By Lindsey Pollaczek, Program Officer

Sierra Leone has one of the highest reported maternal death rates in the world. In 2005, the maternal mortality ratio was 2,100 deaths per 100,000 live births and a woman’s lifetime risk of dying due to complications in pregnancy and childbirth was 1 in 8. Long distances to health facilities, the cost of health services, shortages of health workers and essential drugs, supplies, and equipment, and the low status of women are familiar challenges in sub-Saharan Africa - and chronic issues in Sierra Leone.

But it’s not all bleak. In fact, the documented maternal mortality figures have slightly improved, and after spending the last few days traveling through Sierra Leone I have seen some encouraging interventions which improve quality of and access to maternal health services. These, along with the government’s introduction of Free Health Care Initiative for pregnant and lactating mothers and children under five in April 2010, are working to break down the barriers which limit a woman’s access to care in pregnancy, delivery, and the post-partum period. At Direct Relief, we focus on three key interventions which improve maternal health services and quality of life. In Sierra Leone, I uncovered each of these important interventions during my journey.

Act One: Training the Next Generation of Midwives

School of Midwifery, Makeni, April 18
One of the most important interventions to reduce maternal death and disability is for women to deliver with a skilled birth attendant. The skilled attendant is able to manage normal deliveries and can recognize signs of life-threatening complications that require referral to a higher-level of care.

The School of Midwifery in Makeni, Bombali District, is the largest midwifery school in the country and is currently training 138 midwives. The new school is unique as it trains a lower level of nurse that previously was not allowed to enter midwife training. Only the higher level of nurse was able to train as a midwife, but they often elected to work in more attractive settings following their graduation: hospitals in larger cities or in management positions with the Ministry of Health. Therefore, most deliveries in primary health centers at present time are attended by maternal-child health aides and traditional birth attendants, neither of which qualifies for the title of “Skilled Birth Attendant,” according to the World Health Organization’s definition. The new generation of the midwives at Makeni will help change the current situation.

Bright and early Monday morning, the school was full of eager students working hard to gain the honor of becoming the first graduating class of the Makeni School of Midwifery in January 2012. Most of the midwives trained at Makeni will work in remote clinics in rural areas, where the needs are often greatest. I spoke with a few students who had been nominated by their peers to represent the class. They shared with me their appreciation for the training and their motivation for taking up the course. “There are certain things I used to do, maybe not the right way,” said student Ramatu Kano, “but now that I am in the program I have seen my mistakes and already corrected them. I am very happy to be part of this course.”

This is the first time that midwifery training has been open to qualified males, and several have enrolled in the program. Midwife-in-training Steven Ngaujah lost his sister when she died giving birth to twins without a skilled birth attendant present. “So many other women in Sierra Leone are in this position, so I was moved to be part of this work to see that maternal mortality is reduced in this country,” he explained. He recognized that his position as a male midwife in Sierra Leone was rare but he was willing to break down that barrier to see that women receive better care in pregnancy.

Once the midwives graduate from Makeni and are posted in rural areas, they must have the right equipment and supplies to use their new skills fully. Imagine spending two years in training only to be placed at a health facility that lacks the tools you need to do your job. This is a common scenario in Sierra Leone that is demoralizing for the health provider and potentially life-threatening for the women who need care. Direct Relief is working with the School of Midwifery in Makeni to ensure that when the midwives graduate they have the supplies they need.

“Now in the community and in the health facilities there are midwives working barely without equipment,” said Francess Fornah, the head of the school. “If we can equip the midwives with the midwifery kits and delivery sets then I think we have gone a long way.”

The midwife students agreed. “These [midwife kits] are very difficult to get here,” Ramatu Kano said. “This would help me to work in the community, and I would appreciate this very much.” When Francess introduced me to the first class of 72 students during the tour of the school and she announced that Direct Relief was equipping all of the graduating midwives, the students erupted in great applause.

Act Two: Improving Services for Obstetric Emergencies

Medical Research Center, Tonkolili and Bo Districts, April 19-20 

About 15 percent of all deliveries will be complicated and will require emergency obstetric care. Many complicated cases can be managed at a lower level facility if the skilled birth attendant is trained in the management of basic emergency cases and has the tools they need to do their job. This skilled birth attendant is also trained to recognize the danger signs when a woman does require referral to a higher level of care where cesarean section and blood transfusion are available, and can make that decision promptly in order to save a woman’s life.

Successful emergency obstetric care requires three critical components:

1. Trained providers at each level of the health system who know how to manage and when to refer emergency cases;
2. Availability of the proper equipment and supplies to manage such cases; and
3. A functioning referral system that can move a woman quickly to the appropriate level of care.

Medical Research Center (MRC), a Sierra Leonean nongovernmental organization and Direct Relief’s key partner in the country, is focused on providing inputs to each of these levels in order to improve emergency obstetric care. MRC has been working in Sierra Leone for more than 30 years and works closely with the Ministry of Health to improve healthcare delivery at the level of Peripheral Health Units (PHU), the health centers closest to the community that provide essential primary care and maternal health services. With support from organizations like Direct Relief, MRC distributes medicines, supplies, and equipment to the health centers that care for women in pregnancy and childbirth. MRC has also trained all healthcare workers that provide delivery services in basic emergency obstetric care and has established an ambulance referral system to transport women in emergencies to the nearest hospital.

But the nearest hospital is often very far away. To witness just how far, I traveled with MRC staff to one of their most remote operational areas, the chiefdom of Sambaia. For more than three hours we bumped over incredibly rough terrain which included a long, steep climb and descent through the hill country, then another hour of travel to reach the village of Bendugu. When we told people at the hospital in Makeni town that we were heading out to Sambaia, they all shook their heads and commented on the long distance and disadvantaged community. Our trip was in the middle of day in the dry season, but emergencies happen at the most inopportune times, like late at night in pouring rain. It’s difficult to imagine a woman in obstructed labor making this treacherous journey in any scenario.

This demonstrates the critical importance for MRC to continue improving quality of services in remote areas so that more woman can deliver safely at the health centers, and when a case requires emergency transport, the health workers are able to identify danger signs early enough to make the call and save a woman’s life.

Yele Community Health Center, also supported by MRC, is down the road in Bo District. Yele CHC has been selected as the basic emergency obstetric care referral center for its chiefdom of over 50,000 people. The community health officer in charge, Peter Konneh, is a dynamic man who is passionate about improving maternal health and proudly recognizes that the health center has had zero maternal deaths in the last few years, thanks to its work to educate the community and ensure that its staff is qualified to manage nearly all obstetric cases.

Peter was a young boy when the civil war broke out and rebels invaded his home village in Kailahun District in eastern Sierra Leone. It was a terrible time for thousands of Sierra Leoneans and Peter was one of many who were forced to flee their homes. After spending 10 years in a refugee camp in Guinea, Peter returned to Sierra Leone and trained as a community health officer, which is just below the level of medical doctor. Upon graduation, MRC employed him in 2006 and he was posted to Yele CHC, where he has committed to overseeing this important work for the long term.

Direct Relief has been working with MRC since 2008 and has provided three donations of medicines, supplies and equipment for the 32 health centers, hospitals, and the School of Midwifery in Makeni. MRC purchases medicines and supplies that are not donated, which is a significant expense. MRC is an excellent partner for Direct Relief; the medical supplies we provide do a great deal to support the primary care system and strengthen emergency obstetric care in Sierra Leone.

Act Three: Restoring Health to Women with Obstetric Fistula

Aberdeen Women’s Center, Freetown, April 21  

We hope that Act Three never arrives. We work hard in Acts One and Two - training and equipping midwives and improving emergency obstetric care - so that mothers can experience a safe pregnancy and the health of their newborn. But at present time, we cannot draw the curtain after only two acts, and must also care for women who have endured serious injury during childbirth.
In Freetown, I meet Dr. Alyona Lewis and her dedicated staff at Aberdeen Women’s Center. The Center provides treatment and support for women who have developed a debilitating obstetric fistula as a result of prolonged and obstructed labor. Obstetric fistula is almost entirely preventable with improved obstetric services. In places like Sierra Leone and other countries in sub-Saharan Africa where access to and quality of care is inadequate, obstetric fistula still occurs at alarming rates.

In 2010, Aberdeen Women’s Center provided fistula repair for 189 women who came from all parts of the country and even neighboring Guinea and Liberia. The center includes a maternity ward (which was completely full during my visit) and an outpatient clinic for children. All services are provided free of charge.

The joyful rhythm of African drumming and singing rose up over the compound during my visit, happily interrupting my conversation with the procurement manager as we were discussing how Direct Relief could provide surgical supplies and medical materials to the center. I witnessed the Glady-Glady ceremony, a weekly celebration when the whole center breaks into song and dance to bid farewell and good luck to the women who are leaving to return to their villages. After staying about two weeks to heal following their fistula surgical repair, the women don a new dress and get ready to return home to their families and their community as a whole new person. The hope and positive energy of these brief weekly celebrations underscore the significant value of a center like Aberdeen.

The Center focuses on holistically healing women with obstetric fistula—repairing the debilitating physical condition and treating the emotional and psychological distress attached to the stigma of fistula. A three-month follow-up visit is required for every woman, to ensure the integrity of the surgical repair as well as providing an opportunity to share information on family planning and reproductive health. Dr. Alyona told me that when a woman returns, she often wants to learn about how to plan her family and is curious about her ability to have another child. (Women with a repaired obstetric fistula can have children but are counseled on the importance of having a cesarean section.)

The good news: The long waiting lists for fistula surgery in Sierra Leone have all but disappeared. While there are likely to be women that are harder to reach, or are tentative to come for treatment--many women from remote areas have never been to the Capital and are afraid to leave their village for an unfamiliar place--it is also possible that the incidence of fistula has decreased due to recent interventions to improve access to and quality of obstetric services. Aberdeen is planning an expanded outreach program in the coming months to areas not yet reached to offer help to women who still need treatment. Meanwhile, continued attention remains on improving obstetric care to prevent fistula and maternal death.

