he said, shaking his head.  “The djouras are changing everything.”   

I was absolutely shocked to hear this.  Even if women are not intrinsically valued in this culture, mothers are.  Teranga, the overwhelming Senegalese hospitality, would never allow for such a thing.  Families take in each other’s children all the time, and in any typical Senegalese village, a mother would not have to worry about raising her child if she were unable to.  My host sister has four children from four different men, and while she is not thrilled about her situation, all of her children are welcomed and loved by the family, which is the typical reaction here for children out of wedlock.   

But the djouras are not a typical Senegalese village.  The population is very transient—people looking to seek their fortune and going from one djoura to another, crossing the porous borders of Senegal, Mali, and Guinea to do so.  They are not tied to the location or the people, and the social ills that this phenomenon has brought are at times overwhelming.

When I told my host sisters about the baby later on that day, their reaction was incredibly strong.  (My friend Karin told me that I probably could not have told them anything that would have upset them more.)  “Why did the mother not just give her to someone else?!” they cried.

In a way, though, she did.  After Mr. Sy told me the baby’s story, he concluded by pointing over to where I had originally seen the baby.  “There is a long line of candidates to adopt her.  Including my wife.”  I looked, and Jojo had now joined Yvonne in gazing lovingly and unwaveringly at the tiny bundle.

I understood the first time I got to hold her.  Up close, I could see the gashes, undoubtedly left by the rocks.  Seeing those, I understood that she was not meant to live.  Yet here she was.  I have never been so moved by the miracle that is life.  This tiny life had somehow persevered through the dangers of abandonment in the Senegalese woods during hot season—the assault on her life from rocks, the intense West African sun, the animals.  She lived, and she was found.  If that is not a miracle, I don’t know what is.

Holding this nameless miracle, my thoughts wandered to another miraculous life.  The previous day, I had learned of the loss of Pat Robins, a family member whom I held very dear, to a brain tumor that was diagnosed in November.  Pat and I lived with Pat and Kitte Robins (Kitte is my dad’s cousin) right after we got married and had just moved to Missoula.  You know you have some amazing relatives when you are newly married and are sad to move out of their house.  I will forever treasure that time and all I learned from both of them.  He was truly one of the best people I have ever known, and I was having a hard time imagining a world without his presence. 

Yet, here was this new presence in my arms.  It seems corny to think of “The Circle of Life” while living in Africa, but there’s something to it.  Human life is precious and cannot be taken for granted.  Lives end, and lives begin.   It hurt deeply to be so far away while my family was coming together to grieve, but instead, I was in Senegal and got to see another family come together around the beginning of a life.

I have often thought of the staff at the Saraya Health Center as a family, and I know they do too.  This area does not produce many high school graduates, let alone professionals with the kind of training needed to become a nurse, midwife or doctor.  Everyone with those roles has been sent to Saraya by the Senegalese Ministry of Health to fill in the gaps.  You really can’t get much farther from the development of Dakar than Saraya, so it’s not a desired destination.  Yet, they still come, and even though they don’t really integrate, they leave their families to serve the communities that need them.  And they become family to each other.  It was really beautiful to watch this family welcome this new member that had no connection to them.  A collection was taken to buy formula and diapers.  The midwives took turns caring for her when they were off duty.  Everyone joked (in an only slightly joking way) about how they were each the best candidate to adopt her.  People talked of little else.

A week after she was brought into our lives, a baptism was held.  In the Muslim tradition, the baptism and naming ceremony is held 7 days after a child is born.  The date of the baptism was based on a guess of her birthday and the time that the hospital is typically the slowest.  Her head was shaved, and she was given the name Fatou Traore, after the head midwife of the district.  A fancy chicken meal was prepared to celebrate this new, unexpected life.

I had thought that Madame Loum, the midwife who had taken the most ownership of little Fatou and had come to be referred to as her mother, would eventually beat out the rest of the hospital staff (and the rest of the community of Saraya once the word spread) and adopt her.  However, since the health center was a government entity, they decided they needed to do things by the books.  Senegalese social services (which I didn’t even know existed) made a plan to come to Kedougou to take her.  At the rate that things usually move here, I thought we would have at least a month with her.  But then, only a few days after the baptism, I entered the health center to hear Madame Diarra tell me that I was too late.

“Too late for what?” I asked.

“They just left for Kedougou.  Social services called and said they had to bring her there this morning.”  She would then be taken to Tamba, where a judge would decide which of two candidates for adoption could take her.  Madame Loum was not allowed to apply since she already had a child.  The head doctor declared that the hospital team would follow her case to ensure she was in a good home,  just as quickly and unexpectedly as she had arrived, she was gone.

 

But the reminder about miracles at a time that I really needed comfort…that endures.

   

  

  

BAMM!

Having now been here for over a year, patterns are starting to emerge.  It’s now April again.  April means a lot of things: one of the hottest months of the year, saying goodbye to our friends and mentors who came a year before us and meeting those who will replace them, the ripening of mangoes, and Blog About Malaria Month.

Last year at this time, I was still in the midst of Pre-Service Training and wrote my BAMM blog as a way of sharing information from the big paper I wrote for Tulane before coming about malaria prevention and control in Senegal.  Since then, my experience with malaria has gone from writing papers about a disease to living through rainy season in Kedougou and watching almost half of my family contract this same disease.  It has gone from theoretical to personal. 

Samouro

Diabou

Kharifa

Sadio

Soba

Toumany

My family members that got malaria last rainy season.

Now, in April, as we prepare for the upcoming rainy season (typically June through October in Kedougou), I am using my personal experience from the last year as motivation to put in the work necessary to pull off a really exciting project.   I am also drawing on my theoretical training from both Tulane and Peace Corps in the design of this project.

