Direct Relief Emergency Coordinator, Brett Williams, reports from Afghanistan, where he has been working and traveling with the local Afghan health leaders whose efforts Direct Relief has supported for the past four years. During this period, Direct Relief has provided $4.2 million (wholesale) in medicines, basic health equipment, and supplies. Direct Relief also has provided funding to build health facilities and to support health education, midwife training, and enhanced children's health services. The training and children's health efforts are ongoing thanks to the support of Abbott.

Brett is an EMT and spent several months in Pakistan following last year's tragic earthquake directing emergency shelter efforts and later coordinated emergency response efforts in Java following the Yogjakarta earthquake.

March 2007
Kabul, Afghanistan

Several related factors plague women's health in Afghanistan.

Little Infrastructure, Few Health Professionals, Limited Access: The province of Badakshan, which is northeast of Kabul, exemplifies the enormous health challenges that women confront in Afghanistan. An estimated two percent of women give birth with a trained health professional present. "Trained health professional" doesn't mean a doctor -- it means a nurse or a skilled birth attendant. According to a recent study conducted by UNICEF, Badakshan province has the highest maternal mortality ever recorded.

Access also is affected by geography. Most of the villages in the mountains can not be reached for many months of the year due to poor roads and snow. Moreover, even when clinic a facility exists, the likelihood is very low that a trained female health provider would be present to assist a woman expecting a child.

Thirty years of war in Afghanistan caused a major brain drain - most of the educated professionals having fled with their skills. Among other consequences, this resulted in a generation living with a severe shortage of healthcare providers.

Our Afghan partners have explained how cultural norms also affect women's access to health services. Women traditionally do not travel unaccompanied and, typically, expecting mothers would need to be granted permission from her husband, her father-in-law, and her mother-in-law in order to make the journey to the clinic. Families that are unaware or uneducated about the risks of a complicated pregnancy may forego seeking prenatal care or assistance in delivering a child, choosing instead to follow tradition of giving birth at home. In general, people living in rural areas tend to adhere more closely to these traditional practices.

Maternal and child health is affected by many factors, but these are among the major factors reported that together have caused such a high rate of maternal mortality in Afghanistan. The AIL staff, most of whom are deeply committed Afghani women are working tremendously hard to improve circumstances in each of these areas.

Senior Program Officer Susan Fowler is visiting Direct Relief partners in India and Nepal throughout January.

January 3, 2007
Kutch, India

The opening ceremony for Bidada Hospital’s 33rd medical and surgical camp was held on January 3, 2007. I arrived at the facility the following day, and the medical screenings, consultations, and pre-operative services were already in full swing. The hospital is administered by the Shree Bidada Sarvodaya Trust, and has been providing quality healthcare services to the people of Kutch, in the state of Gujarat , for decades. Their annual medical and surgical camp, held during the first three weeks of January, treats thousands of patients who have no other access to specialty services. In 2006, the camp provided examinations and treatment to 28,284 people, and conducted 1,173 surgical procedures, all free of cost.

This was my second visit to Bidada Hospital, a facility that Direct Relief has been supporting ever since the devastating Gujarat earthquake that occurred in 2001. The hospital, one of the only health facilities that wasn’t damaged or destroyed in the quake, treated thousands of earthquake survivors and still handles an increased patient load as many of the pre-existing medical facilities were never rebuilt. Direct Relief provided multiple earthquake-related emergency shipments to the facility, and subsequently decided to continue our support of the hospital by supplying medical goods for their on-going services and medical camps.

The district of Kutch has a population of approximately 1.6 million people and is home to many different nomadic and semi-nomadic tribal populations. The area’s ethnic diversity is very apparent at Bidada Hospital , with men sporting turbans of various colors and women with tattooed necks wearing fabrics and jewelry representing their respective tribes. A total of 35 medical specialties were being offered at this year’s camp with urology, diabetes, endocrinology, ENT, speech and audiology, cardiac, pediatric ophthalmology, and general surgery services all scheduled for the first week. Healthcare professionals from the U.S. , Canada , and other areas in India volunteer their services during the camp with many coming year after year. Dr. Manibhai Mehta, an Indian-American urologist who resides in southern California, comes to the camp each year to help with the urology consultations and surgeries.

Due to the mineral content of the local water, there is a very high incidence of kidney and bladder stones and many people live with excruciating pain for weeks, months, and even years before getting treatment. During the first three days of the camp, Dr. Mehta, along with three other urologists and a radiologist, examined over 200 patients and performed more than 50 surgical procedures, many involving the removal of 15 or more large stones. When I visited some of the patients in recovery, they expressed their heartfelt gratitude to the hospital, the physicians, and to Direct Relief which had donated many of the surgical instruments, catheters, and medical supplies needed for the procedures.

