Saving Newborn Lives in Ethiopia

I had to wait to draft my post about the field visit yesterday because the travel there and back took so long, the traffic was so horrendous, and I was so tired… but here I am in the fresh light of a new day, well rested and ready to focus on the important stuff!

mother and her child outside the health post

Six of us headed south Friday morning at 7am into the Oromia District. We were scheduled to visit a village health post (the lowest-level of formal health care here in Ethiopia) and a health center (the next level up). We were visiting places that our Saving Newborn Lives program is working with to make sure that babies in the first 7 days after birth are being attended to.

Saving Newborn Lives is a project funded by the Bill & Melinda Gates Foundation and JSI is working with the Ethiopia Federal Ministry of Health (FMOH) and Save the Children to—as the title says—save newborn lives.

It turns out that many health programs in countries such as Ethiopia focus on the health of pregnant women and they focus on getting children immunized, but somehow newborns are forgotten! This is particularly tragic as more than 100,000 newborns die in Ethiopia every year, most of these deaths—42% within the first week of life in fact. So having even minimally-trained health workers (or volunteers in villages, as the case may be) who can recognize some basic danger signs of severe illness (as well as postpartum hemorrhage among women who have given birth) is critical.

The Saving Newborn Lives project's Community-based Interventions for Newborns in Ethiopia (COMBINE) initiative has developed some simple checklists that are all graphical—because many of the volunteer community health workers are illiterate—and is now training these volunteers that they need to visit women and their newborns three times in the first week, the danger signs to look for, and to encourage them to visit the health post for immunizations. If it looks like the baby or mother is in trouble, the volunteer can also get the health extension worker at the health post.

The three community health promoters we met

In the village, we met three community health promoters (CHPs) at the health post. All three are mothers, two can write their names but not read, the third can’t even write her own name. Yet, they were each selected by their community to be a volunteer community health worker and accepted the role. As a volunteer they have the opportunity to try out what they learn at home, too. The first thing volunteers learn about is how to build a latrine. They build one in their yard and then show their neighbors! They’re expected to talk about what they’ve learned about—from latrines to keeping water jars covered (so flies don’t deposit dirt in there that makes everyone sick) and, importantly, to visit the health post if you’re pregnant.

Prenatal care isn’t something women think about here. They tend to keep their pregnancies secret until they can’t any longer and something like 90% of women deliver at home—and and of those, just 15% use a “traditional birth attendant.” Typically TBAs have no formal training, just lots and lots of practice delivering babies. The family members who deliver the other 85% of home births typically have had not one bit of training aside from having had babies themselves!

 

Is it a wonder then that many of those babies die within the first week after being born?

The community promoters took us to a few houses where new moms were living. One’s child had “fast breathing,” indicating a respirator-track infection, which can be lethal. Another’s child had had terrible diarrhea. It might not sound like much, but diarrhea is the second leading cause of under-five deaths a year—killing about 120,000-200,000 kids in Ethiopia a year (estimates vary). It’s a huge issue, so knowing when to tell a mother to get her child to the health post or being able to make her a simple salt solution to rehydrate the baby can make all the difference.

It turns out that in just the two years since our JSI Saving Newborn Lives team trained the health extension workers at the health post and the volunteers, the rate of women who deliver at either the health post or health center has increased a bit to 10%, so there’s still a long way to go!

The volunteers were pretty shy about talking about themselves, but the three women we met all said that they appreciate being able to help mothers in their community. They also gain social status, which is significant for illiterate women. Another project I’ve visited here in Ethiopia, the “Last 10 Kilometers Project,” which is also funded by the Gates Foundation, is looking at how to keep volunteers engaged through “nonfinancial incentives”—not surprisingly, community recognition is huge. The health post we visited also has the CHPs photos on the wall, which is another form of recognition for them.

Until social norms change and people know when to visit the health post or understand the importance of prenatal care is understood by all, the work that CHPs are doing is critical.

Here the health extension worker shows us the family health card, which JSI introduced in-country that helps track basic health of the children.

It was a fascinating visit and it was fulfilling to learn that our Saving Newborn Lives team really is saving lives!

Back in Ethiopia

I’m back in Addis Ababa after a two-year hiatus – the city has changed dramatically! Back in May 2010 it seemed that every block had major buildings being constructed. Now, those buildings are done, but there are more and more going up. The place is just booming!

