To live is to change, to acquire the words of a story.
--Barbara Kingsolover, The Poisonwood Bible

Monday, April 22, 2013

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.
   
  

  






Monday, April 15, 2013

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.

Friday, April 5, 2013

2013 Kedougou Youth Leadership Camp


A drum circle replaces guitars around a campfire, mangoes become the main snack, and the inability to stand for more than several minutes in direct sunlight becomes a main challenge in planning programming.  Yet, it is still camp.  Sessions are held in French, a language that is the mother tongue of no one involved, Griot story telling is the hit night activity of the week, and the trip to the hospital happens not because of a banged knee on the high ropes course, but because of a hand swollen to twice its normal size.  So many things were different during Kedougou Youth Leadership Camp, yet the spirit of camp that I know and love was still present throughout.



Although Senegal is at least 90% Muslim, the school year includes a two week break for Easter.   During this year’s break, kids from all over Kedougou came to the regional capital.  A group of 22 middle schoolers participated, enough to max out the capacity at the campement we rented out.   Malinkes, Pulaars, Jaxankes, Bassaris.  Muslims and Christians.  For many, it was the first time they had been to Kedougou city, and for some, it was the first time they left their village.


Nearly all of the volunteers in Kedougou came together to work on this project, and it was a blast to see everyone’s interests and talents that were brought out in the camps programming.  Drawing on my previous camp counselor experience, I led big group games and team building challenge course activities.  We worked with Senegalese adults who had been trained and certified as camp counselors, but the mentality of letting kids fail and work through a challenge together was really difficult for them, and they couldn’t help but jump into it and tell them how to do it.  In the daily evaluations, I found it fascinating that kids often put the fun sessions like tag or zumba as their least favorite, saying that, yes, it was fine, but it didn’t teach them anything that would help them get ahead in life.  These kids wanted to learn.  Some of the biggest hits were on family planning as well as the First Aid session that Pat did a great job leading.

Since the theme of the camp was leadership, I also led a session on assertive communication.  I prepared this session particularly with female participants in mind, since girls are often expected to be passive recipients of their fates.  I stuck in role plays about girls being told they needed to leave school to help around the house and condom negotiation.  During the session, I included a list of rights of young people (ie the right to be listened to and respected), which kept coming up again and again throughout camp.  I was amazed by the power of simply telling someone that they had a right to express what they wanted in life.


Condom demonstration during the adolescent health session--I recently recalled a thought I had in early highschool where I felt so bad for the nurse who taught us sex ed.  I thought it would be the worst, most awkward job in the world and couldn't imagine how anyone would ever end up having to do that.  Oh, how the tables have turned.  Now I'm all about it.
Role play of using assertive communication with the scenario that one friend wants to leave school to the gold mines and the other friend wants to counsel her against it.
I also facilitated an anonymous Q&A session with a midwife from the Kedougou Health Center.  She was a champ and answered the varied questions about health (but mainly sex) with a lot of tact.  Sex doesn’t really get talked about, but kids start really early, so it was such an important session to clear up myths and misconceptions and to help them at least understand what they are doing. I was glad that it was on the same day as the assertive communication talk so that maybe girls would feel empowered with knowledge and communication skills to say no if they wanted to.

Sage Femme Q & A with Diabou Cissokho, a midwife who is actually from the region of Kedougou, something that is really rare, making her a great example

In 2007, Peace Corps Volunteers made a film called Elle Travaille Elle Vit (She Works, She Lives), where they interviewed working women around Senegal about careers and gender roles.  We screened this film (with some technical difficulties, but it is Africa after all), and it opened up another really great discussion.  At one point, a girl named Mahawa raised her hand and said that she was so grateful for this camp, and that she would feel like she was able to go home and tell her parents what she wanted with her life, instead of living passively as she had done.  I had to try not to cry for the rest of the session.  This session also made me really glad that we decided to do a co-ed camp.  A lot of regions put on girls’ camps, but we decided to invite boys as well, as boys are essential in girls empowerment and really do need to be empowered themselves.  It’s one thing for a female volunteer to tell a girl that she can do whatever she wants, but it’s a whole new level when a boy raises his hand and says that he really wants to marry a girl who is educated.

The afternoon after we screened the film, Awa Traore, Peace Corps’ Gender and Development Coordinator who has a starring role in the film, came to give a presentation.  She is an amazing facilitator, and her skills combined with the sense of community we had created during the week turned into girls opening up about a lot of really taboo and tough issues.  We talked about female genital cutting--health risks and why it is illegal.  Awa shared her own story of being cut, which created a space for girls to share.  I have never heard anyone ever talk honestly about this practice due to its illegality, and I was amazed by their openness.  (I really think that teambuilding activities we did early on contributed to this.) We talked about forced early marriage and early pregnancy, and girls revealed things from their lives and their villages that were hard to hear.  I have known that these things go on (for example, teachers bribing girls with grades in exchange for sex), but to hear it from the mouths of these girls that I had quickly come to love brought my awareness to a whole new level.  Awa really focused on kids knowing who they are and relying on that knowledge when they make decisions. 

Mahawa and Awa role play a young girl being propositioned by an older boyfriend to exchange sex for gifts, a very common scenario.
Looking back, the week of camp can best be captured in soundbites:

-The songs bursting out of the bus of kids pulling up to the Peace Corps house on the way to the Dindefello waterfall—a first for every single camper.

-A late night conversation between two Muslim Malinkes asking a Bassari Christian about his religion and his upcoming initiation.

-The animated voices of the kids impersonating their parents in a skit about forced marriage. 

-Hurried footsteps running up behind me, bringing a drawing or note with “I love Sadio” written on it.
-Sobs coming from both boys and girls as they prepared to leave on the last day, leaving new friends and going back to tough realities.

This camp was funded entirely by donations from volunteers’ friends and family back home, and I know that some readers of this blog contributed and made this camp possible.  I cannot thank you enough, so I leave you with this video, with a message of thanks from the kids themselves.  As the former president of Senegal said, “If you want to see the future of a country, look at its youth.”