I also had the opportunity to observe the second day of cardiac screenings when approximately 50 patients are selected to travel to Mumbai to receive surgical procedures. The most common heart problems requiring surgery include congenital heart defects for children and valve replacement for adults. One woman who was examined by one of the volunteer cardiac surgeons was informed that, due to rheumatic heart disease, she needed to have valve replacement surgery. Hospital officials explained to her that all of her costs would be covered, someone would be available to take care of her during her stay in Mumbai, and that she would receive a free lifetime supply of medication. She was scared and overwhelmed by the diagnosis and need for surgery, and said she needed time to decide if she was willing to take advantage of this generous but frightening offer. I then watched the examination of a young boy who needed surgery to fix a hole in his heart. His family had traveled over 100 kilometers to reach the camp, and they were overjoyed that the boy would receive this lifesaving opportunity free of charge.

It was great to see Direct Relief-donated medications, supplies, and equipment items being used at the camp, and many of the hospital administrators and volunteer physicians conveyed their appreciation. They also asked if it was too soon to submit a new list of needed items for 2008. I assured them that Direct Relief was honored to work with such a first-rate institution, and that we would do our very best to support their efforts in the future.

Senior Program Officer Susan Fowler spent part of January in Fiji with Direct Relief partner Loloma Foundation evaluating the country’s healthcare resources and assisting a vitamin A distribution program.

January 2007

The boat arranged by the village chief arrived on schedule, and we loaded it with medical goods then climbed aboard. I was accompanying a medical team, organized by the U.S.-based Loloma Foundation, and we were traveling by boat around the Yasawa Island group in northwestern Fiji. The team, which consisted of three physicians, an optometrist and his assistant, and the project director, was conducting medical clinics and delivering critically needed medical products, such as medications, first aid and clinic supplies, and screening and diagnostic equipment items, to regional nursing stations.

The Loloma Foundation was established to support the limited healthcare and educational services in Fiji. Every year, the Foundation distributes medical materials, including Direct Relief-donated products, to inadequately-supplied hospitals, clinics, and nursing stations located throughout the island nation. In collaboration with Scripts Memorial Hospital of San Diego, the Loloma Foundation also organizes teams of medical professionals to travel to Fiji to conduct medical clinics in extremely difficult to reach areas such as the Yasawa Islands. These coral and volcanic islands stretch out for approximately 80 kilometers and can only be reached by boat or seaplane. They are rarely, if ever, visited by Ministry of Health physicians.

Major health issues in Fiji include bacterial and fungal skin infections, muscle and joint pain, ear and respiratory infections, filariasis, hypertension, and traumatic injuries. Nursing stations have been established on selected islands and each station is staffed by a trained nurse/midwife who provides basic services to the local community or geographic division. The most critical issues with regard to the availability and quality of healthcare services in Fiji include the number of individuals a nurse may be responsible for taking care of (up to 3,500), the cost and logistical difficulties required to reach a nursing station, and the chronic shortage of medical products and diagnostic tools available.

Yasawans, like most rural Fijians, live a subsistence lifestyle by fishing (both reef and deep sea) and growing/harvesting fruit and vegetables, such as cassava, yams, breadfruit, papaya, bananas, and pineapple. Many Fijians still live in bures - traditional one-room homes with woven mat walls and palm thatched roofs. Most villages do not have electricity or running water. Village life is very communal, and frequent ceremonies and religious services bring people together. Before a clinic begins, the village chief, his spokesman, and other ranking villagers hold a kava (drink made from the crushed root of a pepper plant) ceremony to welcome us.

Our first stop in the Yasawa Islands was to the village of Yasawa I Rara. After being transported to the shore we walked to the village community center where stations for the various physicians had been prepared. The nurse responsible for the area had arrived early and had already started to hand out patients’ medical record cards to those waiting in line. He also worked closely with the physicians all day to provide context, to help translate, and to schedule any required follow-up.

As the incidence of hypertension and diabetes has been rising in Fiji in recent years, all adults received blood pressure and blood glucose screenings before their consultation with one of the physicians. The dermatologist screened hundreds of people as bacterial, fungal, and parasitic skin infections are extremely common among both adults and children. She provided customized treatment plans for each person using an assortment of systemic and topical medications. Micronutrient deficiencies are also an issue in Fiji and vitamin A deficiency, due to the limited diet on outer islands, can put children at risk for vision problems and limit their ability to recover from serious illnesses.

To address these concerns, I worked with the nurse and local school to provide high-dose vitamin A to all village children between the ages of one and 15. Supplements to continue this distribution program (only one capsule is required every six months) for the next 18 months were left with the nurse.

There was also a long line to see the optometrist who was able to diagnose an array of vision problems as well as prescribe prescription eyeglasses, reading glasses, or sunglasses which were then dispensed on site. Cataracts and other eye disorders are common among the rural Fijian population, especially among women who typically spend four or more hours each day fishing on the reef. If a patient can arrange to get to the host hospital – an expensive proposition with the high cost of fuel – they can receive surgery to restore their sight.

