Entry 5 - World Malaria Day
Another method of making both Tuzanet and Primo available is through unpaid “community health workers” - folks who have been elected in their communities to be just that, a health worker.
Believe it or not, our funding expires for this soon. Obscene. It is so successful. But that’s the shortsightedness of some donors: Oh, great job! 60% reduction, problem sorted! But what about the other 40% and when the nets become ineffective in 3 years time, 2010? Malaria will be back where it was in ’06, high morbity and mortality, and disabling the productivity of care givers with sick children.
Ashley, Minister of Health Dr. Ntawukuliryayo and PSI Country Representative of Rwanda, Staci Leuschner, land at Malaria Day event.
I packed up all my stuff and ate a weird breakfast before going to the airport. After a wait, we boarded a heifer of a helicopter, a giant military thing with bench seating lining the length of it. The Minister of Health, a tall, rangy guy and straight talker, and I would be crossing Rwanda to celebrate World Malaria Day with PSI. I listened to my favorite far out spiritual music on my Ipod as I admired the verdant hills below, and began to register what I heard, that every square inch of the land is tilled in the effort to feed all 10 million people living here. The land is cultivated, gardened, terraced, you name it. (The Clinton Global Initiative has programs to help people increase their harvests in sound ways, as well as to help farmers earn money from their yields.)
Children meeting the helicopter in the field.
We landed in a giant field in the East Province, greeted by hundreds of onlookers who were curious about the helicopter. Cries of “muzungu” erupted as my colleagues and I got into our cars. We jolted across rough, red dirt roads to visit to see a community health worker in action; we visited a broken woman holding a limp infant. The community health worker had diagnosed malaria, and was giving her education about her new net and proper use of Primo. When I sat with the woman, she was not easy to engage, she herself was so ill and quite overwhelmed. I tried to squeeze in a few quiet moments with her, as I am not a breeze in, breeze out kind of gal. I like to learn the stories of the people I meet, to share in their lives as much as I can, form an emotional connection. My only real contact with her, however, was that she smelled so rotten I actually had a gag reflex, a first for me in 11 countries of slums, brothels, and hospices. Many women live in such extreme poverty that they have no basic knowledge of any form of hygiene.
Ashley with woman in her home showing her bed net from PSI.
In a back bedroom, a woman who rented the bedroom had her net hanging proudly over her bed. She had a lavender outfit and we sat under her net giggling. She was really precious and very proud of herself!
Beneficiaries of PSI PRIMO long lasting insecticide treated nets.
The community health worker (CHW), as all are, was special. Initially, he had to explain to his fellow villagers, perhaps with some competition from others, why they should choose him for the post. I picture him standing on the grass, surrounded by cassava and beans, maybe some hedges in bloom, with rough finished shanty shacks around him, a few goats or cows near by, with his community quietly assessing his ability. Once elected, he receives 5 days health services training (eventually I met the guy in charge of the hospital in Kigali where the folks who train the CHW’s are trained, the decentralization is fascinating). In his kit he has life saving pharmaceuticals (antibiotics, i.e.), family planning methods, malaria treatment, and some non pharmaceuticals. He is available in his home and goes to those who are too unwell to traverse the mountains to get to him. It is worth noting here that this job is unpaid, and when the CHW’s are asked what they need, wellies are often mentioned, so they can keep walking to serve their community in the rainy season. When I asked him if people stop by at all hours of the night and day, he said no, that they all see each other getting water at the river, searching for firewood, and at those meetings they agree when they can get together.
We celebrated World Malaria Day in this home, showcasing how nets, treatment seeking behaviors, and Primo can reach every household in Rwanda, even the most remote and poor. It was a good visit.
Ashley handing out a PRIMO net.
From there, the MOH galloped off for our visits to rural health clinics. Continuing to lurch and heave over rutted roads, we arrived at a place where rows and rows of locals were sitting on wooden benches on a poured concrete floor covered with a corrugated tin roof. They were patiently waiting for services and by look of it, they would need that patience. The area was open to the breeze, which is a good thing for many reasons, not the least of which is that everyone is so stinky. Water is so scarce, one drinks it mostly, then perhaps uses it for cooking; washing oneself is a very, very low priority in this country and many are unaware of the health needs for basic hygiene. The people at the clinic were reporting with a variety of the usual complaints; so very much of this work is same story, different country (I will never forget when I vividly learned this: I was sitting with commercial sex workers in a brothel in Madagascar. I asked one what her deal was, how she ended up here, and she nonchalantly waved her hand: same old story.) Although we were there to teach the ABC’s of malaria prevention and treatment, he minister never misses an opportunity to reinforce other key health messages. Literally everywhere we went he also discussed point of use water purification and family planning. I would describe him as utterly indefatigable!
