Monday, August 2, 2010

Health Coach Training in Uganda

I have uploaded a couple of pictures here:

Check out this video I made about VHT Trainings in Uganda:

Since I arrived in Uganda a month ago I have been wondering how such a dry place could have such richly green vegetation. By the end of my half-hour walk into the office each morning my clothes, skin, face, and mouth would be coated with dust kicked up by the trucks. We remarked how the weather was perfect -- hot but not too hot during the day and cool but not too cool at night, and an occasional sprinkle one or twice a week at the most, not enough to even wet your clothes. I could not understand how a place that seemed so dry could sustain a sort of jungle vegetation not so different from the rain-forests of Ecuador.

The paradox was resolved three days ago when we were walking home from the office for lunch and the skies opened up in a downpour, turning the dusty dirt road to wet clay and mud. This event has repeated itself at least once a day since then, and brings the days activities to a halt each time. It is on such a rainy morning that I take advantage of some remaining battery power in my laptop to write this.

The program that I am working with here is a remarkable one -- a local NGO called Volset is partnering with a US NGO called OmniMed and the local government to train "village health teams" with one community health worker for every 20-30 families. After a week's worth of training, these "VHTs" go back to their villages and start visiting the homes of their neighbors to collect information about the health status of their communities (how many families have latrines, handwashing places, plate drying racks, how many children are immunized, how many cases of malaria there are, etc). They collect this information to give to the local health centers but also work to educate their neighbors and encourage them to fill in the gaps in order to prevent disease and promote health. It is interesting to be a part of a program in this stage of "scaling up" and interesting to see the tradeoffs of training more and more VHTs versus ensuring good support for the ones who already have been trained.

Most of our time here involves working directly with the VHTs -- training them and following-up with those who have already been trained. And these VHTs are amazing, inspiring people, who do all this work with absolutely no reward except the knowledge that they are making a difference in their communities. They are all proud to tell us about how they are seeing their neighbors boiling water, building latrines, taking children for vaccinations. But it is not easy work. How do you insist that an old woman with several young grand children to take care of dig a latrine? How do you tell your neighbors to go to a Health Center when they are sick when more times than not a person will go to a health center, wait through a long line to see a doctor, be told that they have malaria, or TB, but the health center will have run out of medications so they will have to go to a private pharmacy to buy them. The result of this, of course, is that people begin to go directly to the private pharmacy, where they buy medication based on a self-diagnosis or the diagnosis of a nurse who runs the private "clinic" and save all the time and transport cost that a visit to a health center entails.

Which brings me to the bigger picture -- how can a country like Uganda, with all of this foreign aid, a stable government with strong US support not have medicine in their government health centers? People talk about how most of the money stays in the government for internal workings / kick-backs, which I am sure is a big part of the problem, but there is also a greater context. Most obviously and importantly is the legacy of colonialism which shapes so much of the way people think and the way things work. Then there is the fact that the Ugandan government spends so much money on security (sound familiar?) -- both for defense forces within Uganda and the troops they have sent to other countries like the Congo, Rwanda, Burundi, and Somalia. I actually wound up talking about all of this late at night by candlelight with one of the VHTs in his house. Under a roof made of papyrus and sheet plastic, this man listens to the BBC on a radio powered radio and gets a Kenyan newspaper once a week to stay up on what is going on in the world. He explained that the reason that Uganda has been intervening militarily in other countries is that the United States is using Uganda.

Crazy as it seems, I actually have less than 3 weeks left in Uganda. It is always a sad moment to realize that my time is drawing to a close and that I will be leaving behind all the friends I have made here. I do want to stay in touch and involved to the extent that I can, and one thing I've decided to do is find sponsors for one of the amazing young women I have met here, an 18 year old named Saida, to go to nursing school. I'll be going to Kampala with Saida tomorrow to visit nursing schools and find out all the details, but I think it is going to come out to about $100 a month for tuition, room and board for the three years of nursing school here. A substantial amount of money, sure, but it will transform her life and give her the skills to make a real difference in her community. Let me know if you or someone you know might be interested in contributing.

Friday, January 8, 2010

Water system successes

For more information about the project, see
For more photos from this trip, check out my picasa album

I went back to Santa Ana Ecuador for four days this December. There is something incredibly special about this community, and it was so wonderful to see everyone again. I have been involved in this place for almost four years now, and children I met as one-year olds just beginning to talk are now about to start first grade.

This girl, Shirla, is one example. The photo on the right is me with my beloved comadre Elsa.

The community water system is still working. It is not textbook perfect, but they know about the problems and how to solve them, and that means my role is to step back and let Santa Ana handle these challenges for themselves.

One of my days was spent on a follow-up to trip to La EncaƱada, one year after the Santa Ana water board helped them install family-level rainwater systems in each of 9 family homes.