Yasawa I Rara was only one of the many island villages that we visited during our time in Fiji. The villagers were extremely grateful for the opportunity to obtain medical screenings and care and upon leaving we were often thanked with songs, dancing, and handmade gifts. In addition, each nursing station visited received a midwife kit, diagnostic and testing equipment, and an assortment of medications and supplies. These stations will now be on the official Loloma Foundation list and will receive a supply of medical goods every six months.

Direct Relief program officer Matt MacCalla traveled in India from mid-December 2006 through early January 2007 visiting Direct Relief-supported facilities and projects. His trip also coincided with the two-year anniversary of the Indian Ocean tsunami that took hundreds of thousands of lives in December 2004.

December 26, 2006
Port Blair, Andaman Islands, India

On December 26, 2006, in a modest event commemorating the second anniversary of the Asian Tsunami, a small assembly of people, including officials from India’s national and local governments, gathered in the Andaman Island capital of Port Blair. Together, they intended to illustrate that there is more than grief to be recognized, and more than tragedy to be remembered. Although sadness made its presence felt, the event acknowledged achievement and hope for the future by officially handing over to the government 34 new health care facilities, funded by Direct Relief International, to replace those that were literally washed away in the Tsunami,

Looking back two years, it is not difficult for most to remember reports of the Asian Tsunami, the wrath it brought, and the quarter of a million lives it took. The wave wreaked havoc on five costal countries, each experiencing a great deal of damage. The Andaman and Nicobar Islands—a chain of small, sparsely populated islands located 1,000 kilometers to the East of mainland India—were no exception, and bore witness to a great deal of death, injury and destruction.

Comprised of hundreds of islands, the Andaman and Nicobar chain is India’s most remote state, famous mostly for its underwater scenery, lush tropical forests, wildlife, and, for its remoteness. With a population of less than half a million, it is also India’s least populated state, and many on the 36 inhabited islands are aboriginals from one of twelve original tribes. Still today, many of the islands have little to no contact with the outside world, and parts of their culture, indeed even the size of their population, are officially unknown. Few, if any, other living human populations have experienced such long-lasting isolation.

Interestingly, it is alleged that of those island communities that still survive in their traditional way, not a single person perished in the Tsunami. The reason commonly believed is that due to being more in-tune with nature, they recognized the impending danger in the agitated behavior of the wildlife, and were therefore able to escape to higher ground.

After the Tsunami, many of the islands, especially those in the South closer to the epicenter, were devastated. More than 7,000 lives were lost and 40,000 lost their homes, left to live in one of the 150 aid-camps set up around the islands. Of the many problems faced on the islands after the tsunami, one of the most significant was the slow pace of reconstruction due to a general lack of transportation and medical infrastructure, lack of cargo space and the great length of time needed to reach the islands by boat to deliver supplies.

Prior to the tsunami, the healthcare infrastructure on the islands was based on primary healthcare centers, sub-centers and a few hospitals. After the tsunami, a large number of these (30 primary healthcare sub-centers and 4 primary healthcare centers) were totally destroyed. This created an almost complete breakdown in the healthcare infrastructure and crushed the islanders’ ability to return to their home islands.

As part of its large-scale Tsunami Relief grant program, Direct Relief began funding the reconstruction of these 34 centers shortly after the tsunami hit. The project was carried out through the joint efforts of Direct Relief and Bharatiya Jain Sanghatana (BJS), an Indian charitable organization that engages in and supports education, job training, and disaster relief. By means of the $1.5 million dollars donated by Direct Relief International, and with the permission of the Indian government to rebuild the health clinics, BJS and Direct Relief embarked on reconstructing the healthcare infrastructure throughout the island chain.

The first step of this project was to spend time with and talk to the local communities whose health care centers were lost. Only after asking them what they wanted, what should be built, where it should be built and what services they really needed, was the construction phase begun. And the results and feedback received thus far have been outstanding.

The new health centers that have now been built are of an even higher quality than those that they replaced. The desire to build back better encouraged those working on this project to not only expand the centers, but also to redesign them so as to resist damage by earthquake, flood, and cyclone level winds. In addition, for each center, the project includes an 18-month training program and, for the first time, living quarters for a full-time, live-in, health-care provider or midwife. Lastly, Direct Relief sent four 40-foot containers to the islands in order to equip the centers with the basic supplies they will need.

The entire project was massive, and will have an equally massive impact on people’s health for years to come. For me to be present at this auspicious gathering was a real honor. Not only was I asked to speak to the delegation of national, state and local officials, but the significance of the occasion was ever present and obvious: no other NGO had stepped forward to offer such a large scale reconstruction project on the islands, and the Health Department made it clear that it did not have sufficient funds itself to rebuild the centers and sub-centers. Therefore, if it were not for the many generous donations given to Direct Relief, and Direct Relief’s subsequent funding of this project, it is unlikely that the health care infrastructure would have been rebuilt to this day.