(who says women can't work in construction?!?)

After always having stayed at the big Hilton hotel on the other side of town, I’m staying in a hotel that didn’t exist 2 years ago – the Siyonat. It’s quite nice, small and quiet, and – best of all – it’s within a block walk of our project offices here. Traffic here is abominable. New roads are being built (with Chinese funding) but they’re certainly not finished yet (are roads ever finished anywhere? As soon as they’re done end-to-end, they need to be repaired in places where potholes open up, it seems!).

It's raining season here, so I wake up to sunny mornings and then clouds roll in, rain comes, then sun, then rain, then sun. I learned on day one to bring an umbrella everywhere, because I will need it. Now I just need to remember to bring old sneakers so I'm not jumping across puddles into mud (no paving on one stretch between the office and hotel)  in my new sandals!

I’m here because JSI is having a big meeting of staff from many of our maternal and child health projects. About 25 staff are here from about 14 countries and we have many of our Ethiopian colleagues joining the meeting, too, for a total of almost 50 participants.

It turns out that all our folks who work on immunization issues are also here in Addis; there is a big World Public Health Congress here next week, so lots of groups are taking advantage of the Congress to hold adjunct meetings with staff. So on Sunday before I leave I’ll also join the Immunization Team to help them look at how they document all the good work being done.

But, the most interesting part of the visit will be Friday, when we break into smaller groups and visit different project sites to see the work we’re talking about actually being implemented at clinics and health centers. I’ll be there with my digital and video cameras, capturing what’s going on and learning first-hand about the impact we’re having. That will definitely be more fun that sitting in a conference room all day – even if the content of both is equally interesting!

More to come soon....

Interlude to a Travelog

I just stopped at the local supermarket on the way home and quite a few people were gathering. I ran into my World Education colleagues Inbal and Pierre in the parking lot who said that they were there to check out “the happening,” sponsored by the Alliance Francaise. A few local musicians were playing and a kid was breakdancing. I thought no more about it and ran into the store.

I emerged from Shoprite and heard Edith Piaf on the loud speakers. Many more people were gathered, but I didn’t want to keep Victor, my driver, waiting. I found Victor but from the corner of my eye saw a giant backhoe moving—and then noticed someone hanging from the backhoe. Not hanging, but dancing. Ballet dancing with a giant backhoe to Edith Piaf.

It was an amazing, uplifting, wonderful little interlude in downtown Kampala.

Meeting a Client in her Home

Day 3 continued

After leaving St. Stephen’s School, we drove to a local clinic and picked up a community health volunteer, Mama Agnetta, as well as the local government community health extension worker (CHEW) named Steven and drove to visit a client.

The roads we were driving on got smaller and smaller until it was essentially a path between fields growing corn and beans. When we got to a little shop, we parked and began walking. It was about 10 minutes to Evaline’s house, down paths between more fields—this part of Kenya is quite lush and all the fields had corn reaching about 2 ft high, with beans planted in between the corn. The house was larger than many I’d been to. It had a relatively big sitting room—which I suspect had extra chairs brought in for our visit—and a bed room, a packed dirt floor swept clean. And small windows that opened for ventilation.

[walking to Evaline's compound]
Mama Agnetta had heard that there was a woman who was house-bound when was visiting other people in the community about 2 years ago, and she came by to pay her a visit. Evaline says that her husband was living in Nairobi and her family had abandoned her when she became sick. Her . Mama Agnetta helped get Evaline to the Matibabu Clinic in Ukwala and advised her to get an HIV test while she was there.

When the test showed that Evaline was HIV positive, Mama Agnetta counseled her and talked about how to take care of herself and the importance of good nutrition. She arranged for Evaline to get multivitamins and other nutritional supplements and to get regular check-ups. When her CD4 count reached 120, Mama Agnetta helped Evaline go to the government's Community Care Clinic, across the street from Matibabu’s clinic, to get her antiretroviral drugs (ARVs). Today, Evaline credits Mama Agnetta with saving her life.

[Evaline says that Mama Agnetta, right has saved her life]

Visiting Evaline was very inspirational, and it was particularly interesting to hear how Mama Agnetta feels supported by Matibabu and how she’s seen the community change since CHWs began working in force. For example, the Kenyan District Health Office labels this area as prone to cholera. But in Ukwala, since the CHWs have been trained, there has not been a single case of cholera.

