peacecare and the disease that sits in the birthplace

In Malinke it is known as “the disease that sits in the birth place”.  In Pulaar, it is described as “the disease in the stomach of the mother of the baby”.  Whatever name you give it, cervical cancer is the number one cancer killer of women in the developing world.  80% of the estimated 250,000 cervical cancer deaths occur in developing countries (WHO).  These deaths, which typically happen when a woman is in the prime of her adult life, were projected to rise by 25% from 2006-2016 in the absence of urgent action.

Several years ago, an organization called peacecare was formed with the goal of matching Peace Corps Volunteers to academic institutions to maximize the strengths of both in taking on global health issues.  My site was chosen as the pilot site for this innovative partnership and was matched with the University of Illinois-Chicago.  The first peacecare team came in 2009 in order to do a needs assessment to find the health issue that would be the focus of this pilot project.  Together with the local health infrastructure, they chose cervical cancer.

 This month, the fourth peacecare team came to visit, consisting of Dr. Andrew Dykens, a returned Peace Corps Volunteer who served in Mauritania and the founder of peacecare, two residents and a medical student from UIC, and a recent MPH grad.  It was a whirlwind week, but I left it feeling extremely enthused about this project.  Our role as Peace Corps Volunteers are to handle on-the-ground logistics, and facilitate team visits which happen about twice a year.  I got to work closely with two fantastic second year volunteers and learned a lot from them.

In the US, cervical cancer is prevented through regular pap smears, which is out of the question in a low-resource setting like Senegal.  There are neither the human nor laboratory resources to even consider this approach.  However, a screening methodology known as Visual Inspection with Acetic Acid (VIA), which is low-tech, simple and cost-effective is very promising for preventing cervical cancer in this kind of setting.  Through peacecare, midwives and nurses across the Kedougou region have been trained in this screening method.  Basically, you insert a speculum, dab a cotton ball with vinegar, touch it to the cervix and wait two minutes to see if any changes occur with the application of vinegar, indicating pre-cancer. 

It typically takes 10-20 years for an HPV infection to evolve into invasive cancer (most HPV infections resolve themselves), so there is a large window for prevention through screening.  By January, the peacecare project will have trained all of the midwives and nurses in the region in the VIA method, and training on cryotherapy, a treatment method for precancerous lesions that uses carbon dioxide, will occur in February.  The goal is to eventually move from doing mass screening campaigns to the incorporation of cervical cancer screening into routine care.  With that in mind, the peacecare project has taken a broader approach to strengthen the local health system, training health care workers on things like clinical training skills and quality assurance.   In order to do this work in a sustainable way in this region, support will eventually need to come from the Ministry of Health, and to get them on board, the problem of cervical cancer really needs to be understood.  In January, a prevalence study will kick off, since we really have no idea how many women are affected here.

On this trip, a lot of work was done to prepare for the prevalence study.   We did two screening days in little villages to test out the survey tools.  It turned out that they had to be changed quite a bit—there had been questions designed to measure knowledge about HPV, which is basically just too difficult to translate into Malinke.  The word for germ, virus, and bacteria is all the same: jangardiŋo, or small disease.  So how do you say Human Papilloma Virus to an illiterate woman who only speaks Malinke?  Another issue was determining whether a woman fit into the target age range.  No one has a clue how old they are, so we had to try to guess based on how many children someone had.  Also, since there are no national guidelines for screening ages, it has been an interesting exercise to try to come up with what might eventually become national guidelines based on this study.

The screening days were a great opportunity for me to see the clinical side of things, which I rarely do.  I sat in the hut or classroom where the screening occurred and wrote down the woman’s information in the register and timed the process on my watch.  Depending on whether the midwife spoke Malinke, I sometimes helped with translation during the counseling process.  It was amazing to see this important health intervention taking place in the most basic of conditions and exciting to think that this approach could be scaled up as a national model.   This is the kind of “urgent action” needed to prevent cervical cancer deaths from drastically increasing like the WHO projects.

Angel, a fourth year med student and the matron (skilled birth attendant)  in Samecouta.  Here the screening was conducted in the community health worker's hut.

Screening supplies...doing our best to keep things clean on a dirt floor.

Agathe, one of the midwives setting up on Day 2 of screening in a classroom.  

The peacecare project actually has its own blog, so check it out if you’re interested in reading the perspectives of the other team members, both the volunteers based here and the visitors from Chicago, check it out!

http://www.peacecareworld.blogspot.com

No Easy Answers

Here is a story 

to break your heart.  