Someday, the fistula ward at Aberdeen Women’s Center will become obsolete, like the Fistula Hospital in New York City that was torn down 150 years ago and later became the famous Waldorf Astoria Hotel. Until then, Aberdeen Women’s Center will continue to play a critical role in restoring the health of women living with obstetric fistula and Direct Relief will remain committed to bolstering such important efforts.

Lindsey Pollaczek, Direct Relief program officer, sent this dispatch from the International Society of Obstetric Fistula Surgeons (ISOFS) meeting in Senegal, underscoring our commitment to preventing and treating fistula.

December 9, 2010
Today is the final day of the International Society of Obstetric Fistula Surgeons (ISOFS) meeting in Dakar, Senegal. It has been an incredibly busy few days as fistula surgeons and health professionals have come together to share diverse experiences, research findings, and recommendations for improving quality of treatment, management, and prevention of obstetric fistula. Representatives from more than 40 countries are participating in the conference, all sharing the common goal of working to improve fistula care and a vision for eradication of this preventable condition due to failures in maternal health care.

Representing Direct Relief, I have had the unique opportunity to engage with many of the preeminent fistula surgeons in the world. Many of the pioneers in the field are here, surgeons who have dedicated their careers to treating women with fistula, training other surgeons, and spearheading research to improve the outcomes for fistula care. Many more youthful faces from the next generation are here—motivated, committed, primarily African surgeons from all parts of the continent have come to learn from each other and improve their expertise in a region where the burden of obstetric fistula is highest.

The surgeons provide an essential service for helping restore the dignity of women living with obstetric fistula. Also present are advocates, community organizers, and public health professionals who are addressing the important areas of prevention of fistula through improved obstetric care and also social reintegration of women back into their communities after their physical wound has been healed. This community recognizes that it is simply not enough to surgically repair the fistula and send a woman on her way after she has lived often for many years with a highly stigmatizing and socially humiliating condition. The conference theme acknowledges the increased effort which must be made not only to treat the physical condition but to ensure that women can return to normal, healthy lives in their community.

A great deal of good work is being done by many organizations across Africa and Asia to address obstetric fistula. A shared understanding of exactly where these services are located and the current capacity for treatment remains elusive. Direct Relief is working together with ISOFS and the Fistula Foundation to help illuminate this information in a way that is accessible to all stakeholders.  Using our experience in GIS (geographic information systems) technology, Direct Relief hopes to help create powerful tool for everyone in the fistula care community—to understand the current landscape for treatment, help identify unmet need, and provide a tool to guide decisions on future resource and service allocation.

Direct Relief is currently providing surgical supplies to support fistula-repair programs in seven hospitals across Africa, many of which are represented here.  It is clear through the level of engagement at this conference - and by the preliminary results of the fistula treatment mapping - that there are many more facilities where surgical supplies are needed. Working together with healthcare companies like Johnson & Johnson, Ethicon, Covidien, and CR Bard, Direct Relief hopes to support more surgeons so they have the supplies they need to do this valuable work.

This gathering has reassured my confidence in Direct Relief’s decision in making fistula care and prevention a central part of its maternal health strategy over the next five years. There is a lot of good momentum and energy here at this conference. We all agree that a lot remains to be done.

Now off to the closing ceremony and to the work ahead! 

by Kristi Bullock, Program Officer for Africa

August 12, 2010
Dr. Mike Marks and I just returned from visiting AMREF and the National Health Training institute (NHTI) in Southern Sudan. NHTI was established in 1998 as a school to train clinical officers.  In 2006 it began training community midwives and is now running a third training program, for public health officers. NHTI has graduated 269 clinical officers and 26 community midwives; the first class of public health officers has yet to graduate.

There are 38 third-year clinical officer students, of which Direct Relief is supporting 30. They are currently in the field in Yei and Torit, 75 miles and 186 miles away from Maridi. These locations were chosen because of the staffing and medical supplies available at these facilities. The students will spend one month working within a health unit and two months at the hospital before returning to Maridi in October for final classes and exams. In November, each student will select his or her preferred location for internship. 

Because the one-year internship does not pay, locations are selected based on where the students have family or friends that they can stay with. Preferences must be submitted to the school for approval.  The students will have the month of December off and will begin their internships in January 2011. Although graduated in November 2010, the students will commemorate their graduation in November 2011, as graduation ceremonies are held every other year.

Clinical officers are in high demand in Southern Sudan.  Already now, four months before graduation, the announcement board at the school has notices of posts available. The accreditation received upon completion isn’t recognized outside the country, but within Southern Sudan, clinical officers are seen as the primary access to medical care, as doctors are in such short supply. Of those graduating, 99 percent find jobs and stay within the country.

During my visit I was able to meet, attend class with, and participate in rounds at the hospital with the year one and year two classes of clinical officers. I also spent many hours with the head midwife for the midwife training program, Christine Nakayenga. She is a petite woman, but she has an air of confidence about her and is determined to bring knowledge and access to safe birthing across Southern Sudan. We talked about what organizations are doing in the area and what still needs to be done.  She is a wealth of information. I will send more about the Maridi County Hospital soon.

August 15, 2010
For the last two and a half years Direct Relief has been supporting Maridi County Hospital through its partnership with AMREF in Southern Sudan.  Maridi County has an estimated population of at least 500,000, but in reality no one knows the true population size as people are still returning from the refugee camps in Uganda and the Democratic Republic of Congo after 21 years of civil war in Southern Sudan.

Maridi County Hospital is the only hospital in the area and the only facility able to perform any kind of surgical procedure. The next nearest hospital is in Yambio, a two-hour drive in the dry season and significantly longer in the rainy season.  In 2006 the Government of Sothern Sudan, in partnership with UNICEF, WHO, UNFPA, USAID, and others, released a household health survey.  It found that of all the states in Southern Sudan, Western Equatoria, where Maridi is located, had the worse maternal mortality rate, with 2,327 women dying out of every 100,000 who give birth.

After experiencing the roads and remoteness, visiting the hospital, and seeing for myself the lack of medical staff, sadly, I understood why this number is so high. Women aren’t coming to the medical facilities because the facilities aren’t properly staffed or equipped. Clearly, the training programs for clinical officers and midwives are essential, and I’m proud that Direct Relief supports them. The need is everywhere.

At Maridi County Hospital the staff was doing what they could with what they had. The equipment in the operating theater is more than 20 years old and desperately needs replacement. The operating table no longer adjusts in height and the lights are broken except for one fluorescent light in the ceiling. Anesthesia is administered through the spine. There is no sterilizer; all surgical tools are boiled over charcoal. Blood transfusion takes place on-demand, as there is no blood-bank refrigerator to store it. The good news, however, is that the hospital has its own borehole (or well), so it has access to clean water and has a functioning generator for power.  There are currently two doctors and four clinical officers working in Maridi County Hospital, and 10 nurses and midwives run the 24-hour labor and delivery ward. 

With the support of some generous foundations and others, Direct Relief has committed $63,500 to equip Maridi County Hospital to provide emergency obstetric care services. The theater has been renovated and, once equipped, will allow for increased training for the clinical officers.  A container for Maridi with donated medicines and supplies will ship with the procured emergency obstetric equipment this fall and should arrive at the beginning of next year.

Midwives – A Hope for Safe Delivery
In 2006 there were approximately 58 midwives in all of Southern Sudan, serving an estimated population of 10 million.  Since that time, three midwife schools (two of which are now located at the National Health Training Institute, where the clinical officers are being trained) have trained an additional 151. The majority of births take place in the home attended by mothers, mothers-in-law, traditional birth attendants (TBA) or maternal-child health workers (MCHW). 

The community midwife program at NHTI is an 18-month-long, Ministry of Health–recognized program.  While visiting Maridi I observed the midwife students on rotation at the hospital and sat in on a class teaching the signs of labor and recognizing when a mother has reached the second stage of labor.  The instructor also explained what a fistula is, why it develops, and how a midwife can help prevent it. Earlier that day I had asked Christine, the head midwife at NHTI, if fistulas were a concern here. She replied, “Oh, yes, fistula is quite common and no one here can do the repairs. The girls are delivering quite young.  Many get pregnant when they are 12, 13, and 14. They are too young to be having babies.” 

After some investigation I learned that there is one surgeon in Juba—five or six hours away in the dry season—who is trained, but neither he nor any other trained surgeon has been to Maridi to do repairs. Christine and other AMREF staff were eager to have a fistula repair camp and to offer additional training to the graduated clinical officers.

Today, the hope of access to safe delivery in Southern Sudan lies mostly with NHTI. It is the only school for clinical officers in all of Southern Sudan and trains two-thirds of the country’s midwives.

By Lindsey Pollaczek, Africa Program Officer

Tanzania
July 27, 2010

Jacinta, an eight-year-old girl from southwestern Kenya, started complaining of a toothache three months ago. After the tooth was pulled, the swelling did not stop. Jacinta was taken to a health center where the clinical officer diagnosed a bacterial infection and prescribed antibiotics. Following treatment, the swelling in her jaw only continued to grow rapidly. Two months later Jacinta’s mother, a single mother with two other children and no reliable income, managed to take her daughter to a district hospital. There, the tumor was properly diagnosed as Burkitt’s lymphoma, and because no treatment was available at the district level, she was referred to the Provincial General Hospital of Nyanza, in Kisumu.

Burkitt’s lymphoma is an aggressive cancer that accounts for more than half of all childhood cancers in equatorial Africa. It is a rare disease everywhere else. The disease is related to the Epstein-Barr virus (EBV), the first virus to be associated with human cancer, and current research has suggested that malaria may also play a role in the development of Burkitt’s lymphoma. Research is underway around the shore of Lake Victoria in East Africa, where Jacinta lives and where the burden of malaria and Burkitt’s lymphoma is high.