Mama Agnetta was a traditional birth attendant (TBA) for many years, and was even trained by the CDC as a “TB ambassador.” But as a CHW she is better able to address holistic needs of people in the community. She gives basic health information on health concerns ranging from diarrhea and worms to malaria and HIV, but more importantly, she knows when to refer someone to the health facility and can help clients negotiate what’s needed once they get there.

When asked what she thinks CHWs need, Mama Agnetta was quick to respond. “We need more CHWs who are trained [currently each CHW has about 20 households s/he is responsible for], and we should be more deeply trained in key areas.” She knows they can learn more—even though many of her colleagues are illiterate. Mama Agnetta also said that the CHWs need transportation—a bicycle—so they can get around more easily. All CHWs do their own chores and work in the mornings, in their home or on their farm, and then volunteer in the afternoons. A bike would certainly make their job easier. But few donors want to give funds for that kind of purchase. Philip is trying to find a way to help—though his hands are often tied, too.

Days 2 and 3 in Kenya

Wednesday, October 6, 2010

Our first work day here in Kenya was dedicated to a key message development workshop. The consultant Sarah used a process similar to one I’ve done in the past, whereby participants work to define who the organization is, its key differentiators, and the impact they’ve had on their clients. All this is designed to help Matibabu position itself to partner with other groups and do fundraising once the U.S. PEPFAR funding ends next year.

It was a long day with the staff very engaged in the process—though we never did get to the actual key messages because there was so much other discussion around other issues. (And frankly, I was glad to see that I wasn’t the only one who finds it difficult to reach this point!)

We again met with Amanda and Andrea over dinner. Mel had been with them all day taking photos in the clinic—mostly kids with malaria, she reports. (I made sure I started taking my anti-malaria Malarone once we got there!)

The second day gave us a chance to get out to visit clients, a youth group, and talk with community health workers.

[Bikes lined up outside St. Stephen's Siginga School]

First stop, an “Anti-AIDS Club” at the St. Stephen’s Siginga Secondary School. The Club was formed in 2009 after Matibabu worked with the school guidance counselor to conduct information and behavior change sessions with students. About 70 students, aged 14-20, participated in the information session and 69 of them ultimately got an HIV test (all negative!). From there they formed the club, which gives them a venue to talk openly with each other about issues that might be concerning them. The guidance counselor, Charles, leads the sessions.

Charles said that they all recognized that as western Kenya has the highest rate of HIV in the country (estimated to be 40%), that behavior change needed to start with youth. The club also works to build kids’ self-esteem and enable them to delay sex and “just say ‘no’!” And, in fact, in 2 years the pregnancy rate among girls has gone down, from 10 girls (of 200 students) to 4 this year.
[at right: Charles introduces us to the kids]

After meeting with Charles, we had a chance to meet and talk with the students (who were pulled out of class to meet the special visitors out on the lawn!). We asked a few questions of the kids, like what did they discuss at their last meeting, what do they tell a friend who might be getting into trouble. Philip, our project director, asked if they were able to pass along information they learn in the club—thus informing others of the factual information they've learned and hopefully help change others' behaviors, too.

[Philip fielding the difficult questions!]

The kids were then given a chance to ask us questions. One boy asked whether we had any advice on how one can approach one’s parents or aunts and uncles because it’s difficult. I piped up that as a parent of a 16-year old and an 18-year old, there have been times that they’ve come home and said “this is what I learned at school today…” so the issue is approached from the side, as opposed to directly telling an adult what to do. Not sure the advice resonated with him, but I tried! Other questions posed were more difficult to field—like “why don’t we lock up everyone who has AIDS” or “what do you say when a pastor says it’s a curse from God?” I did not have to respond, luckily, but these are some of the moral issues the kids are clearly thinking about—and at 40% prevalence (even though many people still don’t know/admit to being HIV positive because of fear of stigma) almost every kid there likely has had a family member infected… they are all affected even if not infected.

more on the other community visits soon...