Participating in the handing over ceremony with me were the National President and National Secretary of BJS, the Union Minister of State for Home Affairs, a member of the National Disaster Management Authority, the Director of Health Services of the Andaman and Nicobar administration, and the Secretary of Health.

I will not soon forget this occasion, just as I will not soon forget that tragedy is not the only thing to be remembered each December 26.

December 24, 2006
Cochin, Kerala State, India

I went to southern India to visit a hospital that was using a telemedicine van that Direct Relief International had bought for them. Recently there had been an international conference about the van put on by the United Nations and the Indian Space and Research Organization, and I was going to see the van for myself. While I was there, however, I heard of something perhaps even more impressive: a miracle that was about to happen near to where I was. Just a few days ago, on January 14, as it does every year, the miracle occurred—at least that’s what thousands of Hindu Indians who witnessed the miracle from high atop Mount Sabarimala will tell you.
 
For many weeks now, spiritual devotees have been making their way from all over India and all over the world, to reach Mount Sabarimala, the eternal dwelling place of the Hindu Lord Ayyappa. And far below the peaks of the divine mountain and its Hindu Shrine, at its base camp in Pampa, in what could perhaps be called a perfect paradox between religion and science, faith and reason, stands a fully functional telemedicine van, outfitted with the most high-tech bio-medical equipment on the market—the same one that I had now traveled half-way across India to see.

Located in the southwestern-most state of Kerala, 400 kilometers from the coastal city of Cochin, Mount Sabarimala (‘mala’ meaning mountain), is visited each year by tens, if not hundreds of thousands of devoted worshipers, some of whom make the trip a yearly sacrifice. They come to celebrate, pay their respect to, and worship Lord Ayyappan, a Hindu symbol of religious unity and communal harmony. Most of the last part of the journey is undertaken on foot, and many walk for days on end to reach this sacred place. In order to participate in this ceremony, pilgrims must fast for 41 days, and are not permitted liquor, tobacco or sexual relations.

The only complaint that I’ve heard made about the experience is that injuries and illness are a fairly common occurrence along the path. Which makes sense, when one takes into account the fact that there are countless thousands of people, walking long distances in unpredictable weather over rough, rural and wild terrain with animals and sickness hiding in every corner. One example of the dangers involved occurred just a few years back, when so many people had jammed their way onto a hillside that the hill collapsed, killing a large number of people.

But what is there to do when the mountain is so far from any form of health care? Bring the doctors to the pilgrims, says Dr. Kumara Menon, who is the telemedicine director at AIMS Hospital in Cochin, Kerala. The Amrita Institute of Medical Sciences and Research Center (AIMS) is a multi-specialty, charitable, non-profit medical center that provides healthcare services to thousands of low-income and indigent patients. The 800-bed facility was established in 1998, and has already treated tens of thousands of inpatients and hundreds of thousands of outpatients. The hospital also runs half a dozen educational programs and medical universities. Beyond their on-site activities, however, AIMS is perhaps better known for their free or low-cost community-based health programs, medical outreach camps, health awareness campaigns, and other services provided to people living in remote areas throughout the state.

Another example of their service is evidenced by their response to the tragic effects of the tsunami that devastated much of Kerala State’s coast. Immediately thereafter, AIMS deployed teams of medical personnel and ambulances to the hardest hit coastal areas in Kerala and its neighboring state of Tamil Nadu. Numerous medical camps were quickly set up and free services were given to tens of thousands of tsunami survivors. Those that needed additional treatment were transported back to AIMS or to other local hospitals.

Unfortunately, the medical directors at AIMS still faced problems: they realized that temporary camps were only able to provide so much care; some cases were difficult, if not impossible to treat at the camps without more advanced equipment or specialists; and other, even more remote places, were still not receiving any health care services. But they had an idea.

If they had a telemedicine van that was able to move amongst the camps as well as travel to the more remote areas where camps had not been established, they would be able to improve their services and increase the number of patients they could treat. “Telemedicine” means using satellites and internet technology to send and receive data from a more rural site to a more sophisticated hospital. There, experts and specialists stationed at the hospitals who could otherwise not help or advise patients, are able to be of service to them. Utilizing telemedicine, patients—regardless of where they are—can be ‘seen’ by doctors at the AIMS hospital, diagnosed, and treated on site, or can be transported back to the AIMS hospital to be given more advanced care.