With limited resources at home, Jacinta never made it to the oncology ward at the Provincial Hospital in Kisumu. Instead, someone in her village told Jacinta’s mother about a place called Shirati, across the border in Tanzania, where her daughter might be able to get help. Despite any assurances that making the journey would yield any results, she decided to go, leaving her other two young children at home in the care of a relative.

When Jacinta and her mother arrived at Shirati they were directed to Sota, a small village down the road, where the Shirati Education and Development Foundation (SHED) is located. A new partner, SHED had just received its first container of medical supplies from Direct Relief when we visited. Under the guidance of Dr. Esther Kawira, a resident of Shirati for over 25 years and a regional expert in Burkitt’s lymphoma, SHED has made available specialized chemotherapy treatment at the small health dispensary Dr. Kawira runs.

The treatment regimen for Burkitt’s lymphoma is six doses of chemotherapy given every two weeks, which takes at least a month and a half for care. This is long time to stay under in-patient care, especially if it means lost wages for the parent who accompanies the child. Also, the cost of travel back and forth to the clinic is often prohibitive. Once they leave, patients may never come back, which can lead to a relapse requiring more expensive treatment that is even more difficult to source. At SHED Foundation, the chemotherapy is donated and can be administered at no charge to the patient. This is unusual in this region, where the patient must purchase the drugs and bring them to the hospital (which, at several hundred dollars a course, almost never happens); the hospital has to cover the bill, which is a huge challenge for resource-strapped facilities; or, most likely, the patient goes without treatment.

With adequate therapy, Burkitt’s lymphoma has a high cure rate. In developed countries, 90 percent of children with the disease are cured. For countries in sub-Saharan Africa, the disease has been a low priority, given the high prevalence of other illnesses that affect more children and are cheaper to treat. With limited disease-management capacity and treatment available, the mortality rate for Burkitt’s lymphoma in Africa remains high.

When a child is put on treatment, as Jacinta was at SHED Foundation, the improvement is remarkable, even after just one course of chemotherapy. As quickly as the tumor grows, it shrinks away faster. This almost instant visible change which occurs in many cases is incredibly hopeful for the child, their family, and the healthcare providers overseeing their care. During our visit at SHED, Dr. Kawira asked us to take a photo of Jacinta, which we left with her when we departed. She in turn sent us a photo that a group of medical students had taken just two weeks before, when Jacinta first arrived at the clinic. The transformation is incredible. Jacinta’s mother said to Dr. Kawira when she arrived, “She used to be beautiful.” Dr. Kawira had replied, “She will be beautiful again.”

Soroti, Uganda
July 21, 2010
For two hours we bump down a dusty red dirt road heading out of Soroti town toward the village of Kagwara, situated at the shore of Lake Kyoga, the second largest lake in Uganda. We are joined by members of AMREF Uganda and Terrewode, two organizations working in the Teso Region to improve outcomes for women during pregnancy and childbirth. AMREF Uganda, a longtime Direct Relief partner, is implementing a safe motherhood project in this region, and works with groups like Terrewode, which was founded in 1999 during the period of civil war to provide support to women and girls who were acutely affected by the conflict. Direct Relief works with indigenous groups like these to improve maternal health care, and today, we find ourselves heading deep into the bush of eastern Uganda, to the end of the road where maternal health complications often arise.

Ugandan women have an incredibly high fertility rate—nearly 7 children in their lifetime. Given long distances to health facilities, lack of means to cover the costs of transportation, and chronic shortage of supplies at all levels of the health system, the majority of births in the country happen in the village at home. Births which occur outside a health facility without the presence of a trained birth attendant are prone to risk and complication. Community sensitization and education is essential to promote the importance of attending antenatal clinics, having a birth plan, and delivering in a health facility, which takes the involvement of community-based organizations to be most effective.

A woman who experiences complications in delivery is in a really difficult spot if she comes from Kagwara village. The nearest health facility providing comprehensive emergency obstetrics care—a cesarean section—is back where we started our journey in Soroti town, two hours away in a sturdy 4x4 vehicle. The thought of making this journey quickly in unreliable public transport, or on a bicycle, is hard to imagine in the best of scenarios. It’s just too far. Add to that a woman who has been in labor for two or three days and you begin to understand why maternal death and disability remains high in this country. While there is a health center closer to the village which should be able to provide this service, there is no doctor that is on staff to oversee the operation.

If the delays in receiving a cesarean section are too long—delay in deciding to seek care when complications arrive, delay in reaching a facility where the procedure can be performed (for the laboring woman in Kagwara, only in Soroti General Hospital), and delay in receiving care at the facility (at Soroti General there is one theater that performs over 2,000 major operations every year)—major injuries, such as obstetric fistula, can develop. A woman left incontinent of urine and or feces due to obstetric fistula is a severe and heartbreaking consequence of lacking obstetrics care.

“We are mopping the floor but the tap continues to leak.”

The women in Teso Region are fortunate only in that competent fistula repair services are available at the regional referral center. Under the guidance of the consultant specialist Dr. Fred Kirya, about 50 women receive treatment annually. But here, like at all levels of the health system, there are challenges: lack of special supplies for the repair, the burden on the healthcare workers to take on additional work with no commensurate pay, and the demand on the one incredibly busy operating theater. Considering the barriers a woman with fistula will be confronted with all along the way, if she receives the repair it is truly a thing to be celebrated, as this is a procedure that is completely life-restoring. However, for every woman who is repaired, another will develop a fistula unless comprehensive improvements in obstetric care are made. Dr. Kirya acknowledged the great value and importance of fistula repair and his belief that there are many women with the condition which have not yet been reached. However, the preventive component is essential, because as he put: “We are mopping the floor but the tap continues to leak.”

Back in the village of Kagwara we talk with Terrorode volunteers and their local affiliate TEETE, a group of 26 community members concerned with uplifting the economic and health status of their people. Terrewode volunteers demonstrate the education which is provided on use of the mama kit—very basic delivery supplies including sterile gloves and blade, which can reduce the chance of infection and be a lifesaver for mother and child. In just two months since being trained by Terrewode, the volunteers have identified six women with fistula in their village and surrounding area. One of the ladies identified and educated about her condition sits quietly during the meeting—she has agreed to get treatment but is still unable to afford the transportation to the hospital. I fight the urge to put this woman who has already been through so much in our vehicle and drive her straight to the hospital; we discuss potential solutions to remedying this so that once a woman is identified and agrees to be treated, she can get the care she deserves.

A nurse-midwife unpacks a safe birthing kit at Tiriri Health Center.

We return by the same dusty road at dusk, whizzing past villages filled with children and pregnant mothers. I imagine the clock ticking down to the arrival of labor pains—I hope for the best outcome, but fear the worst. The challenges for a woman to receive proper care during her pregnancy and delivery are stark and myriad: distance, poverty, education, and a health system in need of serious repair. We at Direct Relief are working to equip midwives, doctors, and surgeons and the health facilities where they operate. This includes midwife kits (see above photo) which include basic materials for outreach to remote, lower-level health facilities; equipping the operating theater at the Health Center IV (one level below hospital) so that comprehensive emergency obstetrics care can be provided, bringing cesarean section capacity closer to the mothers while easing the demand on the hospital for this service; and equipping surgeons with tools for fistula repair.

During this brief visit, we have also identified areas where we hope to provide additional resources, working through local groups like Terrewode and AMREF at the village level and through government health centers and regional referral hospital. Our input alone will not solve all of the issues--deep-seated cultural, economic, and political challenges—but with these committed organizations and people, we’re moving toward improving health for mothers in pregnancy and childbirth.

Soweto
November 4, 2009
I woke up this morning to thunder rattling the window panes. Unlike yesterday’s brief and powerful storm, the rain has not stopped falling for the past two hours. I keep thinking about Gloria’s family in their small tin shell of a home. I hope it’s not raining in Snake Park.

Conditions in many townships of Soweto have improved markedly in the last few years—in the vast, sprawling area of 3 million some are living rather comfortably. Homes have TVs, running water, a gas stove. But you don’t travel far before you meet abject urban poverty. Our visit yesterday in the Soweto township known locally as Snake Park illustrated how dire the situation is for many, particularly those who are sick and poor.
 
The dark sky has been threatening rain for an hour, but the deluge starts just as we enter the final home of the day. I watch Sr. Freda and Wilhelmina, Soweto Hospice’s nurse and community health worker, offer words of support to their patient Gloria when  the downpour on the tin roof becomes deafening. The conversation fades as the sound of the rain overtakes the small space. Gloria’s daughters hurry to place small containers around the one-room home to catch the rain falling through the holes in the roof. The small puddles outside quickly turn to muddy rivers that begin to rush through the settlement. Twenty minutes pass and the rain stops as quickly as it has begun.  Sr. Freda and Wilhelmina say their parting words to Gloria and we pick our way through the mud back to our 4x4 vehicle and wave goodbye.  Freda and Wilhelmina are already thinking about when they’ll be able to come back—to bring a lifeline to Gloria and her family, to ensure she has adequate support to live comfortably with HIV in this terribly impoverished neighborhood of Soweto.

We are in Snake Park. The name conjures up a wild, inhospitable place. Nearly a decade ago, informal settlements started appearing in the grassy fields, apparently the original home to a number of resident snakes.  It didn’t take long before the fields were overtaken with tin shacks, the homes of tens of thousands of people who couldn’t afford to live anywhere else. I’m told that the government’s Reconstruction and Development Program is  undertaking infrastructure improvements here to provide better housing, water, and sanitation. Unfortunately, this is not at all apparent from Gloria’s neighborhood. 