We found all 9 tanks still working, in good condition, and getting very positive reviews from the community. We tested all of the families' water: some had extremely clean water and some quite contaminated. They all emptied and cleaned their tanks in anticipation of our arrival (little bit of mis-communication there), so we had to test water that they had stored in other containers, so it is hard to know whether the rain water tanks themselves were the source of contamination or the storage containers.

Either way, we know that it is possible to have very clean water with this system, but it likely depends on the maintenance each family provides and if and how they store it in another container.

We also repeated a house to house health survey and found that the reported number of times a child had diarrhea in a year dropped from an average of 6.9 to 1.9 times per year from before our intervention, which is quite promising.

The most exciting part of all is that the new mayor has made water her top priority for the next 5 years. Two communities have asked for Santa Ana's help to apply to her for funding for the tanks, and they have both gotten tanks and are working with Santa Ana's water technical team to do the installations. How amazing is that?

The fact that this work is starting to take a life of its own is the ultimate success. However, on this trip I was also touched by a number of anecdotal stories that help me feel in a smaller more personal way that somehow, with all of this effort, we really are making an impact.

Melida, who is one of the people most active in the Santa Ana water system and outreach to other communities told me that she first got interested her first summer when her son came home from school and told her that their water was contaminated and they needed to boil it. I think that the water quality testing kit, which I just restocked thanks to a generous donation, is one of the most important parts of the work that Santa Ana is doing, because it enables people to have these kinds of "ah-hah" moments when they see for the first time what sources are cleanest and why they need to treat their water.

Another anecdote came from the first operator we trained, Oldemar, told me that in his new job in another part of the country, there was a broken pipe and he fixed it with a patch he made by heating up each end of the PVC pipe and molding them with another pipe. The community was so thankful and called him a water engineer.

Medical School

Sooner or later I figured I should write a blog post about Medical School at UCSF. Hopefully I will put up some more thoughtful and reflective posts at some point in the future.

Last September marked the beginning of a great transition in my life – from the world of water and engineering to the world of health and medicine. It is exciting and at times overwhelming to be entering such a complex world, but I have really been enjoying med school so far. It is hard to capture in a few paragraphs what it means to be studying medicine, but I’ll try to give you at least a rough idea. UCSF is completely pass-fail for the first two years, and the curriculum is based on blocks divided by organ system or major theme. I just finished the 6-week cardiovascular system block in December, for example, and an now a week into the 3-week pulmonary (lung). We have an exam every three weeks or so. Even though the exams aren’t cumulative, it is like studying for the most intense final of undergrad every three weeks. I enjoy the rhythm, because I can focus on thing other than school for two weeks and then put it into high gear for the last week before each exam. The material is interesting and challenging, but it is not very stressful because there are no grades; we only need 70% to pass, and if we don’t pass a test we just take it again. I think it is a brilliant approach, because we can focus on learning as much as we can, and don’t have to play games of selective studying to optimize our test scores.

Since September, I have learned to take patient histories, practiced the routine physical exam, developed a basic understanding of human anatomy over many dozens of hours working with a cadaver in the anatomy lab, and begun the tremendous task of understanding the workings of the human body, how to tell what has gone wrong, and if and how we can intervene to put things right. I loved the cardiovascular block – all the talk of valves and flows and pressure gradients were comfortingly reminiscent of water system engineering.

In many ways I feel very much like I felt as a freshman at MIT – my interests piqued by so many issues and questions but with little knowledge or experience to grapple with any of them. I am thrilled that so many of my classmates are also interested in healthcare for the underserved, global health, health disparities, single payer health care, etc, and that our school not only allows but encourages us to invest our time in such issues. As I anticipated when I decided to come back to the US from Cuba for medical school, sometimes I get extraordinarily frustrated with the US health care system, or, as speakers on the topic tend to quip: the US disease treatment industry. I wish I had some sort of hope to offer in this regard, but I am only beginning to understand the depth of the issues. I believe we need some kind of single-payer solution, and am starting to work through the practicalities and subtleties. This Sunday I am going with a number of other students to a training and then Monday we will be meeting with California legislators about the state-level single payer healthcare bill. Then in the Spring, I will take a comparative policy elective which discusses the health care systems of a number of different countries, which may help me flesh out my thoughts a bit more.

I am often asked what kind of medicine I want to go into. I realize that I am only at the beginning stages of this process and my ideas will most likely change and evolve as I go, but right now I plan on doing some kind of primary care. I am interested in figuring out innovative ways to foster health and increase access to health care in marginalized communities. For a while, my debt will require me to do this kind of work in the United States, but after I have paid it off I want to move abroad, maybe to Latin America, maybe to some other part of the world. I have grand visions of being the village doctor someplace, training and supporting local health promoters, mentoring future doctors in the region, and maybe traveling occasionally to learn from others and share any insights I manage to glean. I am beginning to realize how much I love to teach and how teaching could serve to multiply my impact, whether that is by training health promoters or teaching medical students. However, I think I would rather teach in another country besides the US– solutions to global health issues must be born in the global south, in the minds and hearts of people who share a language, culture, and history with the people they want to serve.