Having worked with Direct Relief in the past, and having just received from them a huge amount of supplies, medicine and relief immediately after the tsunami, AIMS thought of asking Direct Relief for help and support in their project. Prior to their request to Direct Relief, AIMS had already received a commitment for a portable satellite link from the Indian Space Research Organization (ISRO), which is the rough equivalent to NASA in the United States. Because AIMS proved that they had the technical capabilities to handle the project, and had proven their dedication to service based on their work before and after the tsunami, Direct Relief International agreed to fund the project. Shortly thereafter, the fully-functional telemedicine van was in operation, equipped with general diagnostic supplies, an X-ray, a lab, as well as endoscopy, cardiac and ophthalmic equipment, not to mention the ISRO satellite.

When I visited AIMS hospital in early January 2007, the tsunami was two years in the past, and much of the physical injuries and suffering had thankfully ended. As I arrived at the hospital, they at first appeared very apologetic, and I immediately assumed the worst. Luckily, I soon surmised that they were apologizing that the van was not at the hospital, and thus I was unable to see it firsthand. I, on the other hand, was thrilled that it was not at the hospital, because it presented proof that it was out working as intended.

“Where is it?” I inquired. “Glad you asked”, they replied. They then asked me to follow them, as a patient had just entered the van, and they wanted me to witness the consultation between a doctor at the hospital and the doctor in the van. Up the stairs in the hospital’s beautiful, cylindrical main building, we came to a small, white door. Inside was a massive wide-screen TV, computers, cameras, a sound system, a couch and two reclining chairs. This was not an entertainment room, but instead the main center for telemedicine conferencing. And there, on the TV screen, was the patient, wearing the same traditional outfit that I had seen a hundred others wearing earlier in the day. As I was driving to the hospital, I saw many pilgrims as they walked along the road on their way to Mount Sabarimala. Now, one had made it to its base camp, but something had gone wrong. Luckily for him, that is also where the tele-medicine van had been sent.

I quickly learned that this traveler had been bitten by a snake as he ambled, barefoot, in the grass. His heart rate was irregular, and the doctor in the telemedicine van at the base of the mountain was unsure how to diagnose the problem. Over the computer screen came digital photos of the bite and real-time EKG heart monitoring that were sent by satellite from the van. In addition there was video and audio that Dr. Kumar, who I was with, used to see and talk to the patient and the other doctor in the van. I was amazed at the clarity of the video and that the information was being seen at both locations simultaneously. My only problem was that I couldn’t understand the language being spoken.

More interesting than my own amazement, however, is the long list of others who have been amazed at this van. A few months back, the United Nations, in coordination with ISRO, sponsored a conference at the AIMS medical campus, specifically to talk about the van. As it is the first of its kind in India, and was so unique in the world, and has performed so successfully, the UN was interested in learning more about it, as they were toying with the idea of utilizing the same technology in Afghanistan.

At another event I was attending a few days earlier on the Andaman and Nicobar Islands to commemorate the second anniversary of the Asian Tsunami, I was on stage sitting next to Mr. M. Shashidhar Reddy, who is a member of the national disaster management authority in New Delhi. As we were chatting about other international programs designed at preventing and reacting to natural disasters, he mentioned his desire to see more mobile tele-medicine being used throughout India, and said that the program in Cochin was a good example of the system he would like to see used more.

Additionally, just before I arrived at AIMS hospital, another group of visitors arrived to take a look at the van and learn more about it. This group was from National Geographic, and they had come to document and record a special program for National Geographic about the van.

It seems in the end, that the Direct Relief International funded telemedicine van has been a success, and hopefully it will be the forbearer of more technology like it to come. And, even though I was not able to see the van in person to verify its capabilities, I was able to experience it through the miracle of modern science and technology. Now, if only I could figure out a way to experience that other miracle that was occurring on the mountaintop, high above the van...

Direct Relief staffer Susan Fowler, who has nearly 20 years experience overseeing aid in Asia, traveled to Indonesia and Cambodia in September. Indonesia continues to struggle with rebuilding efforts in the wake of the December 2004 tsunami, and Cambodia, one of the poorest countries in Southeast Asia with 35-40% of the population living below the poverty line, is struggling to construct civil society after decades of civil war and unrest.

September 14, 2006: Angkor Hospital for Children, Siem Reap

As we entered the Angkor Hospital for Children’s open air courtyard, located between the outpatient department and the surgical ward, we were greeted by the smells of Khmer cooking. Mothers, grandmothers, and other relatives of sick or injured boys and girls were busy making lunch. Patients’ relatives are responsible for preparing meals for family members, and are provided with a variety of high-protein, nutrient-rich foods by the hospital.

The cost of the fish, meat, and vegetables, purchased daily at the market, is currently covered through a Direct Relief-supported nutrition education and support program. This facility-designed, comprehensive nutrition program is being funded by Abbott, one of our most active and generous corporate partners.

Under the ruling of the Khmer Rouge in Cambodia, health facilities were destroyed and most of Cambodia's medical professionals were killed or escaped (in 1979, at the end of the regime, all but 40 of Cambodia’s doctors had either perished or fled the country). Today, after decades of conflict, Cambodia is struggling to rebuild the infrastructure of its health system as well as that of its work force.