Gloria was diagnosed with HIV in 2006. Freda, a specialized nurse with six years of training, received a call from Gloria’s brother in 2007 and was asked to come by for a visit. When they first met, Gloria was very sick and barely able to care for herself. Since then, Freda has provided support all along the way through the many ups and downs in managing Gloria’s illness. This week Gloria is feeling relatively well, but she still has some chest pain and is coughing a fair amount. Last week Freda referred her to get a sputum test for tuberculosis and she is still awaiting her result. There is a good chance Gloria has TB, as co-infection among HIV patients is very high.

Gloria adheres closely to the antiretroviral regimen therapy she receives for free from the government. However, without a consistent supply of food, she struggles to remain healthy. The family has no source of income aside from the small government grant that her eldest daughter receives for her child. This is less than $28 a month to feed a family of five--not remotely enough.  Her HIV drugs will not have the maximum benefit if she is not able to keep herself well nourished. Food scarcity also affects her family. Her eldest daughter has epilepsy and had a seizure last time Freda visited. When asked if she took her medicine, she admitted she had not because it made her ill to take it on an empty stomach, and there was no food with which she could take it.

During their near-weekly visits, Freda and Wilhelmina often bring food if the hospice has it available. It is not always possible, because the hospice itself is very strapped for resources as it attempts to care for over 1,250 patients at home and many more in their pediatric and adult in-patient units for those requiring around-the-clock care. Gloria is just one of Freda’s 250 patients to which she provides home- based palliative care. But in Soweto, a township of 3 million, there are undoubtedly many people that cannot be reached.

Soweto Hospice is a member of the Hospice Palliative Care Association of South Africa (HPCA), an umbrella organization that provides financial and technical support to develop the capacity of its more than 150 member hospices. The hospice and palliative care approach is to improve the quality of life of patients and their families facing a life-threatening illness through prevention and relief of suffering. In sub-Saharan Africa, over 90 percent of patients have HIV/AIDS. Fortunately, with the support of nurses and community health workers like Freda and Wilhelmina, many HIV patients in hospice care are becoming healthier and learning to manage their illness as a chronic condition that can be kept under control. Direct Relief has supported the efforts of HPCA and its member hospices by providing donations of medical supplies which are needed in home-based settings and in-patient units. Wound care dressings, through support of Johnson and Johnson, are currently being distributed throughout the HPCA network. 

The amount of compassion and commitment shown by the hospice and palliative care staff is admirable. With very limited resources they are managing to uplift many to good health and provide relief from suffering and pain for those that are nearing the end of their lives. They are just touching the surface of caring for people living with HIV, but they are wholly dedicated to providing the best care they possibly can.

October 28, 2009
It’s Saturday night on one of the main streets of Kisumu town. Against the backdrop of a busy night scene—music blaring from a nearby shop, people of all ages milling about in the street—are six Coleman camping tents which have been set up on the side of the road. Three bare lightbulbs strung across the row cast a pale light over the tents, which tonight are serving as private consultation rooms for voluntary testing and counseling of HIV. People congregate outside the tents, waiting their turn for the free service, asking questions and raising concerns about HIV and its mode of transmission, treatment options, and what it will means to know their status. Inside the tents, which are all occupied, HIV counselors provide information on these very issues for people who would otherwise not make it to a health center.

Several days later, many miles north of Kisumu in Wenyila village of Bungoma East District, Florence and Matutu, two skilled counselors, go door-to-door in an HIV counseling and testing program designed to leave no one behind. This is their second week canvassing the village to reach all 140 households, which were alerted prior to their visit by a respected member of the community. Florence and Matutu carry their green Home Counseling and Testing bags over their shoulders, stocked full with HIV testing accessories, and the electronic handheld device on which they gather detailed information about the household and the individual’s HIV status. If someone in the household is HIV positive, the counselors will set up an appointment for them at the nearest health center, will even offer to accompany them to the facility, and will return to do a follow-up if the person does not make their appointment. High priority is given to pregnant women that are HIV-positive to ensure they will be able to access treatment to prevent the transmission of the virus to their child. 

Innovative approaches such as the Twilight Voluntary Counseling and Testing and the Health at Home Initiative are important for making HIV testing and counseling accessible to more people. HIV testing and counseling is often referred to as the gateway to prevention, treatment, and care, because it is essential for people to know their status in order to stop the spread of the virus and to be referred to treatment without delay. While the number of health facilities providing HIV counseling and testing in sub-Saharan Africa has grown rapidly in recent years as governments work toward universal access to HIV prevention, treatment and care, a very large part of the population remains unaware of their HIV status.

Community-based approaches have great potential to reach the segment of the population that is not able to invest the time, effort, and resources to get to a health facility for testing. During the night I visited the Twilight VCT, supported by Ringroad Clinic in the Nyalenda slum and Marie Stopes Kenya, I talked to men and female sex workers who thought it very convenient that these services were being offered at a time (6 to 10 pm) and in a place where they could be easily reached. Men in general and commercial sex workers are two groups that often do not come for testing in a facility setting.  Florence and Matatu, the counselors with AMPATH (Academic Model for the Prevention and Treatment of HIV) were essentially reaching all community members, many of which did not have access to testing prior to the visit.  More than half of the people I met that day in their homes had never had an HIV test and knew very little about the virus.

The 2009 United Nations report on universal access to HIV prevention, treatment, and care discusses where the global health community stands on this internationally endorsed goal. Although many indicators are moving in the right direction, many countries are still far from reaching the goal of universal access. While the number of people in 2008 who received HIV testing and counseling increased over the previous year, recent surveys indicate that more than half of all people living with HIV are unaware of their status.

Direct Relief is helping to address this issue by providing donations of Determine rapid HIV tests in partnership with Abbott, so that more people are able to know their status, primarily pregnant women to work to prevent the transmission to their child. The rapid test is an important tool in diagnosing HIV, but universal access to testing and counseling—and to the essential treatment and care which must accompany it—is only going to be accomplished if a variety of strategies are used. Innovative approaches like the Home Counseling and Testing and Twilight VCT are bringing us one small step closer.

Jamaa Mission Hospital
Nairobi, Kenya
October 21, 2009

Today is a typical Wednesday at the Fistula Ward at Jamaa Mission Hospital in the Eastlands area of Nairobi. Thirteen women, ranging in age from 15 to 34, wait patiently for their turn to be wheeled down to operating theater. They have come from just outside Nairobi and as far as the islands of Lake Victoria, some 350 miles to the west. Most all have obstetric fistula due to prolonged and obstructed labor—too many days in the village without proper care. Physical, financial, and social barriers all contribute to the women's inability to get a hospital in good time where a C-section is available.
 
In the ward today there is also a medical fistula case, Ebby, age 34, caused by the slip of the knife during a surgical procedure performed at another hospital. From her hospital bed, Ebby assures me that the staff at Jamaa are “angels of compassion” and have treated her with great respect since she arrived. Due to her incontinence caused by the fistula, it has been a long time since she has been treated with such dignity. Ebby will receive the repair and post-operative care—and the money to take her back to her village—all completely free of charge.
 
Ebby has identified a key component in the equation for a successful fistula repair: compassionate and competent medical staff to oversee her care. Dr. Julius Kiiru, the fistula surgeon at Jamaa, is an essential part of this success, and under his guidance the hospital has become one of the leading institutions in Kenya providing fistula repair. Dr. Kiiru is a young 46, with an abundance of energy that helps propel him through the 40 to 50 repairs he does every month. His dedication to this cause took root when completing his studies in the 1990s when he witnessed many women suffering from fistula and very few surgeons that were able or willing to do the repair.
 
It was his commitment to helping these women that lead him to self-finance his certification in fistula repair surgery in Nigeria in 2001, becoming the first Kenyan to complete the course there. Back in Kenya, he began to provide fistula repair surgery at Jamaa Mission Hospital in 2003. Due to resource constraints, the hospital was only able to provide six to eight repairs a month, although the demand far surpassed this. In 2009, with additional support since committed, Dr. Kiiru himself will provide fistula repair for over 1,000 women. This is an incredible figure for one surgeon at one relatively small mission hospital.  The consequences of the repair extend far beyond improving the physical, mental and social health of the woman to her family and community that will benefit from her reintegration into society.
 
I meet Ebby again in the operating theater—she was Dr. Kiiru’s fourth patient of eight for the day—and says she is relieved to be there and grateful that there was no pain (her previous surgical experience at the other hospital had not been so pleasant). Dr. Kiiru is gracious enough to walk me through the delicate procedure and deftly completes the repair in less than 55 minutes. I feel lucky to be able to see a procedure for a condition that many in the developed world do not even know exists.
 
When I ask Dr. Kiiru about his goals for the future during our lunch break of chicken and rice, he speaks enthusiastically to the importance of incorporating fistula prevention into the program. Preventing fistula by ensuring safe motherhood and delivery is critical. To address this, Dr. Kiiru has designed a plan which would establish maternal waiting homes in five high-risk districts in the Eastern Province, from which a majority of the fistula patients come. Getting women closer to a hospital before labor so they can deliver in the presence of a skilled birth attendant will eventually mean fewer fistulas. Dr. Kiiru also envisions a program in which the women that have received repair—some of the hospital’s strongest advocates—become peer educators in these high-risk areas to emphasize the importance of safe motherhood practices and to explain firsthand the consequences of doing without. 
 
Before heading back to theater for his fifth patient of the day, Dr. Kiiru expresses his appreciation to Direct Relief for providing many of the medical consumables that are used during fistula repair and post-operative care. The first consignment of supplies will arrive at the hospital in December. He hopes that these ongoing contributions will help to lower the cost of each fistula surgery and therefore enable the hospital to provide perhaps even more repairs.  As long as Dr. Kiiru can stay on his feet, I hope this will be the case.  He and the Jamaa Mission Hospital staff are doing an exceptional job providing this critically needed service so a thousand women like Ebby, and their families, can be the deserving beneficiaries.