Are you willing?

Mary Oliver, Lead

The irony was not lost on me when I returned from Malaria Boot Camp and found my very pregnant host sister Diabou sitting in her room with her head in her hands, her temperature through the roof.  There was no one else around to talk to about taking her to the health center for a malaria test, so I acted on instinct and demanded she come with me to get seen right then.  Which implied that I would pay.

To get seen at the health center, you have to purchase a ticket, which, depending on the time of day costs the equivalent of either 20 or 40 cents.  Then, if needed, you will be charged for medication.  Some medications, such as those for simple malaria, are provided free from the National Malaria Control Program and their international partners.  However, other medications like fever reducers cost around $4.  With the issues of language barriers between the providers, who primarily speak Wolof or French, and patients, who speak Malinke and are often illiterate, a lot of confusion exists around medicine and their prices.  This is a tough issue because reticence to go to the health center obviously can exacerbate the health issue, but also carries an economic cost.  In the case of malaria, if you wait long enough for it to develop into complicated malaria, you have to get treated with intervenous quinine, which costs around $10, plus the other medications that they will give to you during your hospitalization, versus the free 3 day treatment with pills for simple malaria.

  Pat and I had previously paid for health center visits for Kharifa, our other host sister's four year old and for Sadio, our host mom, when they clearly had malaria and weren't going to get tested/treated a few months ago.  As I walked with Diabou to the health center, I tried to ignore the thought that they had waited for Pat and I to get back into town with the hope that we would take care of things for her as well.  

  

Because of her pregnancy, her case was automatically considered complicated malaria.  Her fever was high enough that the midwife told me to run to the pharmacist's house to bring him to the health center so that we could get the medication she needed.  It ended up costing about $26 just for the initial medicine.  I didn't know what to do besides just pay for it, since the situation was so scary.  As this was all unfolding, I felt myself retreat into robot mode. I did what was asked of me and went through the necessary motions, without allowing myself to really feel or process the situation.  This is a trend that I have noticed in myself as my service has progressed.  In life before Peace Corps, I was a person that felt things, both positive and negative things, very strongly.  I wore my heart on my sleeve, and my emotions were not kept from anyone.  Here, I have found myself retreating away from strong emotions, becoming numb to things that would hurt too badly if I let myself feel them at my normal rate of feeling.  

All in all, Diabou was hospitalized for about four days, and everything turned out ok.  However, in the midst of her illness, I just barely took note of Alamuta, her two year old daughter, and the bandage around her finger.

Let's just be honest.  Alamuta (on the left) is my favorite of all the kids.

A few days after Diabou was released from the hospital, a team of doctors from Chicago came to our site as a part of a project called peacecare (blog about the peacecare project coming soon).  The group normally ate at the health center during the stay, but we arranged for them to have a real Malinke culinary experience one day, and they came to have lunch with our family.  Alamuta came out of her family's hut holding her hand   at an awkward angle next to her chest and grimacing.  She no longer had the bandage, and now it was plain to see that her middle finger had a nastily infected wound, and her hand was swollen to twice its normal size.  The doctors took a look at it and said that she should be taken to the health center to get it lanced and drained.  I relayed this information to Alamuta's parents and grandparents and was assured that they would take her that evening--the sun was presently too hot.

When I went back to check that evening, they said they would take her in the morning.  Her father, Sambaly, who is deaf, shrugged sadly and rubbed his fingers together to suggest that it was a money issue.   A slightly different version of the same interaction continued to unfold when we would check in each morning and evening for the next several days.  Pat and I found ourselves faced with a moral dilemma.  Taking her to the health center ourselves would alleviate both her suffering and our consciences, but would continue on the path to creating a dependency on us.  It didn't feel like either answer was right, and I felt like I was robbing myself of my humanity but not responding to Alamuta's cries for the sake of sustainability. How could I be ok with myself for not paying an amount that was nothing to me while it clearly presented a major obstacle to my family?  On the other hand, we had just heard the story of another volunteer who had returned to his village to the news of his little host sister's death from malaria.  When he asked why they hadn't taken her in, the response had been that he hadn't been around to take her.  Thinking back on Diabou's condition when we had arrived from Kedougou the last time, it was scary to think about not drawing a clear line and potentially creating a situation where they would wait for us before taking action on scary health situations that occur all too frequently here.