Back on the Road - Uganda and Kenya

Monday, October 4, 2010

I landed in Kampala on Sunday morning, had a day at the hotel meeting with my colleague and friend Barbara Durr who was in from Nairobi. I wasn’t at the hotel long, though. Monday morning I checked out, went to the office, and we quickly left for Kenya. Our project director, Philip, did the driving (a first! Typically projects have hired drivers who cart us all around), ably dodging potholes and shepherding us through the crush of the border, where hawkers descend on the car offering to change money for you, hand you forms you may need, showing you what’s what. You get to do it all twice, as you leave Uganda and, 100 yards later, as you enter Kenya. It was quite the scene—a well coordinated chaos, it seemed!

Along for the trip was another communications consultant, Sarah, an American living in Kampala, and Mel, a British photographer visiting Uganda.

It was about a 6 hour drive all told. We landed in Western Kenya, in Uganya district, at a surprisingly nice hotel. Frankly, I was prepared for the worst, but the Hotel Camunya isn’t at all bad, all things considered.
(hotel Camunya at right)

After checking in, we drive the 20 minutes to the Matibabu Clinic. Matibabu is a small local NGO that JSI is working with through the Technical Assistance to the New Partner’s Initiative project. Matibabu received a direct grant from the CDC under the New Partner’s Initiative and JSI has been asked to help strengthen Matibabu’s management systems—along with about 15 other organizations. We just took a quick tour of the clinic and met some of the people working there and made plans for the next day, when Sarah would be conducting a workshop on key message development.

It turns out that while Matibabu is “homegrown,” they were founded and are extensively supported by a group of doctors from San Francisco--now called the Tiba Foundation. We found this out at dinner, when two Americans came into the hotel restaurant; one we had seen at the clinic. Amanda and Andrea are doctors who have volunteered for two weeks at Matibabu. Amanda, a pediatrician, has been involved since day one and volunteers twice a year. This was Andrea’s first trip—she’s an intensive care pulmonologist who’s known Amanda for years and was persuaded to come to Kenya by Amanda’s enthusiasm!

Matibabu Pharmacy window below

Back in Lusaka

We arrived back in Lusaka on Tuesday afternoon after our lovely time in Livingstone — and definitely feeling like we could use a few more days at Tongabezi!

Back in the office on Wednesday, my schedule was mapped out to interview staff and key partners to learn more about the program and look at ways to write-up the work. There was also an event planned for Thursday morning in the Zambia Parliament. SHARe had helped write the strategic plan for the Coalition of African Parliamentarians against HIV and AIDS (CAPAH for short). Building political leadership’s abilities to effectively talk about HIV is a critical component of SHARe’s work. This launch is a key piece in their leadership component.

The Zambian Parliament is a long, low building, seen at the top of a hill. We were ushered into a staid auditorium, where the Parliament PR flack was busy running around, getting everything organized. The US Deputy Ambassador was scheduled to speak (the day before we’d thought the Ambassador would be there — which would have caused significantly more flurry and work, but by the end of the day he’d backed off and left the task to his deputy), along with the Parliament Speaker and the chairman of CAPAH.

Politics is politics (led by the same-style politicians) in whatever country one is in, I think. Lots of pomp and circumstance, and everyone makes speeches that no one really listens to… unless there’s an error made, and in this case, there was a huge one… the CAPAH chairperson thanked SHARe for their support (not mentioning USAID as SHARe’s funder — a big faux pas) and then went on to thank the Chinese government—and even bigger faux pas, it turns out. The many folks in the audience from USAID were decidedly not pleased! I’ve no idea whether the Chinese government has funded CAPAH at all, but, Thursday morning there were many American faces in the audience and no Chinese faces. People were pissed, wondering who reviewed his speech, etc. Oh well. It sounds like everyone’s hoping for an apology now…

Meanwhile, I did interview the guy after snacks and cokes on the lawn-covered second-floor veranda. In our interview he said all hit all the right notes about SHARe and the US government and how instrumental our support has been (and how he wants it to continue — a key quote as our project is due to end next year!).

That afternoon I interviewed another partner, ZamAction, that receives funds for it’s work and training to build their capacity to better manage USAID-funded work (on things like financial systems and reporting requirements, all critical to getting USG funds!). ZamAction is working in the “informal sector” — which means markets and bus stops — essentially workplaces where people gather and work but have no formal workplace systems — like HR or medical care — in place. ZamAction trains peer educators and sets up temporary HIV voluntary counseling and testing (VCT) tents, so folks working in the markets can get advice and be encouraged to get tested and know their HIV status. Before I left the interview with the ZamAction director, we discussed my visiting one of the markets or bus stops where they’ll be working next week—should be much more interesting than sitting in an office!

