Blogging as an RPCV: Belated World Malaria Day

Well, as of April 17th, I officially gained the status of Returned Peace Corps Volunteer, and as of 2:40 am on April 29th when Bozeman welcomed us home with a blizzard that made it impossible to land the plane for nearly three hours, I physically became an RPCV. I still have more to write about, however, and I really hope that whatever I end up doing next is interesting enough to keep blogging about, because it turns out I really enjoy it. But for now, being that today is the last day of World Malaria Month only 13 days after my Close of Service date, I'm going to take the opportunity to write about the project that has dominated most of my waking hours over the last year: PECADOM Plus.

In past blog posts, I wrote about a fellow volunteer's idea of paying a small wage to low-level community health workers to conduct sweeps of every household in their village once a week during rainy season to seek out any suspected cases of malaria (typically identified by fever, headaches or vomiting), administer a Rapid Diagnostic Test (RDT) and treat any positive cases on the spot. An existing program called PECADOM had already trained these health care workers known as DSDOMs (French acronym for home-based care providers) in rural villages to administer the tests and treat simple malaria. Ian called his active version of the model, where the DSDOMs actively sought out the patients instead of waiting for them to seek care themselves, PECADOM Plus. In 2012, Ian and his counterparts conducted a pilot of the model in one village and saw amazing results. By the end of the rainy season, the point prevalence of symptomatic malaria in the project village was 88% lower than that of two neighboring villages with the passive PECADOM model.

Rapid Diagnostic Tests were introduced in Senegal in 2007.

With results like that, it was clear that a larger pilot was necessary to see if the same effect could be seen with a larger sample size. As Ian prepared to finish his service around this time last year, he and I started to work with local health officials and the National Malaria Control Program to design a scaled-up pilot of the model. Dr. Youssou Ndiaye (the Chief Medical Officer of the Saraya Health District at the time) and I co-authored a research protocol to submit to the ethics committee of the Senegalese Ministry of Health and prepared to scale up the project to 15 intervention villages with the active sweeps and 15 comparison villages that would retain the original passive model. From the beginning, it was all a bit daunting, but I fortunately had an amazing mentor in Dr. Julie Thwing, the CDC's Technical Advisor to the Senegalese National Malaria Control Program for the President's Malaria Initiative.

The region of Kedougou. Project villages in red, comparison villages in blue, and health posts in green. The Saraya Health District is the most spread out health district in Senegal.

 The 2013 rendition of the project rolled out in early July, a time picked on account of a) the fact that the 2012 pilot had started in late July and the prevalence was already quite high--this year we wanted to start earlier on in rainier season to try to keep the point prevalence from reaching as high, and, b) a ton of Peace Corps Volunteers come all the way down to Kedougou for the 4th of July, and we would need one volunteer to supervise the sweep in each of the villages in the intervention villages.

Training of volunteers for the project launch

The days of July 7-11 were definitely the craziest of my Peace Corps service. We needed to supervise the sweeps in the 30 intervention and comparison villages along with a training of women in the intervention villages on the signs and symptoms of malaria and the importance of early treatment in order to facilitate the sweeps and encourage early treatment seeking.

When those days were all over, I honestly couldn't believe we had managed to pull off the launch. All of the health district's cars/ambulances were having mechanical problems, so I had to beg Peace Corps to send a car, which came through at the last minute.  Right as we were leaving Saraya to disperse to the project villages, they told me that since the DSDOMs had only been trained and not installed, none of them had tests or medications.  Then one of the DSDOMs informed me that he had changed the village he was living and working in (this is ridiculous, since it is the village that selects the person to be trained to care for them). We got that sorted out, grabbed meds to bring to the villages, but of course realized by the time we got to the first health post that we had forgotten the thermometers in my hut. One DSDOM who met us at the post volunteered to ride his motorcycle the 30 km back to Saraya to get them. While we waited, the clouds darkened and darkened: I still had a 25 k bike ride ahead of me, and it started raining right as I left. My phone rang every five minutes with either volunteers or DSDOMs with questions about exactly what was supposed to happen. Then it stopped ringing and I realized it had fallen out of my pocket back on the trail. I had assigned myself supervision of the one village where I hadn't been able to contact the DSDOM since the training several weeks prior, so I had no idea if he was expecting me. But, the beauty of Senegal is that you can show up anywhere with no warning without knowing a soul and they will be thrilled to feed and shelter you. I finally got there at dusk, and if the DSDOM and his family were surprised to see me, they made no sign of it. After supervising the training and the sweep, I started to bike back in to the health post, thinking that any moment the Peace Corps car with Pat in it would meet me to take me back and prepare for the comparison village sweeps of the next three days. It turned out that the car missed the turn onto the tiny bush path where I was and went all the way to another village on the Mali border. I was already back at the fields surrounding the village with the health post by the time they met me.