On a two-week visit in April and May to seven partners in Malawi, Kristi Bullock, program officer for Africa, and Dr. Mike Marks, Africa medical adviser, met dedicated people caring for their communities with what little resources they have. Direct Relief’s support allows them to provide that care. Kristi reflects on two especially memorable days during her visit.

Day Two: As we drove for hours off the main road through the Rift Valley, the dirt road connected heavily populated village after village. After all, Malawi is about the size of Pennsylvania but is home to 14 million people. Along the road I saw women dressed in brightly colored clothing cutting and carrying wood, collecting water, washing clothes, and bathing in the rivers flowing down the escarpment. Children were playing, swimming, and walking home from school. The men walked along the street, worked in the fields, and were transporting items--including goats--on bicycles. After the rainy season the Rift Valley is green and beautiful; the land is rich with maize and cotton.   

Unfortunately the joy of rain is often punctuated with sorrow. With the rain comes malaria, and alternating floods and drought often destroy crops. The largest malnutrition ward in Africa is located here in the city of Blantyre at Queen Elizabeth Hospital. The pediatric department serves 100,000 children a year for various illnesses, including malnutrition, malaria, and gastritis. Of the 24,000 admitted, 60 percent are found to be HIV positive. HIV is rampant here.

In southern Malawi, Direct Relief provides support to Queen Elizabeth Hospital’s pediatric department and to three rural hospitals south of Blantyre: Mulanje Mission Hospital, Trinity Hospital, and Montfort Hospital. These facilities are well run but only receive limited drug support from Malawi’s Ministry of Health (MOH) and salaries from Christian Health Association of Malawi (CHAM) and thus are heavily dependent on donations to operate.

Direct Relief’s support helps fill the gaps when pharmaceuticals and supplies are out of stock or not available from the MOH. When I visited with Sister Elizabeth Namuthuwa, who works in the pharmacy at Trinity Hospital, she repeatedly said, “We are very, very grateful for all the things you’ve sent.” 

Thankfully, more is on the way. A 20-foot container for Queen Elizabeth Hospital and a 40-foot container for Montfort Hospital are currently in transit to Malawi and a 20-foot container is being prepared for both Mulanje Mission and Trinity Hospital.

Day Four: Dr. Mike Marks and I made our way to Montfort Hospital in the south of Malawi, near the border with Mozambique. The paved road crossed the Shire River, where crocodiles waited in anticipation for careless fisherman. The day before, while at Trinity Hospital, we viewed the crocodile-scrubbing bath where patients suffering from bites have their wounds scoured out. I am told that the mouth of a croc is filthy--I can only imagine. The hospital administrator told us a recent story of a fisherman calling his daughter to help him pull in his nets when a croc flashed up out of the water and grabbed the girl’s arm. The fisherman saved his daughter by beating the croc and poking at its eyes, then grabbing his daughter and running away. There are a minimum of seven croc bites treated each rainy season at Trinity Hospital; many more that end in death and are never recorded.

In sharp contrast to the to the dirt road along the escarpment to Trinity, the road to Montfort is paved and cuts through fields of sugar cane, which stretches in all directions as far as the eye can see. Operating since 1970, Montfort Mission Hospital is a rural 120- bed hospital located in Nchalo, a town in Malawi’s southern Chikwawa district. It serves a local population of about 100,000, the majority of whom are subsistence farmers. The others are migrant laborers working on the sugar estate. Medical care across the border in Mozambique leaves much to be desired, so it’s not surprising that many make the journey to receive the higher standard of care here.

When we arrived at the hospital, I counted nine pregnant women sitting outside in the shade chatting as they waited to deliver. While we were visiting the delivery room, outfitted with only flat beds to deliver on, a very pregnant woman lumbered in. She didn’t say anything and didn’t look concerned, and just waited for us to leave the room. Less than 10 minutes later we heard a newborn’s first cries. In a room nearby, an intern medical assistant sat with six new mothers teaching them about breast feeding, infant care, post-delivery care for themselves, and local practices and herbal remedies to avoid. With the next closest hospital 25 miles away, Montfort is lucky to be able to provide emergency obstetric care. 

Despite a lack of support for its maternity care, Montfort admits approximately 500 patients a month, delivers more than 150 babies, and supports nearly 2,000 patients on ARVs. Direct Relief International is the only donor providing in-kind support. Ilova, a nearby sugar estate, provides food for all patients and a monthly contribution of 500,000K (about $3,333) to provide in-patient support for its laborers. This consistent monthly contribution and Direct Relief’s support are the primary reason that Montfort can continue to offer their services. Of all the visits conducted thus far in Malawi, Montfort was the most appreciative and in need of Direct Relief’s support.

Today I met Celestina, Nkwimba, Speciosa, and many other incredibly brave women who have found their way to the fistula ward at Bugando Medical Centre in Tanzania. Their stories are different but revolve around the same themes: prolonged and obstructed labor, often in the village in absence of a trained birth attendant. When no baby is delivered after many long hours—or more likely days—there is no money for bus fare to take them to the nearest health center or hospital where a cesarean section is available. These women have endured what we women in the developed world will never have to endure; many of us outside the public health circle do not know this condition exists. Why should these women have things any differently? Here are their stories—certainly sad but also hopeful, as they are some of the lucky few that have made it to a surgical center and have great potential to leave Bugando with their dignity restored.

Meet Celestina
Celestina is from Kigoma region along Lake Tanganika, many hundreds of kilometers (about 300 miles) from Bugando. She was in labor for three days at home with her eighth child. She did not have the bus fare to make it to the district hospital in time. When she finally arrived, her baby was stillborn and she had developed a fistula. During a routine outreach visit that the Bugando Medical Centre surgeons do in hospitals around the country, Celestina learned of the fistula repair services available at Bugando. (There were too many people on the waiting list in Kigoma for Celestina to be treated there). She had her fistula surgery two weeks ago and is healing nicely. When she is discharged from the hospital, she will be given  bus fare for her trip home. Only when she arrived at Bugando did she realize that she was not alone in suffering from this condition. She will spread the good news that treatment is available at Bugando to others in her village who may have fistulas.

 
Meet Nkwimba
In March, Nkwimba went into labor with her eighth child in her village in Shinyanga District. She was also at home and had no bus fare to the hospital, which was too far on bad roads. Nkwimba suffered significant injury in childbirth, including paralysis of her right leg due to prolonged obstructed labor, severe back pain, and two fistulas, vesico-vaginal (VVF) and rectal-vaginal (RVF). She has been at the hospital since May when her husband was able to afford to bring her to the VVF ward. Her leg feels much better now, and the RVF has been repaired. She is still waiting for her VVF surgery, which could be several more weeks, given the ever-expanding waiting list. It is amazing that she can still smile given what she has been through.

 
Meet Speciosa
Speciosa is from a small island in Lake Victoria. She is one of the older ladies in the VVF ward at 39 years old. Speciosa developed a fistula 10 years ago when giving birth to her first child, which was stillborn. Since developing a fistula, she has been divorced from her husband and has no children. She is waiting for her third surgery; the first two, performed over the last five years, have not been successful. For many women, one surgery repairs the fistula; Speciosa remains hopeful. She has taken on a maternal role among the  pre- and post-surgery patients in the VVF ward.

I was very much affected by these women’s stories and I wanted to record them while they are still fresh in my mind. Over two million women suffer from fistula and have similar stories to Celestina, Nkwimba, and Speciosa; 80 percent of these women are in Africa. I think we can do a significant amount for them and for the incredible surgeons who have dedicated their life to helping these women who are the poorest of the poor. There are not many doctors who want to do VVF repair as it is a time-consuming procedure and more urgent cases take precedence (i.e. cesarean sections, which, of course, are critical to preventing the fistulas in the first place). Fistula repair is clearly part of maternal and child health that is at the core of what we do. Fistula does not directly cause maternal mortality—very often prolonged and obstructed labor results in the death of the child—but it is the worst kind of injury and morbidity in childbirth I can think of.
 
I realize what I've written sounds rather sad, but really it was a hopeful day as these women have access to treatment that will truly change their lives. The women were happy to tell me their stories and were laughing and smiling, and particularly enjoyed looking at their digital portraits.

Women must have access to cesarean section and good emergency obstetric care if the incidence of maternal and infant mortality and morbidity, including fistula, is to be reduced. Small steps are being taken by our partner facilities in Tanzania and throughout Africa to make this a reality. In select regions Direct Relief is helping to facilitate the installation of operating theater suites that have enabled more women to get the care they need.

Until fistulas are eradicated in Tanzania—as they have been in the developing world—with the advancement of good emergency obstetric care, Bugando Medical Center's VVF program and its outreach treatment services give women a reason to smile.

August 6
The vibrancy and passion about HIV is evident in diverse and powerful imagery at the International AIDS Conference, where 22,000 delegates are in attendance. For example, a throng of wailing, mourning skeleton-clad people paraded the conference corridors while hauling a casket as they protested the high cost of pharmaceuticals and their inability to afford life-saving drugs. This issue strikes at the core of why Direct Relief International provides its services to partners across the world. 

The need for access to free medicine and medical supplies has been a dominant theme throughout the conference. A powerful photography exhibit, “Access to Life,” graphically documents the positive impact that free antiretroviral drug treatment is having on the lives of millions of people living with AIDS internationally. The AIDS pandemic has had a devastating impact worldwide, especially in countries with limited healthcare access. An estimated 33 million people are now living with HIV. Of these, 72 percent live in sub-Saharan Africa. Without access to life-saving drugs, millions will die unnecessarily. Families will be destroyed, children will be orphaned, and countries will suffer as their work force rapidly dies off.

The deadly co-infection of HIV and malaria is an issue that’s shouting to be heard. Together, HIV and malaria cause more than 4 million deaths per year—more than 80 percent in Africa. HIV-infected people are more likely to contract malaria, as their immune system is suppressed. Co-infection can transiently increase HIV viral load, which can impact the progression and transmission of HIV. Circulating the conference is a petition seeking action in HIV/AIDS and malaria-endemic countries that demands access to insecticide-treated nets, other preventive interventions, and effective malaria treatment as a vital part of healthcare. Nearly a quarter of conference attendees have signed the petition thus far.