By the time I got back to the office around 3:30, the power was out and almost everyone had gone home, rather than work in a stifling hot office without computers! So I followed everyone’s lead and went back to our home away from home, the InterContinental hotel.

Friday morning I got a call that the power was still out, so we basically hung at the hotel most of the day.

Meanwhile...

The plan all along has been for Colin to volunteer in an orphanage while we’re here — though nothing had been set up yet. I’d reached out to one place that an ex-pat working for another JSI project here — Wendy Nicodemus — had told me about. The American who runs the facility had emailed me that she’d be out of town but they could definitely use Colin’s help. But when we got here and I reread her email, she didn’t give me any of the contact info on the place. I’ve emailed her back, but haven’t heard back from her yet. A dead end thus far.

There’s a woman at the SHARe office who is involved with a network organizations for Zambian orphanages who said she’d hook us up — but that hasn’t transpired yet either. So Wednesday and Thursday, Colin basically slept in and then came and hung out at the office in the afternoon.

Thursday night we had drinks with a friend of my British cousin Tim Malthouse. Tim Ware has lived here for 14 years and runs a commercial real estate enterprise. He ended up making a few calls on Colin’s behalf and Friday afternoon we went to check out a school here run by the Pestalozzi International organization, a British charity that selects very poor, very bright kids and essentially has them board in their facility (village), sends them to a better school than they’d otherwise attend, and teaches them skills in the afternoon. Pestalozzi runs facilities in India and Zambia.

Once we got to the school it was clear that they’re pretty well-funded and what they really had for Colin was busy-work, helping around the grounds... he will be cutting grass (with a scythe, no doubt) tomorrow. This afternoon (Sunday), however, the kids will be planting trees and we will be joining them in this venture.

Friday night we were both feeling a bit despondent that an orphanage hadn’t worked out—Colin was pretty good about it all, but I talked about shifting expectations and going with the flow.

Saturday I’d arranged to meet up with Wendy Nicodemus. She’s an American who’s been here with JSI’s DELIVER project for about 18 months. She picked us up at the hotel mid-morning and kindly let us tag along as she went to the once-a-month Dutch Reform market (so called because it’s on the ground of the Dutch Reform Church). Lots of ex-pats shop there and Wendy seems to know about 1/4 of them! It was a great market with foods, plants and vegetables & herbs (for planting), and lots and lots of crafts for sale. We bought Wendy some cilantro and basil for her garden and a few things to bring home for folks. We didn’t get as much as we could/should, because I was a bit worried about running out of money. The ATMs I’d tried hadn’t worked for me — and Wendy finally explained that she’s only found one ATM in all of Lusaka that works with her US bank. She ended up loaning us a bit of cash and luckily the ATM in question was nearby and we were able to get some cash.

We then went and hung at out Wendy’s house. She and her husband, Eric, have found a great place with a lovely yard, huge fruit trees, and have slowly been acquiring animals… they now have 2 puppies and 2 tiny fur-ball kittens. Colin was so happy to be around dogs again! The oldest, Bowie, is about a year and a very rambunctious hound/mutt. The little one, Cleo, was a cute-as-can-be 7-8 week old named Cleo (for Cleopatra, because she was found on Cairo Road). Colin happily played with them, charging around the garden for about an hour.Bowie and Cleo want to play!

When Wendy’s husband returned, he invited Colin to help him at the youth center where he volunteers on Saturday and Wednesday afternoons. Colin was thrilled, I think, to hang out with a 30-year old cool guy!

Eric dropped me off at the hotel while Colin ran in to put some sneakers on and retrieve the 4 soccer balls we’d brought over with us. It sounds like they had a blast! Eric had erected basketball nets at the center last week and this was the first chance the kids had to learn the game. They also played Frisbee, foozball, and, of course, soccer with the balls we’d brought.

They didn’t get back ‘til almost 7pm, but it sounds like Colin had a wonderful time with the kids — he got a photo (with Eric’s camera) of a boy who’d lined up one of the balls we gave them next to his “Zambian football,” which was essentially a mass of bags rolled up and wound with string. –I’ll have to try to get that off Eric’s camera before we leave here next week!

Anyway, it sounds like Colin will join Eric again later this week and put in just a day or 2 cutting grass at the Pestalozzi village.