During a series of photographic trips to Cambodia’s Angkor monuments, international acclaimed photographer Kenro Izu had numerous encounters with children disfigured by landmines and in desperate need of medical care. He decided to dedicate himself to establishing a pediatric hospital in the region, and as a result of his efforts and determination, the Angkor Hospital for Children (AHC) was founded in 1999. Located in Siem Reap, the city closest to Angkor Wat, the facility was established to provide both quality health care for the children of Siem Reap and neighboring provinces, and to provide training for healthcare providers countrywide.

AHC provides outpatient (average of 300 to 500 patients per day) and inpatient services, basic surgery, 24-hour emergency service, and dental care. The hospital’s acute care unit includes three emergency room beds and three intensive care beds. Each month the hospital serves 600 to 700 emergency patients and 25 to 35 intensive care patients, with the majority of cases involving acute respiratory distress/failure or trauma. Other common illnesses seen at the facility include dengue fever, dysentery, tuberculosis, HIV/AIDS, malaria, and intestinal parasites. Malnutrition and dehydration is clinically evident in 66 percent of children admitted to the hospital, and 10 percent of admissions are due primarily to severe malnutrition.

Due to the extreme shortage of trained medical professionals in the country, AHC was initially staffed by an international team of healthcare providers and administrators. The facility immediately began to provide intensive training to Cambodian doctors, nurses, dentists, and other hospital personnel, and has since handed over most of the medical, nursing, management, and other positions to an extremely motivated and enthusiastic local staff. In 2003, AHC was recognized by the World Health organization as the only pediatric medical training facility in Northern Cambodia. The hospital also participates as a training site for the Ministry of Health (MoH), WHO-led Integrated Management of Childhood Illnesses (IMCI), playing a key role in improving the quality of pediatric care for the entire country.

Direct Relief has supported AHC with shipments of medical and nutritional products since 2003. The Family Nutrition Education and Support Program had just been launched on September 1, 2006, and I was visiting the facility with Thomas Tighe, CEO and President of Direct Relief, and Reeta Roy, Vice President of Abbott Citizenship and Policy. While visiting, we observed nutrition trainings, cooking classes, the care and utilization of demonstration gardens, and the distribution and use of donated nutritional products – all essential components of the program.

We watched as the family members of malnourished children learned about the importance of serving balanced meals containing a source of protein such as fish, meat, eggs, or beans, as well as fruits and vegetables that can be easily grown or inexpensively purchased. Nutrition education staff members discussed the health effects of the different foods, and demonstrated the best manner to prepare them in order to preserve essential vitamins and minerals. One-on-one bedside nutritional counseling is also provided for parents of severely malnourished children, and provides specific advice and guidance on how to care for the acute and on-going needs of their particular child.

We also accompanied the outreach team on one of their home visits to check on a two-year old boy who had recently been admitted to the hospital with severe malnutrition and dehydration. The team was expected by the boy’s family and other community members had been encouraged to meet at their home. Over 50 adults and children were waiting for us when we arrived, and the outreach team took advantage of the gathering to provide nutrition and hygiene education, as well as to distribute Direct Relief-donated albendazole, or de-worming tablets, to the children. Eliminating, or reducing the worm load in children can significantly improve their nutritional status and overall health. Boys and girls, ages one year and up, now receive the medication twice yearly – an easy and very effective intervention.

Over the past four years, seven shipments of Direct Relief-donated medical goods have been provided to AHC. The most recent shipment consisted of an ocean freight container of Abbott-donated nutritional and medical products. The new partnership between Direct Relief and Abbott, to provide critically needed products and fund the facility’s expanded nutrition program, will allow the hospital to more effectively address the high incidence of pediatric malnutrition, and improve the health of thousands of Cambodian children and their families.

Direct Relief staffer Susan Fowler, who has nearly 20 years experience overseeing aid in Asia, traveled to Indonesia and Cambodia in September. Indonesia continues to struggle with rebuilding efforts in the wake of the December 2004 tsunami, and Cambodia, one of the poorest countries in Southeast Asia with 35-40% of the population living below the poverty line, is struggling to construct civil society after decades of civil war and unrest.

September 24, 2006:
Aceh Province , Indonesia

“How do you protect yourselves and your families from getting malaria? What are three good sources of protein? What vegetables are high in vitamin A?”

I posed these health-related questions to the 100 or so women gathered at the large wooden community center built in between rows of barracks at an IDP (internally displaced persons) camp in Banda Aceh. The women were divided into teams and received 100 points for each correct answer. They were all anxious to display their newly acquired knowledge, and every correct response received a round of applause from the competing teams and from the representatives of Direct Relief’s partner agency Yayasan Psikodista.