Other hot discussion topics include circumcision as a clinical means to decrease risk of HIV transmission (found to protect 51 to 67 percent of the time); pediatric HIV care and treatment; and decentralizing HIV testing from the health facilities to communities through outreach and home-based care services. Despite the fact that HIV was identified a full two decades ago, much remains to be learned about the care and treatment of those infected and affected by the disease. The International AIDS Conference creates a forum in which all interested parties can learn from each other and continue to combat the devastating HIV pandemic.

April 10
As we're finishing up work at both project sites, here is a short update and some photos of what the volunteers have been up to in the last week:

There has been amazing progress at Motoka in establishing an electronic inventory system for product and reorganizing the entire storehouse.  One of BD’s field salespeople has been great at getting Vivian and two staff members on the computer and comfortable with the new program. The lab at Motoka looks great as well. The construction team basically gutted everything and re did it and with the new equipment installed it looks wonderful. A BD employee who is also a Registered Nurse is on boat outreach today.

The Bonkwaso construction team is rushing to finish by Thursday when there will be a ribbon cutting ceremony to open the new clinic. One of BD’s marketing managers has been busy in the lab at Maranatha installing new equipment and doing trainings for the lab techs at the 15 other maternity clinics in Maranatha's Kumasi maternity clinic organization. Computer training was a big hit at Maranatha as well. The BD corporate manager who set up the system is very popular in Kumasi now.

We're all staying healthy, and while some of the volunteers seem ready to go home others may have to be dragged onto the plane. Everyone is looking forward to this Friday and Saturday in Accra for the two sites volunteers to meet again and share experiences.

April 6
Things are going well here in Motoka, as the BD volunteers and clinic staff are making some significant progress in improving both the infrastructure and the operations of the clinic. The storeroom is nearly completed - a real facelift - as well as the laboratory shelving, concrete floor and re-wiring. One of the BD volunteers (a marketing manager back in the States) will start working to set up the new equipment in the next day. He's been working with the new lab technician at Motoka on standard operating procedures that will be recorded for Simon's use and for future employees. Another BD lab expert has been in Motoka’s lab the whole time, and his input has been great.

The rainwater collection system and septic tank, which has proven to be the most challenging project, will be completed this week. A BD field sales specialist has three Motoka staff members in computer training three hours per day, and they are recording their entire inventory in an Excel spreadsheet as it is put back into the newly shelved store room. This will be a good starting point for tracking inventory for them.

Things at the Maranatha Bonkwaso clinic are also going well. The clinic will be finished by this Thursday and the construction folks are working all weekend to make that happen. On Tuesday, all Kumasi volunteers will paint the clinic, each taking one room.

One of BD’s lead scientists worked at Komfo Anokye Teaching Hospital (the second largest hospital in the country) yesterday on their CD4 counter, a device that is useful in monitoring T-cell counts in HIV/AIDS patients. They’ve has been doing training sessions for other lab techs and assistants throughout Maranatha's midwife clinic network in Kumasi for such things as tuberculosis staining, malaria testing, and more. She is also helping the hospital staff revise their standard operating procedures and working with two new lab assistants on their training.

Other volunteers are helping emphasize the importance of safety and preparedness at the clinic. Two BD volunteers, who are also trained nurses, did a seminar on healthcare worker safety yesterday at Komfo Anokye to a 90 person crowd.

In other good news, the Henry Schein shipment of additional medical products was received, and we're sending it to the two sites today!

March 29
We had a really nice meeting this afternoon with the Paramount Chief (the local political figurehead) and all of the elders from his districts so they could meet us, get to know about our mission, and thank us. This meeting was a chance for us (Direct Relief and BD) to explain our mission here and for the chief and elders to hear about Vivian’s work providing local healthcare for the last ten years. It’s novel in Ghana that Vivian set up this clinic in an area where she does not come from originally. That act brought healthcare to this region, from which the chief’s people are benefiting. Many thanks were offered for this ongoing assistance.

The chief and elders were all in full traditional dress. The chief wore a huge gold tortoise ring to symbolize that his are a peaceful people.

Everyone is settling in well in Motoka. We spent time today tasking out jobs, finalizing work plans, gathering a few final supplies, and by the end of the day all seemed to be moving in the right direction. Anders spent some very productive time with the lab technicians today, and introduced the BD lancets at a well-baby clinic. They were very well received!

The heat here can be overwhelming, reaching a very sunny 100 degrees Fahrenheit during the days, but now, at night, it is about 70 degrees and windy.

In about four days, I will be back in Accra, hoping to clear through customs a shipment of additional medical supplies donated by Henry Schein for the clinics.

January 7, 2007
Ekona, Cameroon

I arrived at the Holy Trinity Foundation Hospital in Ekona, a small town in western Cameroon accessible by a dirt road outside of Buea, the former German colonial capital, to meet Dr. Adeh Sylvester and the staff of this long-time Direct Relief partner facility. The 30-bed hospital is staffed by two doctors (including Dr. Sylvester, a gynecologist by specialty), three lab techs, an administrator (Dr. Sylvester’s wife), a pharmacy attendant, and a number of nurses, nurse-midwives, and nurse aids. The staff is friendly and extremely enthusiastic about their work as apparent in their caring attitude toward the in-patients we met as we toured the facility.
 
The aim of the facility, established by Dr. Sylvester, is to provide quality, affordable healthcare to the impoverished subsistence farming population of rural villages surrounding Buea as well as to low-income urban residents of Buea itself. Prices for services are set on an exact cost-recovery basis, much less expensive than other public and private facilities in the vicinity. However, Dr. Sylvester noted that many patients cannot even pay minimal fees and are therefore treated free of charge.

Dr. Sylvester performs surgeries in the hospital nearly every day of the week. With minor and major operating theaters, surgeries are undertaken in minimalist conditions with the constant threat of electricity failure and a lack of proper supplies available for procurement on the local market. Dr. Sylvester noted the lack of sutures available for purchase as a major obstacle to maintaining regular surgical services. But, for many patients in Ekona and beyond, Holy Trinity Medical Foundation is the only affordable provider of health care and thus the only option. Dr. Sylvester is ever creative in his ways to maintain consistent, high-quality services for those in need.

Direct Relief has sent 12 shipments to Holy Trinity Foundation Hospital since partnering in 2003 worth over $2.37 million (wholesale), with the latest shipment set to arrive in port this January. The shipment includes much needed items including surgical lamps as well as other requested pharmaceuticals and supplies to alleviate the strain on this exemplary medical staff to carry out their mission. 

January 1, 2007

Douala is a densely populated metropolis whose temperature in this part of the dry season remains easily in the upper 90s each day with full humidity, dust, and diesel fumes in the air. Douala, the largest city in Cameroon and a port serving all of Cameroon, Chad, and the Central African Republic - is home to over two million, many recent migrants from rural areas in search of jobs in the urban informal economy.

I spent the day with Dr. George Assam, one of 30 radiologists in Cameroon, and director of the Help Medical Foundation, a charitable medical facility located in Bonaberi, an over-populated, under-developed urban slum section of Douala. For 80,000 people in this part of Bonaberi, this eight-bed in-patient clinic is the only source of affordable health care. Over 75 percent of the patient load, which averages 30 per day, is unable to pay anything for services and receive examination and treatment free of charge. With barely enough income to cover medicines, reagents for the laboratory, and salaries, the facility is hard-pressed to meet its budget each month. The three doctors on staff work on a volunteer basis (running private practices on the side in Douala for income), and the nurses and lab tech receive a nominal stipend each month.

Dr. Assam is the fiery, charismatic glue that holds the whole charitable operation together. A specialist doctor at the Douala government referral hospital part time, Assam founded the clinic and takes great pride in knowing on a personal basis, the residents of the Bonaberi area and their health needs, personally encouraging them to adopt healthy lifestyle habits for better nutrition and HIV/AIDS prevention, a growing problem in Cameroon (10 to 11 percent adult prevalence rate, though some statistics put it as low as seven percent).

Poor nutrition and very crowded living conditions along with lack of access to clean drinking water make disease prevalent in Bonaberi. Dr. Assam treats many cases of malaria, respiratory illness, complications related to HIV/AIDS, all made worse by inadequate nutrition. "The greatest health problem in Africa" he says "is hunger" though he quickly adds the problems of infectious disease. For his part, Dr. Assam has been very pleased with the supplies sent by Direct Relief that arrived last August. They have been very valuable in treating infections in both children and adults that come through the Help Medical Foundation's Bonaberi compound.

September 20, 2006: Bo District, Sierra Leone

As we left Freetown for the southeastern Bo District, the chaos and fumes of the city gave way to a beautiful landscape of bright green rolling hills dotted with cocoanut palms. The outline of the mountains – for which Sierra Leone is named – looked particularly dramatic with the contrast of blue sky against dark clouds that produced quick and frequent bouts of hard rain typical of this time in the rainy season. Soon, the smooth, paved road ended and, for the next six hours, the traveling was extremely rough and the four-wheel-drive capability of our vehicle was critical.

It was dark by the time we reached the Bo town, the central town of the district with over 1 million people – the second most populous in the country after Freetown. The section of town in which we would stay had just lost electricity, and the busy street was dotted with kerosene lamps as people continued about their business seemingly unperturbed. We waited in the courtyard to check in at the Sir Milton Margai Hotel as the building’s generator was fired up.