Photo time with the Satadougou DSDOM after the women's training. This village is waaay out there on the Mali border. 

Satadougou DSDOM training women from the village on how to recognize symptoms of malaria and the importance of early treatment seeking.

That's just a small taste of the shenanigans of the PECADOM Plus launch. During the five launch days, both the Peace Corps car and the one remaining district cars broke down at different times, and it rained nearly every day, turning the roads into rivers. Two volunteers from outside the Saraya area who were supervising one comparison village walked into a compound where people were burning mercury to process gold, which freaked them out enough that they left the village and we couldn't use the data. Fortunately, due to another mix up involving a nurse inviting way too many DSDOMs to participate, we still had 15 comparison villages. At one point, I was preparing to send a volunteer with a DSDOM to his village to supervise him, and another DSDOM asked me, "Has this guy ever even done a rapid test?" To which he responded, "What's a rapid test?" Turned out that his supervising nurse was in Mecca for the Hajj, so he had never been trained, and was not ever supposed to be a comparison DSDOM. He had somehow just shown up, gone through the orientation and never said a word.

No big deal, just a river in the road.

Taking advantage of cars going to remote villages, the health district sent nets with us for the Universal Coverage distribution that took place soon after our project launch in all villages in Kedougou

This craziness is what makes Peace Corps Peace Corps. The bulk of my job was figuring out how to adapt to unideal situations. But we pulled it off. Sweeps were conducted and supervised in 30 villages. The project was launched. At that point, the prevalence of symptomatic malaria in both sets of villages was approximately 1.1%. Sweeps continued every week after in the intervention villages. For the next five months, I coordinated supervisions of the sweeps, both through the supervision we had set up through the health district and supplemental supervision by Peace Corps Volunteers for research quality purposes. Sweeps were conducted on Mondays in most villages, which meant that I would call each of the DSDOMs on Saturday mornings to check in with them and make sure they had tests and meds for the upcoming sweep. I was worried that checking in each week would annoy them, but in Senegalese culture, calling super often just to greet is a preferred communication technique, and they loved it. Every Monday that I was free, I would bike to a project village to supervise a sweep myself--I really wanted to know intimately how things were going in each village to be able to understand the final data when it was ready for analysis.

DSDOMs hard at work conducting active sweeps

In September and November we went back to the comparison villages to compare the prevalence of symptomatic malaria. Whereas in July, before the program, the point prevalence had been the same in both sets of villages, in September (half way through the rainy season), the prevalence was 2.5 times higher in the comparison villages than in the intervention villages. By the time the program ended in late November, the prevalence in comparison villages was sixteen times higher than that of the project villages. From supervising closely throughout the project and monitoring the data from the sweeps each week, I had sensed that the active model was making a difference, but I was blown away by the difference we saw at the end of the program. In all of the 15 villages, only six cases of symptomatic malaria were found on the last sweep!

At baseline, both sets of villages had relatively low prevalence of symptomatic malaria, except in this village where Pat supervised. It was a tiny village, but they found 19 cases...over 15% prevalence. Fortunately, after that first sweep, the prevalence quickly dropped and stayed low the rest of the rainy season.

Doing this scaled-up pilot showed that this active model really is both feasible and effective. There had been concerns that weekly sweeps for a five month period would be too much for a DSDOM to take on, but our DSDOMs as a whole completed 89% of their possible sweeps. Only ten sweeps total were missed because of gold mining, whereas, when we went out to the comparison villages in November, only 8 of the 15 DSDOMs were in there villages--all the others had left to mine gold (in the intervention zone, nonetheless!). It could be that the active role (and the accompanying payment) provides an incentive for the DSDOM to stay in the village and be accessible to those who need care. The other big concern about the model was that people would wait until the sweep to get seen instead of seeking out the DSDOM when they first got sick. I was delighted to find that the DSDOMs actually consulted the majority of their patients during the week using routine surveillance rather than during the active sweeps. What I observed was this: in doing the sweeps, the DSDOM starts a virtuous cycle in which he proves that a) he was competent as a care provider, b) the medication is effective, and c) the medication, contrary to widespread misconception, is free, all factors which encourage early treatment seeking on behalf of the community.