Yayasan Psikodista is an Indonesian NGO that provides critically needed psychosocial care for the population still living in relief camps in Nanggröe Aceh Darussalam, or Aceh Province, on the hard hit island of Sumatra. This women-led indigenous group, which had years of experience counseling conflict victims before the tsunami, has received funding from Direct Relief to provide services at eight different sites in the region.

I visited one of the sites with Nur Janah, the director of Psikodista, and a few of the organization’s staff psychologists. This particular camp, called Klieng Cot Arun, is one of the smaller ones and is home to 516 tsunami survivors who continue to wait to be relocated or return to their villages. The conditions at the camp are cramped and dreary, and after 21 months, residents are becoming impatient and disheartened with the seemingly endless wait for replacement housing.

Over 8,000 tsunami survivors have received individual or group counseling from Psikodista via focus group discussions, psychodrama, story telling, drawing, recreational activities, and relaxation techniques. Health education is incorporated into these activities, and the women had clearly acquired valuable information regarding a variety of important health issues. Community leader training, designed to educate selected members of the community in psychosocial assessment and techniques, and income generating courses such as sewing and baking, have also been provided.

Following the health education game a dancing competition was held for the 65 children in attendance that day. Rap music blared from the loud speakers and kids from six months to 12 years leaped, hopped, and twisted to the beat encouraged by the clapping and laughter of the crowd. I had the difficult task of choosing three winners and then everyone sat down together to eat a picnic style lunch cooked by the women and served in homemade paper boxes. It was good to see everyone enjoying themselves despite the gloomy and difficult living conditions at the camp.

It was very clear that Psikodista is providing a number of essential services for IDP (internally displaced persons) camp residents, and that their professional but caring and affectionate approach was working wonders with this extremely vulnerable population.

Direct Relief staff members Annie Maxwell and Brett Williams traveled to Yogyakarta, Indonesia to visit local health partners. The 6.3-magnitude earthquake in central Java killed at least 5,857 people and injured 36,299 others, while leaving more than 130,000 homes damaged or destroyed, according to the government. The following are their notes from the field.

June 8, 2006

We spent almost all of Thursday with Direct Relief partner CHF, Community Housing Finance. Alia Patton, CHF’s project director, served as our guide for the day as we toured three villages that had Direct Relief-funded projects. Born in Jakarta, Alia was an incredible asset as we visited some of the more remote villages in the district of Bantul Her perfect Indonesian, easy sense of humor, and generous nature meant that we were welcomed with open arms as we walked among the rubble of people’s homes.

When you walk into any of the villages, there are several common features. First, there is an incredible level of activity dedicated to excavation. People are not sitting around and waiting for aid or external help. Men and women are intensely working to break down their damaged homes and begin the process of rebuilding.

Second, there is a high level of community work to rebuild, as opposed to just individual efforts. Alia said the Indonesian word was “gotong royong,” meaning “working together as a community.” It’s a deeply held principle in these communities, most likely for both ethical and practical reason since people live so closely together.

And this leads to the third commonality. The densely populated villages have been built right up to the edge of the one lane roads that enter the village, with their agricultural fields on the other side of the road. Consequently, when the homes were destroyed, there was little to no room to move except into the road. The small roads are therefore taken over with temporary shelter and as we walk into the village, you are literally walking through the bedrooms of several families.

Seeing all the shelter in the middle of the road, reminded us of something that Mr. Sumadi, the program coordinator for PKPA, told us the day earlier. He said, “If you walk down the road at night, you will see a peculiar thing. People are all sleeping in front of their houses and shops because they are scared to sleep in their cracked homes.” The lack of space combined with the fear of physical structures means that practically entire communities are sleeping on or in the road, with only small paths for people to walk through the community.

All of this activity in such a small space has meant an increased opportunity for injury. And while we did see some face masks used during construction, flip-flops were also standard foot wear. Through CHF, Direct Relief has funded twenty nurses from Persatuan Perawat Nasional Indonesia (PPNI), the Indonesian National Nursing Association, to work in Bantul and Klaten. As we walked through the village of Bendok in the Imogiri district, the nurses explained that they were seeing a second wave of injuries caused by the demolition work.

This village alone had suffered 100 percent damage and many people suffered from lacerations on their arms and legs from moving broken bricks and concrete. These people were then vulnerable to infection and skin diseases due to a lack of clean water combined with hot and humid weather.

As we walked through the village, the nurses stopped to check several people’s stitches. Along with injuries from the earthquake and rebuilding, some of these rural communities are receiving health care for the first time. The nurses checked on one woman who had a stroke 17 years earlier, but had never received care.

The team of doctors is treating patients for medical conditions that range from upper respiratory infection from the dust and smoke in the air, to suturing lacerations from broken rebar and concrete. These dedicated health professionals are working hard to keep abreast of the evolving injury patterns as the relief efforts mature. They understand the importance of keeping the people healthy and able while they work together to rebuild their lives “gotong royong.”