In the morning we left Bo town with John Ganda, PhD, Executive Director of Ndegbormei Development Organization (NDO), a respected Sierra Leonean social service and economic development organizations active in Freetown and Bo District. Established in the mid-1980s, NDO had operated throughout the years of Sierra Leone’s brutal civil war, even maintaining an office and program work in Freetown when the rebels took over the city in 1999. NDO’s current activities focus on helping rebuild the rural and urban poor’s access to health care, shelter, and economic opportunity in a post-conflict climate in which major infrastructure components were damaged or destroyed (For example, the rebels destroyed Freetown’s electrical lines in 1999 and they have not yet been completely rebuilt, leaving sections of the city without electricity seven years later).

From Bo town we drove 16 miles in nearly an hour to the rural village of Bumpe and the site of a community clinic built and operated by NDO. Bumpe’s approximately 4,000 people are mainly farmers, and homes are made of mud and thatched straw roofs that must be replaced after each rainy season. There is no running water or electricity available, and goats and chickens ran around in front of each home along with many little children.

The Bumpe clinic is a ten-year-old cement structure that includes an exam room outfitted with a delivery bed, an administrative office that doubles as a pharmacy, and a patient waiting room in which there are also two in-patient beds. Supplies of medicines and consumables at the clinic were low, and the two full-time nurses, Beatrice and Rilla, spoke enthusiastically about the latest shipment from Direct Relief that had just cleared customs in Freetown and was on its way by land to the clinic.

In addition to the two nurses (both trained as midwives as well), the clinic employed one nurse’s aide and an administrator/ program coordinator. Nearly 1,000 patients sought preventative and curative services at the clinic each month coming from Bumpe as well as surrounding villages. Once per week, the clinic administered immunizations to children under five years and offered well baby exams. Other days at the clinic were consumed by providing prenatal care, primary care services including wound care and suturing and the treatment of common illnesses. Referrals including complicated deliveries were made to the nearest hospital facility in Bo town.

Patients needing care beyond the level available at the clinic needed to find a car for hire to travel on the pitted, muddy roads (vehicles are not readily available in the villages, if at all) and have available both the payment for the transport and the payment for the emergency service at the hospital in Bo. It was widely reported that services were routinely withheld until patients could pay in full for the procedure needed.

For complicated obstetrics cases, this lack of access (geographically and financially) to emergency services, including c-sections, compounded with inadequate tools in rural clinics to make early diagnoses of potentially complicated cases helps explain why Sierra Leone’s maternal mortality rate is the highest in the world.

As we sat in the clinic’s office discussing with the nurses the range of services provided and the needs of patients seeking them, a very young mother arrived with a baby tied to her back accompanied by her little sister for her five month old baby boy to be immunized. Her face and arms were glistening with sweat and her clothes and her sister’s clothes were damp. She had just walked eight miles in the hot sun, humidity, and spurts of hard rain to reach the clinic so her baby could be immunized – a stark reminder of the obstacles for these rural mothers in obtaining even basic preventative care.

September 12, 2006: Kumasi, Ghana

We awoke at 5:30 AM as the sun came up outside of Ghana ’s second largest city, Kumasi , located in the central Ashanti Region. Even with the loud hum of the fan, I could hear clearly through the open windows roosters and their typical morning greeting, dogs barking, and a baby crying from the maternity clinic above the residence of proprietress, Mrs. Agatha Amoateng-Boahen, with whom we stayed during our two day visit to Maranatha Maternity Clinic in Kumasi . For two years, Direct Relief has supported Maranatha with donations of medicines, medical supply consumables, and advanced diagnostic equipment.

The water pipes to this part of Kumasi had shut down, leaving the clinic and the residence without running water for a week. Every morning, Agatha drew water from the well in gallon-size white buckets for all the day’s washing, drinking, cooking, and clinic use. After a quick wash from a bucket of warm water, heated on the stove, we departed Kumasi for the small rural village of Bonkwaso , an hour’s drive on smooth roads which faded into difficult bush roads.

The village of Bonkwaso was home to approximately 50 families with mud huts with straw and tin roofs clustered around a main road with dilapidated cement building and wooden stands of unclear purpose. Surrounding the villages are plots where nearly all of the families work on a subsistence basis – some crops are grown for sale in the city including cocoa, oranges and various vegetables, and plaintain, a popular banana-like fruit. These self-subsisting villages are not uncommon in the region.

Bonkwaso had no running water or electricity, and health care services are inaccessible without making the long journey to Kumasi ; without a vehicle – of which there appeared to be none in the village – it would take all day. Each Friday, Agatha and her staff conduct medical clinics in the village from a two-room rented space, which consistes of an exam room and a storehouse for medicines and supplies. The clinics offer a full range of primary care services, maternity care, and general medicines with an emphasis on combating the widespread malnutrition in the area. On Fridays, the outreach clinic offers medical services to those visiting an area-wide market, hosted in Bonkwaso, where agricultural goods and household goods are traded between surrounding villages.

On our arrival in the village, we were taken to the home of the chief to meet him and several of the elders. A growing group of curious children followed us around eager to show us their drawings and have their photo taken. Young women sat out of their huts and nursed babies or washed laundry in bright colored buckets. Agatha smoothly shifted into clinician mode, making “rounds” among the young women with babies most of whom she appeared to know from previous clinics.

Agatha called us over to one baby who, though held by his mother, was whimpering in a more plaintiff way than normal. His forehead and eyes were large, but his cheeks were sallow. His arms and torso were very thin and the skin on his torso sagged in excess. Agatha took the baby and examined him – she confirmed with the mother that he had been suffering from acute diarrhea and was dangerously dehydrated and in need of fluids.

Agatha went to her clinic storehouse and returned with packets of oral rehydration salts. It took a significant effort to convince the young mother that this remedy would be useful, and Agatha demonstrated the salts and instructed the mother on their continued use to help the tiny body regain fluids and keep the baby alive.

Agatha saw a number of other people in the village whose cases she had been monitoring ahead of her scheduled Friday clinic. It was obvious that her attention to their health was immensely appreciated and she was treated in the village with palpable affection and respect.

As we prepared to return to Kumasi, Agatha explained her plans to expand the level of services and frequency of clinics in Bonkwaso including the training of two resident community health workers to monitor cases in the interim between visits by health care professionals. It was obvious that her efforts are making an incredible difference to this rural area in central Ghana.

Lucy Anderson, Development Coordinator and Program Officer Christienne Durbin traveled to Africa in April to meet new partners and expand Direct Relief’s programs in Malawi, Rwanda, and South Africa. They provided brief notes from the field while they traveled.

April 21, 2006 - Rwanda

Direct Relief has signed a Memorandum of Understanding with Community, Habitat, Finance, (CHF) to provide material assistance to 86 clinics throughout Rwanda. CHF International is running a $40 million project that aims at providing communities with access to high-quality and sustainable HIV/AIDS services.

According to the United Nations, Rwanda is currently considered one of the least developed nations with 83% of their population living on less than $2 a day. The average cost of triple anti-retro viral therapy for HIV/AIDS is $13 per day, leaving treatment out of reach.

Rwanda continues to suffer from the effects of the 1994 genocide that left almost one million of its people dead. The results of the genocide are numerous: tens of thousands of orphaned children, widows left as sole heads of their households, and a ruined economy, to name just a few. Like all African countries, Rwandans have the additional burden of HIV/AIDS on an already struggling health system, society, and economy. Life in Rwanda is not easy for most, 60% live in abject poverty, for those with HIV or AIDS life becomes exponentially more difficult.

The Society of Women and AIDS in Africa (SWAA) was started in 1992 and now has 40 branches throughout Africa. SWAA is one of the many partners supported by CHF and CHAMP and the Rwandan division of SWAA has three branches. We visited the Central (Kigali) branch today and were pleasantly surprised by the extent of the comprehensive services offered.

SWAA’s main effort is to combat HIV/AIDS and offer services to those affected by the disease (though these services are also available to people who do not have HIV). SWAA serves men, women, and children in a range of areas. One area in which they work is behavior change communication (BCC) – the cornerstones of which are A&B – “abstinence and be faithful.” More than 100 people attend these BCC meetings which are held every morning, 98 percent of these are people living with HIV/AIDS, and some begin walking at 2am in order to reach SWAA for the 8am discussions. A large part of SWAA’s draw is that they have counselors on staff to listen to people’s stories. Many HIV+ people hide the fact that they have this disease from those in their community – having the opportunity to talk, in confidence, to someone about their disease and life in general seems to have a therapeutic effect on SWAA’s clients. SWAA also provides palliative and home-based care for those with advanced cases of AIDS, much of this work is undertaken by SWAA trained community volunteers. SWAA’s reach extends to orphans and other vulnerable children and micro-credit schemes.

We met a woman and her baby who were recipients of SWAA’s services. The woman is HIV+ and attending a lecture on micro-finance, in this instance the selling of fruits and vegetables. Upon completion of a training course, SWAA provides the man or woman the money to begin their business venture. SWAA also provides them with a bank account and helps them keep track of their money. Others in attendance had plans including selling coal, importing cloth and small fish from Bujumbura (the capital of Burundi), and looking after other people’s children. Although many people have been educated, there are few opportunities to make a good living, especially for those whose health is compromised.

Direct Relief International looks forward to providing material, namely personal care products, for the community volunteers to use when making house calls. Basic items like soap and towels are in very short supply and the purchase of these items taxes SWAA’s already stretched budget.

Lucy Anderson reviews project plans
with SWAA's directors in Rwanda.

April 17, 2006 - South Africa

The first stop on our trip took us to Johannesburg, South Africa. The HIV rate in South Africa is between 20-30% and some of the most notably affected are children. Located in Maraisburg, Roodesport, about 40 kilometers from Johannesburg International Airport, Sparrow Village functions as an orphanage, hospice, and school for local children.