Last year in October, I wrote about helping out with a project that dear friend Ian dreamed up and carried out in his area.  As soon as Ian told me about the project last May, it sounded too good to leave in just the five villages where he was working, and I told him from the beginning that I was interested in working on scaling it up during the next rainy season.  It turns out that I was not the only to recognize the project’s potential.  It has gotten a lot of attention from both Peace Corps and the Senegalese health system, both on the ground here and at the national level.

So here’s the concept: In 2008, Senegal introduced a program called PECADOM (Prise en Charge à Domicile or Home Based Management), where villages that are at least five kilometers away from a health post elect someone from their village to be trained to become a DS-DOM (Distributeur de Soins à Domicile or Home-based Care Provider).  These people receive very basic training on the signs and symptoms of uncomplicated and severe malaria, how to administer a Rapid Diagnostic Test (RDT), how to treat uncomplicated malaria with medication known as ACTs, and when to refer a case of severe malaria to the health post.  They are then given a backpack with RDTs and ACTs (which are both available free of charge in Senegal) and sent back to their villages as a way to address the multiple barriers (primarily geographic and financial) to treatment seeking.  In the pilot of the program, no malaria deaths were seen in any villages where PECADOM had been introduced.   A 2009 study of PECADOM’s potential showed that in the regions where the program had been introduced, malaria-related hospitalizations were reduced by 43.1%, and malaria-related deaths dropped by 62.5%.

This program clearly has made an impact in the hardest to reach places, but there are some gaps.  It is largely a passive model: the DS-DOMs are given their supplies but have no action plan.  They go about their lives and wait for the population to come to them if they are sick.  As I have discussed before in this blog, treatment seeking is a difficult issue here (http://lineoverthee.blogspot.com/2012/10/no-easy-answers.html) Last spring when he was out on a run, Ian conceived of a way to transform PECADOM into an active model, which in turn came to be known as PECADOM Plus.  In the final iteration of this model, the DS-DOMs do a weekly sweep of all of the households to find anyone presenting symptoms of malaria.  Anyone complaining of symptoms gets their temperature checked to verify.  If they do in fact have a fever, a Rapid Diagnostic Test is given.  A positive diagnosis with no signs of complication means immediate treatment with ACTs.  Negative tests are referred to the health post for the nurse to find and treat the source of the fever.  Any severe cases are also referred, since severe malaria needs to be treated with intravenous quinine instead of ACTs.  As opposed to the volunteer work of the DS-DOMs in the orginal model, Pecadom Plus DS-DOMs are paid a small per diem to do the weekly sweeps, since it takes up a day during the rainy season that they could be farming. 

Newly trained DS-DOMs 

Community education to supplement the sweeps.  Women were trained to identify signs and symptoms of malaria and to encourage treatment seeking.

 The idea was to implement this project in the 5 villages that are covered by the health post in his village.  On the first day of the project alone, 148 people were tested for malaria, and 88 were positive.  87 people received free treatment on the spot, and one was referred to the health post for severe malaria.  On the other hand, the health post treated 368 cases of malaria throughout the entire rainy season, illustrating the gap in malaria control caused by a lack of treatment seeking.

Getting ready to do a Rapid Diagnostic Test during a village sweep

Pat fording a river separating one of the project villages from the health post.  Barrier to access to care?  I think so.

After that first day, unfortunately, a district-wide shortage of RDTs and ACTs obligated the decision to only implement the project in one village.  The weekly sweeps were continued, therefore, in Sekhoto, while the other villages continued with the regular PECADOM model.  At the end of the rainy season, we went back for a final sweep Sekhoto and Touba Couta and Khouleya, 2 neighboring villages, to compare the results.  On the first day of sweeps in July, the malaria prevalence was estimated by our sweeps at 10.7% in Sekhoto and 9.7% in Touba Couta.  On the day of final sweep in November, however, the prevalence had dropped in Sekhoto to 0.9%, while in Touba Couta and Khouleya, it was 7.7%.  This is a big difference. 

Graph from Ian's presentation on the project that he was asked to present to the National Malaria Control Program

Seeing this success, where do we go from here?  That’s where I come in, conveniently placed at the Health District level.  The results from Ian’s project are very promising, but the sample size is very small.  I am currently working with the Saraya Health District, Peace Corps, and the President’s Malaria Initiative on a study protocol for the scale-up of this project.  There have been many issues to consider: how many villages do we need to make it in order to have a sample size big enough to be confident that the results we are seeing are actually representative of the reality?  How many villages can we realistically provide tests and medications for, since this project is obviously going to demand more?  Should we target all age groups or just the most vulnerable groups, like children and pregnant women?  How can all this be financed?  Is it possible to randomize the villages selected to get more statistically powerful results?  What is the role of Peace Corps Volunteers?  Should we train new DS-DOMs or just use existing ones?  Are there villages that are too big or too small for the project to work?  How would this work in the gold mining villages?  What are the outcomes of interest here?   Number of cases detected? The time elapsed before diagnosis? The mean severity of malaria?  The prevalence in villages with and without the program during pre and post sweeps?  The weekly incidence during sweeps?  And how will we measure all of things?

Taking all of these factors into consideration, we are working to put together a protocol as soon as possible in order to (Inshallah) conduct trainings and June and start sweeps in July.  Tulane requires Masters International students to choose one project to be their practicum, and this will be mine. Sadly, Ian will be leaving us in May, so it will be up to the remaining health volunteers in the Saraya Health District to bring his baby into toddler-hood.  And with the results we can show with this bigger pilot, who knows where this project will go, and how much disease and death it can prevent!    

To check out other Blog About Malaria Month entries from volunteers across Africa or to learn more about Peace Corps’ Stomping Out Malaria in Africa Initiative, go to stompoutmalaria.org or http://www.facebook.com/StompOutMalaria.