June 7, 2006

As we drove along the main artery that links the city of Yogyakarta and the farming villages of Bantul, the only thing as common as the rubble and rice paddies were the children who lined the narrow road begging for aid. This is a new phenomenon to the area, something born out of the tragedy of the earthquake. Pusat Kajian dan Perlindungan Anak (PKPA), a child protection agency and one of Direct Relief’s partners in the earthquake response, is concerned about the surge in children begging. Not only is the act physically dangerous for children, but the roadside begging also breeds dependency on charity and hinders any type of normalization for the traumatized children. There is little to stop the children from begging though as the older members of the family work to excavate their homes and care for the sick.

PKPA is working in Bantul to ensure that children have another opportunity other than begging and that this vulnerable population stays healthy – both physically and mentally. PKPA has set up several “child safe zones” in the district, and today we visited one of their projects in the village of Ganti Warno. At PKPA,, the safe zone includes a Direct Relief-funded health post, with a medical team of three doctors, three nurses, and one midwife.

PKPA’s community center was literally like stepping into a world untouched by the tragedy of the earthquake. While the small road leading up the project was lined with the shells of destroyed homes, the yard of the PKPA center was clean of any debris with children playing outside. Children sat on the wide porch and colored pictures, while others played badminton in the front yard or sang along with one of the staff members.

Inside the building, the medical team reviewed their outreach work from the previous day r and talked about the upcoming needs assessment of a neighboring village. It is all a reminder that despite all the of the discussion on improving coordination among NGOs and the Indonesian government and the transition from the humanitarian phase to long-term recovery, sometimes the most needed item is space for kids to play.

June 4, 2006

Pulling into the front of the hospital, we were immediately greeted with Direct Relief’s distinct blue pallets shipped just days before from our warehouse in Santa Barbara, California. The pallets, filled with $372,000 of specifically requested medicine had reached Jakarta the day before and had been trucked to the hospital in “Yogya” in lightning speed.

Muhammadiyah’s main hospital in Yogya is a 250-bed tertiary facility. The light green, three-story hospital  resembled a Japanese tea house, with courtyards of  fish ponds and gardens. The hallways and rooms were much less Zen like, with patients filling every possible space. The earthquake caused a severe spike in patient load, and each room housed three patients, accompanied often by their families.

Nurse Ani explained that within hours of the earthquake, the hospital had received approximately 1,000 patients. The hospital currently houses over 350 patients, though this figure does not include the patients’ family members that were resting on the benches outside or sitting on the veranda railings.

The vacant building neighboring the hospital used to be a bank, but was converted into an additional ward and filled with 40 earthquake victims. The space served not only as a ward for overflow patients, but also as a temporary shelter for their families made homeless by the earthquake.

We next visited one of Muhammadiyah’s community centers recently converted into a ward for post-op patients in need of consistent observation. The Muhammadiyah staff did an impressive job organizing the area filled with patients and their families. Patients were kept in rows labeled Block A-K, the “block” marked with paper signs that hung across the room on a makeshift clothes line. The staff of approximately eight nurses and two doctors kept detailed medical records of all in the room, and performed morning rounds to check on wounds and for possible infection. While the community center had hosted a wedding two weeks before, it now served as a high-functioning patient ward. The professionalism of the staff, particularly considering the circumstances, was commendable.

Outside a tent kitchen prepared food for the injured and their families. Another room served as the pharmacy and repository for patient records. Amazingly, this community center was only one of three overflow areas that the Muhammadiyah team had created in order to care for these people.

As we left the community center, we passed thanks from Direct Relief and its donors to Dr. Taufier. A quiet man with simple English, he humbly answered, “I am just trying to do right by the patients.”

As we drove from Yogya to Bantul (the town closest to the epicenter), evidence of the massive earthquake became overwhelming, the streets lined with rubble.. Roofs were stripped of their tiles, and often all that remained was the bare wooden skeleton of a building. Most haunting was a house that had completely collapsed, except the furniture remained exactly in order, most likely put back into place by the tenants to recreate some sense of normalcy within the chaos. Children lined the streets holding bowls, hats, and boxes to collect money from passing motorists.

Most people stayed near their homes to prevent looting, and they stretched tarps over the rubble to create tents. Some people found shelter in the camps of international aid groups, in tents often set-up on the edge of the rice fields that dominate the landscape of the agricultural community of Bantul.

Parked in front of Muhammadiyah’s Bantul Hospital was their ambulance, smashed by falling debris (Direct Relief is providing two new ambulances). The story at this hospital was familiar: crowded beyond capacity, a tent was set up in the back to handle overflow and the road had been closed to allow a place for the 1,500 patients treated in first two days following the earthquake.