After the project period, I spent most of my time going to all of the health posts in the district to find the village of origin of every case of malaria in order to look at the incidence of both simple and complicated malaria at the post level. From 2012 to 2013, both simple and complicating cases originating from project villages decreased more than cases from other villages in the catchment area of the intervention health posts. More evidence that this model is really good! For a cost of just over $1 for person protected, it's very cost effective for these kinds of results. There is a debate about whether or nor community health workers should be paid or should work as volunteers. In doing this work, I have come down strongly of the side of: pay them for the work they do! If they have an actual task, like a weekly sweep of their village, they must be paid to complete the task. As I was preparing to leave Saraya, one of the DSDOMs called me and said that he had never known the value of his work as a DSDOM until this year--it was one of the comments that touched me most as I wrapped up my service.

In early February, I was invited to present the findings to the National Malaria Control Program, which was a huge honor. Pat and our friend Karin Nordstrom, who were both huge in leading the implementation of this year's program, came with me, along with the nurse and community health worker who helped design the original pilot and one of the DSDOMs. I was really happy with the presentation--the NMCP members were really engaged and asked great questions. A few weeks later, I got word that they were interested in scaling up the model to the entire region of Kedougou. Right around the time I was leaving, they got funding for the scale-up, and the model will be deployed in approximately 150 villages. I'm so proud of everyone who was involved in this project and so excited to see where it goes. If we want to reach the goal of near zero malaria deaths by 2015, I think this is a really promising approach in high endemic areas, and it has been an honor to work with people at all levels of the Senegalese health system to show the promise of the PECADOM Plus model.

Our team of presenters at the National Malaria Control Program

Definitely the biggest deal presentation I've ever given

Most of the DSDOMs from this year's project. It was amazing to see what these men, most of whom had very little education, were capable of doing in their communities when empowered by this model for malaria detection and treatment.

.

Time to Say to Goodbye

The thing about Peace Corps is that it lasts for two years. You know that going into it. It seems like a really long time. And you fantasize about it ending--with the end comes eating delicious and healthy things whenever you want, escaping the 110 degree heat, not getting constantly called out and asked to give people things or deal with horrendous public transport situations.

But then it actually ends. And it's awful. Pat described yesterday as one of the hardest days of his life. We had been trying to make it known for a while that we would be leaving Saraya on April 10th. But still, some people were surprised as we made the rounds to the compounds where we had really gotten to know people. The goodbyes to the littlest kids and the oldest adults were hardest. Will these kids that we've loved so much remember us? Will these wisened old ones who have taught us so much be around if we make it back some day?

We said goodbye to a lot of people yesterday. According to Malinke tradition, we asked them for for forgiveness for anything we may have done and forgave them in return. We blessed each other (well, they know a lot more blessings then we do, so it was a little one sided; the most fervent blessing was that we would receive a child as soon as possible). And we shook hands with our left hand--the taboo hand, the poop hand. I heard this ritual described as doing something wrong so that you have to see each other again and do it right.

Over the last few days, we had a goodbye dinner at the hospital and a goodbye lunch at the bar that Pat's counterpart opened several months ago. We prepared a goodbye radio show where we greeted everyone we had ever worked with or known, all with carefully chosen farewell-themed songs in the background. (Since that show, the Blind Boys of Alabama have been singing "This may be the last time" over and over in my head.) We did it all the best we could, but it still didn't prepare us to leave. We were leaving people with no assurance of ever seeing them again, we were leaving the puppies that were born under our bed 3 weeks ago,we were leaving a place that has become home, and we were leaving a way of life. It was different than any goodbye I've ever experienced. Goodbyes accompany change, but this will be the biggest life change. Bigger than coming here. Coming here, it was temporary, and we knew we would be coming back to the life we knew in the states. But leaving this life, with its difficulties and joys...this, we will never get back.