So, as the time passed, we waited, agonized, and tried in vain to convince them to take her in.  Finally, after about three days of this, and a week after the initial injury to Alamuta's hand, Pat couldn't take it any more.  When Sambaly said there was no money, Pat pointed angrily to the building where he runs a barber shop(the cost of a hair cut is more than the cost of an appointment at the health center).  He was told that no one had gotten their hair cut that day.  "Then cut my hair!" he yelled.  He put the 500 cfa piece directly into Alamuta's undamaged hand and accompanied mother and daughter to the health center.  I got back from doing a cervical cancer screening in a distant village and met them on the road, feeling relieved at the semi-solution Pat had found of paying for a service but ensuring that the money went where it was needed.

Since we work so closely with the health center, Pat was able to just go find Elodie, one of the nurses and a dear friend, and have her look at Alamuta immediately.  Upon seeing the condition of her hand and learning how long it had been since the initial wound, Elodie chastised Diabou for waiting, saying that it could have been possible for Alamuta to lose her hand or even to die from the infection. (It was all in French, so the words weren't understood, but I think the tone carried the message.)  Then Pat had to hold Alamuta's entire body as she thrashed and screamed while Elodie lanced the infected finger.  I have never heard cries like that and had to leave the room.  I can't imagine having to watch your own child go through that, but Diabou kept a straight face and later teased me about crying.  I guess I'm not as numb to things as I had thought.

Alamuta was given a prescription for oral antibiotics, but Diabou wanted to go home without stopping at the pharmacy.  She didn't have any more money.  Not wanting to start the whole charade over again, I said that I would pay for it as long as I they paid me back.  It cost $4, and they paid me half of it back that night.  I also had a conversation with Diabou about how if she would just go in earlier, she would have to buy less medication and then pay less money.  Although this seems like a basic logical principle, it's not as simple when you haven't had any education.  She acted like she was hearing this information for the first time, and that the wheels were turning...let's hope they turn into action next time.

The crisis at hand seemed to have been averted, but we still were worried about the next time something happened.  We pay 20,000 CFA ($40) as a family contribution for food, etc each month, and Pat had the idea that if we increased that by about $10 (which we usually give anyway in direct vegetable contribution), we could put it in a special envelope that was designated particularly for visits to the health center and medication.  It would serve as a health insurance for the family that we paid into at a set amount each month. That way, since they would have the money, there would be no excuses for not going to the health center, but it would still feel like it was costing them something from this special fund that was now theirs.  I'm very interested to see how this works out.  It seems like a great idea, but many great ideas here just don't work.  At this point though, I'm willing to try anything.

These are tough issues, and there are no easy answers.  My struggles with guilt over my own affluence are sometimes all-consuming, but how to best deal with that guilt?  By solving the short-term problem and relieving the guilt right then or by somehow working toward lessening the problem in the long term?

I started this tale of infection and woe with the beginning of a Mary Oliver poem, and I'll finish it with the end of the same poem.

I tell you this 
to break your heart,
by which I mean only
that it break open and never close again
to the rest of the world.

Malaria Boot Camp

The Initiative: Stomping Out Malaria in Africa

The Goal: Near zero deaths from malaria by 2015

The Strategy: Provide intensive training to Peace Corps volunteers across Africa who will in turn provide leadership in the fight against malaria for the 3000 volunteers working on the ground across the continent.

This continent-wide initiative actually grew out of my health district in the south-east corner of Senegal when volunteers several years ago that there was no good reason why every person should not have a bed net and started doing mass distributions to try to achieve universal bed net coverage.  The distribution was very successful and got a lot of attention.  It was eventually scaled up nation-wide, and other countries are following suit. With this history, I was incredibly excited and honored to be selected to represent Senegal at the fifth Malaria Boot Camp.  This intense ten day training (they don't call it boot camp for nothing!) was attended by Peace Corps volunteers and staff from all over Africa: Zambia, Namibia, Mozambique, Botswana, Kenya, Uganda, Madagascar, Burkina Faso, Guinea, The Gambia and, of course, Senegal.  Many of the participants had extended to do a third year focused on malaria or had completed their service elsewhere before and had been recruited to do malaria work through the Peace Corps Response.  This meant that I had a lot of experience and geographic diversity to learn from.  It was fascinating to exchange stories--a good reminder of the enormity of Africa and the many differences, from culture, to climate, to malaria.

Here I am presenting to the group about the malaria situation in Senegal.  My newly formed ideas about a potential primary project for my Peace Corps service were a result of the Zambia presentation.