We met the clinic staff, whom I always love to celebrate and honor, and saw the “laboratory” (they do have rapid result HIV tests) and other offices. Everything was so utterly simple and plain; they would be beautiful if I didn’t remember the complex nature of the needs they are struggling to meet effectively. The wards themselves were bare cement rooms with simple aluminum cots lining the walls. Over each cot was painted a number, 1, 2, 3, 4….the beds were all filled and newborn babies slept and nursed everywhere. A few women had visitors from their other children, one granddaddy was there. The minister and I talked with them about how undeveloped their children’s immune systems are and why mousquitaires are essential. I got to hold a sleeping 2 day old baby, but not for long….he was off, again! I barely got to make good eye contact with everyone. I think that baby was premature, it was very tiny. Low birth weight is a big factor in maternal child health in poor countries.
Ashley in a rural health clinic serviced by PSI.
In the pre-natal ward, identical in appearance, the minister spent time chiding the pregnant women, especially the very young, and reinforcing family planning behaviors once their babies are born, as he did on malaria. He told stories using local color and references to reach them, including some stuff that really cannot be translated right. If I told you he encouraged them not to be dogs constantly having puppies it would give the wrong impression of him; it was appropriate and effective use of imagery to illiterate and traumatized people who do not have the advantage of understanding diplomatic terms and euphemisms. I really like, too, how much emphasis he puts on men’s accountability, and how they must change their behavior, too. This guy is very switched on. He is very hard on men and boys who pressure women for sex, do not use birth control, and who do not take care of their families.
A young child suffering from malaria.
We continued to run around to rural clinics scattered in all directions in a convoy of government, USAID, UN, WHO, PSI, and other alphabet soup cars. For Rwanda, it is about “la base,” the base, the people, and reaching them directly with what they need most….they totally get this is what creates a healthy nation.
PSI PRIMO bed net.
We had our formal World Malaria Day in another fine field, this one with a few simple tents and a microphone powered by a generator in the back of the truck. It was loaded with government officials from all levels and each made a speech, heard by locals who closed the field in a thick square of dirty bodies. During all the thank you’s to one another, the mentions of the mayor/governor/minister/goat herder/you name it, I was so sleepy. I should be awarded the “manages to stay awake on beautiful, breezy day in the mountains during lengthy African events with way too much protocol attended by a ton of people one has been sternly warned not to offend” award. My thoughts went like this: Don’t think about how nice it would be to lie down on a quilt, right here, Ashley. Oh, for sure, do not think about a glass of Pellegrino with lime. Do not think about playing gin rummy with Dario on the bed, oh a bed, God, how good would a bed be okay, tooth picks, think about tooth picks keeping your eye lids open….look around, find something to be interested in, get curious, become attentive, oh, look at that, isn’t that mother fascinating, the way she ties her cloth to secure the baby on her back, if I lean forward I can see her better, if I lean forward I could maybe just sit on the grass, oh, the grass, wouldn’t it be lovely to lie down on the grass?”
Eventually, we got back to the pasture where the helicopter was, and what fun lied ahead for me! Hundreds, if not thousands, of people had gathered and were lining the field in the most orderly fashion. They were tiered, littlest sitting to tallest standing in the back, silently staring at the big machine. I practically dove into the crowd, and plopped myself down in their midst. I was immediately surrounded by an epic mural of faces, seemingly from grass to sky. Several of the boys had sticks of grass in the mouths, and unbeknownst to me, one was tickling me. Thinking skeeter, I swatted it, and kids roared, they’d pulled one over on me! I put some grass in my mouth, too, and in this non verbal way, we began to cut up and have some fun. We carried on like this for a while.
I noted a boy in a ragged shirt holding a bundle of old plastic bags which he had compacted and tied up with string to make a precious football! I gestured to him and the ball, stood up, and we were off. In one of the most memorable moments of my life, the kids and I began to stream joyously all over acres of Rwandan’s green grass, passing the “football,” shrieking with joy. I suddenly (by the grace of God, for sure) became a really good footballer and passed swift and straight to my team mate. It was him and me against a growing crowd of 60, 70, 80; one of those blessed moments. I was in a state of grace, and I knew it. It felt like it lasted forever, the running, lungs heaving, laughing, looking around at all their unmitigated joy, the color of their skin so black with my own little white body so safely nestled in the herd.
We collapsed in some tall grass and panted. An outgoing young man wanted to be my new teammate. Instead, I called him “capitain numero deux,” trying to organize things a bit, and we began running again. But the moment had passed. Now it was more manic and I thought the littlest ones might get hurt. Plus the military kicked us off the grass as they wanted a wide area near the helicopter cleared. It was good while it lasted.
When the helicopter lifted, the giant throng ran in fright. I saw them streaming by ones and tens in every direction, fleeing. A little too much excitement after all, I guess.