Pat and I with our namesakes and host parents in front of the family compound (which a grandchild recently labelled with our names)

For two years, I went by the name Sadio Tigana, a name that carried a lot of weight in the community of Saraya. It tied me to an amazing woman and to all of the relationships she had formed. For two years, I carried my daily water on my head from a tap several compounds away to my hut. For two years, I was a radio celebrity and could go to any village and be known once someone heard my voice. For two years I spoke a language I had never heard of prior to arriving in Senegal. For two years, I participated in every activity possibly with our host family and neighbors--baptisms, weddings, funerals, hut-raisings, hut-demolishings after a fire. For two years, my love of the people of Saraya grew until it burst yesterday during our goodbyes. "Don't cry," we were told. "Crying means it will be a longer time. Just bless." Some of those telling us this were hiding tears themselves, even though Malinkes rarely cry.

Allah mu nioxojela sonoyala. May God ease our seeing of each other again.

We are leaving the region of Kedougou at a tumultuous time, with an Ebola outbreak just across the border and gold-related bandit attacks on the rise. But it is also an exciting time. Next week, the new hospital that sat shining and unopened during our entire service will open its doors with an inauguration conducted by the president. It is never a good time to leave, but it is our time to leave. We are looking forward to exciting things coming up. After a summer of playing in Montana and travelling, we will head east, and Patrick will start a Masters in Public Affairs at Princeton in August (as for myself, my plan is to be determined, and I'm trying to be ok with that).

I'm looking forward to having more control over my nutrition but will miss knowing exactly where my meat comes from. I'm looking forward to running water but will miss knowing to the cupful how much water I use. I will not miss the heat or the dust. I will miss being greeted aggressively by toddlers racing to throw their arms around my legs. Let's be honest: I'll miss feeling like I'm really important. I'm afraid that, once we settle in, life in America will be so easy that it will be boring. I will miss my family and friends (both Senegalese and other volunteers) so dearly, and I pray that I'll call as much as I have promised to.

There are so many feelings right now, and it's exhausting. Now just one more week to slog through the final paperwork and health appointments, and we'll earn our "R" and become Returned Peace Corps Volunteers. Our replacements will come in May and take our friends, our family, our work. (We met them last week, two female volunteers, one health (a Masters International student from Tulane!) and one community economic development. Fortunately, we really liked them, which makes all of this a lot easier to know we're leaving Saraya in good hands.)

We don't know if or when we'll be back. All we know is that we were here. It was hard, it was wonderful. I have no regrets.

More Poems I Want to Write

White Heron Rises Over Blackwater by Mary Oliver

I wonder what it is that I will accomplish today

If anything can be called that marvelous word.

It won’t be

My kind of work, which is only putting words on a page,

The pencil

Haltingly calling up

The light of the world,

Yet nothing appearing on paper half as bright

As the mockingbird’s verbal hilarity

In the still unleafed shrub in the churchyard-

Or the white heron rising over the swamp and the darkness,

His yellow eyes and broad wings wearing

The light of the world in the light of the world-

Ah yes, I see him.

He is exactly the poem I wanted to write.

In June 2012, I wrote a blog post inspired by this poem and by the images striking me at the beginning of my service. Now, a week before I leave my site, there are different images filling my mind, spilling out of me in the form of tears, bursts of laughter, and, now, words: the poems I want to write.

The wobbling legs of the crew of toddlers in my host family’s compound who race to greet me and be the first to throw their arms around my legs.

The two lines on the pregnancy test and the wide eyes of the young teenager who came to me in search of medicine for when you haven’t gotten your period.

The streaks in my vision for hours after standing in the rain to watch the lightning.

The circle of ash and rubble where my neighbor’s hut had stood just the day before.

The solemn face of the chief of Khossanto as he pronounced that he would make it illegal to burn mercury without the retorts we had extended there.

The bottle of water with floating sticks that I was instructed to drink to cure my stomach ailments.

The red rock of the Spires jutting out of the mountaintop as we approached and looked for a place to camp.

The flow of women with empty basins towards the water tower on days when the water cuts out extra early, their looks of desperation increasing with every dry faucet they pass.

Flakes of gold in an outstretched palm.

The seven-foot cobra literally snaking up the dry waterfall.

The sealed labia of a woman undergoing cervical cancer screening and her contorted face as the speculum entered her radically mutilated genitals.

Seny’s grin as I make a tricky shot on the basketball court.

The parade of men walking home from the mines at dusk in Kharakhena, the red dirt covering them a stark contrast to the gold they had been seeking.

The gang of girls singing in the neighboring compound, straightening up and switching to the national anthem once they realized we were filming.

My real mom and my host mom pulling away tearfully from an embrace that spoke the words they could not speak to each other.

These are exactly the poems I want to write.