Boot Camp V Participants

In addition to learning from the experience of other volunteers around the continent, we had a daily 9-9 schedule packed full of training from experts who either in person or via Skype.  We heard from Tim Ziemer, the head of the President's Malaria Initiative, Carrie Hessler-Radelet, the acting director of Peace Corps, Pascaline Dupas, the economist who did the bednet study highlighted in the book Poor Economics.  We got in-depth technical training in all aspects of malaria prevention and control and the science behind it, as well as presentations from many of the big players in the field about how we could partner with them.  I now know more about logistics of bed net distribution, supply-chain management, vaccine development, parasitology, entomology, indoor residual spraying, malaria in pregnancy, HIV and malaria co-infection (and so many other topics) than I ever thought possible.  The training definitely brought out my nerdy side, and my suspicion that I would be ecstatic to continue to focus my global health career on malaria was confirmed many times over.  It is such an exciting time to be doing work in the field of malaria: so much ground has been gained in the past few years alone.  Child deaths from malaria have been reduced from 1,000,000 per year to 650,000 per year.  This is huge, but it is just the beginning and there is much work left to be done.  And important work can be done by Peace Corps volunteers, who speak the local languages and are deeply integrated into our communities where we can understand the people and the health decisions they make.

Learning audio-editing software for radio shows after a session on  the use of mass-communications in the fight against malaria from Malaria No More/Speak Up Africa

 In the nearly seven months that I have been in Senegal, malaria has gone from being a terrible exotic disease to a terrible daily reality. Globally, the statistics are that the equivalent of 7 jumbo jets of children die of malaria each year.  Locally the statistics come to life. About a third of my family members have gotten malaria just this rainy season, some more than once.  The health center at my site is filled to capacity with complicated malaria patients.  Pat's counterpart (work partner/designated best friend) and his pregnant wife both got malaria right as she was due to give birth, which was really scary.  But while I have seen the ravages of malaria up close, I have also gotten to experience the power of of Peace Corps volunteers to combat this disease in their sites.

Ian Hennessee, a second year health volunteer, who has become a great neighbor, mentor and friend, asked us to help out with the roll out of his project that focuses on the early detection and treatment of malaria at the village level.  The National Malaria Control Program has a program called PECADOM that involves very basic training on how to test for and treat simple malaria in villages with limited access to health care (ie much of Senegal).  Ian's project takes it a step further by giving the recipients of this training an action plan to aggressively seek out and treat cases by doing twice-weekly sweeps of the village and working with groups of women to identify and do a rapid diagnostic test on anyone with symptoms of malaria (typically fever/headache/vomiting).  This has big implications, because if you start treatment within the first 24 hours, you can't transmit the parasite to mosquitoes who would bite others in the community.

On the first day of the project, we shadowed the health care workers to make sure everything ran smoothly and to make suggestions of improvements.  In the five villages (total population 1395) covered by the project, we tested 149 sick people.  88 were positive for malaria and all got treatment at home except for one case (which had a fever high enough to indicate complicated malaria and was referred to the health post for treatment).  In one village, 22% of the village population was tested for malaria, with 12% testing positive and getting treatment!  That is a lot of people getting the care they need.  It was by far one of the best days of my Peace Corps experience thus far.  Kids (and adults) who might never get access to the treatment that is technically provided for free by the government were sought out and cared for.  Access came to them.  (Pat had to cross several raging rivers to get to the village where he helped out!)

Children under 5 and pregnant women are the most vulnerable to malaria. This little girl had a fever and was tested for malaria and received treatment.

The most striking thing to me about the day was the reaction of the health care worker I was shadowing when a diagnostic test was negative for malaria.  To my great surprise, he would say, "Oh, that is so unfortunate.  I'm so sorry."  I was initially quite confused by this--shouldn't we be glad that this child didn't have malaria?  But as the day went on, I began to understand: we have the tools to diagnose and treat malaria on the spot.  Fevers from other origins may not be easily treatable and require the sick person to seek treatment at the health post, which may be difficult due to geographic or financial barriers.  If a child is sick, it is better for that child to be sick of one of the world's biggest killers, because we can now fight that killer.  Challenges, big challenges, definitely continue to exist in this fight.  For example, Ian's project had to be put on hold and then scaled down due to stock-outs of diagnostic tests and medication, which is happening across the country.

The in-depth training provided at Malaria Boot Camp left me feeling empowered to take on these challenges and do the hard work that is needed to meet the goal of near zero deaths from malaria by 2015.  Let's stomp out malaria in Africa!  

With this team, a failed jumping picture from our day off on the beach in Popenguine can be reinterpreted as a stomping picture.