According to Reverend Corinne McClintock, the founder of Sparrow Village, there are 800,000 orphans in South Africa and estimates predict that this number will more than double, to two million, by the year 2012. Reverend McClintock shared his firm belief that without Sparrow Village all of the HIV positive children they have treated would be dead. There are 200 children and 30 adults currently residing in the Village. According to staff, 75% of these children are orphans and 70-80% are HIV positive. Due to the need in the area for medical services Direct Relief International provided a hand-carry consignment in February to Sparrow Village, which consisted of essential medicines such as analgesics and antibiotics, as well as wound-care and personal care products.

Sparrow Village staff shared with us a number of heart-warming stories that were encouraging indicators of the progress being made by this organization. For example, they told us about a baby who arrived four months ago weighing only four pounds, but as a result of care, the child, Isa, is now thriving. At the Village the children live in domed huts, with one “housemother” for every 12 children. We had the opportunity to hear from Justine, who has been a housemother for the past five years. She spoke of how much she cared for the children, that they make her heart “soar” and that she loves them “too much.” She went on to tell us about a specific case where she was given a little boy in a wheelchair to take care of. She said that all she could do was care for him as best as she could, and pray; miraculously, two weeks later, the child began to walk.

Reverend McClintock is aware that simply being at Sparrow Village will not ensure that these children will be able to secure a future. She is currently looking into how she can provide the children with a quality education and marketable skills so that they will be successful after they have left the Village. She said they are also seeking to increase the amount of health care that they provide. Their goal is to set up movable health villages so that they can provide care to a wider range of people, including child-headed households.

As for Direct Relief’s involvement, we will be examining the possibility of Sparrow Village becoming a more active member of our partner network. Direct Relief is currently working to become a registered South African Public Benefit Organization (PBO) which would help facilitate further assistance to the Village.

We are off to Kigali, Rwanda on Wednesday and will report from there.

In July of 2004, International Program Officer Christienne Durbin visited our overseas partner KADERES - Karagwe Development and Relief Services - a non-governmental organization in northwest Tanzania, to assess and evaluate 7 of the 31 clinics and Health Care Centers it supports through the shipment of medical products provided by Direct Relief.

Children's Ward, Nkwenda, Tanzania

According to the United Nations Human Development Index, Tanzania ranks as one of the poorest countries in the world whose ability to cope with the extreme health problems of AIDS, malaria, and malnutrition is extremely limited. KADERES is a non-governmental organization, located in the northwestern region of Tanzania, bordering the republics of Uganda in the north and Rwanda in the West.

Young Girl with Malnourished Baby, Nkwenda, Tanzania

Following the crisis of genocide that occurred in Rwanda in 1994, over 300,000 Rwandan refugees poured into northwestern Tanzania, causing a sever strain on an already overburdened and resource poor health care and social services system. The following description, taken directly from the Karagwe District government website, explains the on-the-ground situation quite well:

Apart from insufficient levels of qualified staff, the majority of health facilities do not have sufficient other resources to be able to provide quality services. Necessary equipment, drugs and medical supplies are all in-adequately supplied….Equipment, including infrastructures, is often in bad shape or poorly maintained. Drugs for the Government of Tanzania health facilities are supplied in the form of a monthly pre-packed 'EDP-kit' (National standard). As the contents of the kit are not 'demand-driven', most of the drugs are either under- or over-supplied. Although it is safe to assume that prescribing of drugs could largely be improved, in most cases, essential antibiotics are only sufficiently available for a period of two weeks. Other, rarely used drugs pile-up and expire. Generally, non-profit facilities (including church funded facilities) do not receive drugs (or funds to buy drugs) in a sufficient and consistent manner. In part this is caused by declining levels of support from abroad.

Patient Records, Mabira Clinic

Apart from insufficient levels of qualified staff, the majority of health facilities do not have sufficient other resources to be able to provide quality services. Necessary equipment, drugs and medical supplies are all inadequately supplied. Equipment, including infrastructures, is often in bad shape or poorly maintained. Drugs for the Government of Tanzania health facilities are supplied in the form of a monthly pre-packed 'EDP-kit' (National standard). As the contents of the kit are not 'demand-driven', most of the drugs are either under- or over-supplied. Although it is safe to assume that prescribing of drugs could largely be improved, in most cases, essential antibiotics are only sufficiently available for a period of two weeks. Other, rarely used drugs pile-up and expire. Generally, non-profit facilities (including church funded facilities) do not receive drugs (or funds to buy drugs) in a sufficient and consistent manner. In part this is caused by declining levels of support from abroad.

Woman Receiving Exam in Maternity Ward

KADERES facilitates the provision of primary health services in isolated villages in Karagwe District, where more than 78% of the citizens of these remote areas walk more than 20 (six miles) kilometers to reach medical services. There are only 3 Hospitals, 3 Health centers, and 45 dispensaries to serve 500,000 people. The infant death rate is currently 110/1,000, or over one-in-ten. For comparison, in the United States the infant mortality rate is 7 in 1000. In Karagwe District, 47% of deliveries are in the home and 53% in a health facility. The term "facility" includes dispensaries, which are generally only open a few days a week. The local facilities see approximately, 1,626 pregnant women per month.

Maternal deaths are primarily caused by ruptured uterus, disseminated infection (puerperal sepsis), antepartum and postpartum hemorrhaging and infected (septic) abortions. The main indirect causes of maternal death are late referrals to the medical centers due to poor health infrastructure (e.g., no transportation to a clinic and no radio communication system), malaria, anemia and AIDS. The main causes of infant deaths were fetal distress, birth trauma, neonatal sepsis and prematurity. Though these numbers seem very high, they are an improvement on the infant death rates of the previous year of 130/1,000. Current statistics from the Karagwe District Medical Office highlight the prevailing top ten causes of death in the district:

PROGRAM PARTNERS VISITED

KADERES

KADERES Vital Statistics:
Five full time and one part-time staff, including the Executive Secretary and Financial Controller. Of the fifty-three existing board members, twenty-four of them are founding members. All board members are local people from Karagwe District who volunteer their time.

Public Health Nurse and Medical Secretary, Karagwe

History
KADERES was formed on June 26th 1997. Their main objective is to improve the provision of Health, Water, Education, and Agriculture in rural areas of Karagwe District in Tanzania. KADERES also operates micro-enterprise, educational, agricultural, and environmental programs. The health-related goals of KADERES include reducing infant and maternal mortality rates, decreasing the rate of HIV/AIDS infection, providing comprehensive reproductive health services, immunizing all children less than 1 year of age, and building three new dispensaries in specific villages where, at present, no medical services are provided.

In 1997 and 1998, Karagwe District was seriously affected by the El Nino weather phenomenon that resulted in high levels of malaria and anemia that took the lives of many children under the age of five.

KADERES Staff and George Buberwa of Kagera Salient Dispensary (far right)

KADERES responded to the El Nino crisis by trying to financially support the health clinics in Kibimba village, in Mabira Ward from their own contributions. When they realized that they would not be able to keep the clinics operating through their own efforts, they began to look for possible donors to assist them in their efforts to strengthen the health services provided by Kibimba and other clinics to their the neighboring villages.

In 1998, KADERES submitted an application to DRI for Medical support. A year later, DRI began providing medical shipments that KADERES distributed to the Kibimba Health Care Project a 25-bed clinic and dispensary serving approximately 23,730 villagers. Donations to KADERES have since supported 31 dispensaries and clinics, three health centers (including Nkwenda Rural Health Center where Direct Relief is currently helping to equip a operating theater) and three hospitals. Direct Relief now sends an average of one large shipment annually to support the Karagwe District healthcare infrastructure. Two primary schools have also been provided with first aid kits. Donations have benefited more than 55,500 patients in all the health facilities in Karagwe District.

Introduction to Two KADERES Health Care Sites

Nkwenda Rural Health Center
KADERES is supporting the Nkwende Rural Health Center's initiative to reduce maternal and child mortality by requesting from Direct Relief assistance in equipping an efficient operating theatre. In the past three years, there have been 45 maternal deaths due to ruptured uterus and post-partum hemorrhage as a result of late referral due to poor transportation. It is expected that a functioning operating room will drastically reduce maternal and infant mortality rates. Nkwenda serves a population of more than 100,000 who have to walk to the nearest hospital for surgical services 43 kilometers away.
Staff: 4 physicians, 6 midwives

Women's Ward, Nkwenda

Kibimba Health Care Project
Kibimba Health Care Project operates a 25-bed clinic and dispensary which serves approximately 23,730 villagers. The major health problems are malaria, diarrhea, anemia, upper respiratory infections and AIDS. Approximate number of people served by pharmaceuticals and supplies: 8,581
Staff: 2 physicians, 2 midwives

In May of this year, the U.S. Agency for International Development (USAID) invited Direct Relief International to Senegal to meet their local NGO partners and identify ways that Direct Relief might be able to support their country-wide efforts to improve health care, particularly for women and children.

Mother and baby waiting for well-baby exam
(photo by Kelly Darnell)

With little natural resources and a per capita income of $500 per year, Senegal is one of the poorest countries in the world. It sits just 18th from the bottom of the United Nations Development Program (UNDP) scale, which ranks countries according to life expectancy, education levels, and standard of living. Even so, Senegal could be considered a success story compared to many of its West African neighbors with a rapidly growing tourist industry and extremely low HIV/AIDS rate at slightly over 1 percent. It also has an organized health system that is relatively well supplied with essential medicines and in a position to provide health to even the most remote areas through a network of staffed health posts, health centers, and hospitals.

Senegal's progress in addressing health issues despite its development status to a great extent results from the government's commitment to keeping health a priority and to a forward-thinking medical community that has responded quickly to health issues like the outbreak of HIV/AIDS. In addition, the country has established a medical training program that includes peer to peer mentoring, is looking at ways to address the chronic "brain drain" taking place, and has committed to providing anti-retrovirals to the over 27,000 Senegalese living with HIV/AIDS.

Despite clear improvements in the past decade, Senegal remains an unsafe place to be under the age of 5 or a pregnant woman with delivery complications. Nearly one in 160 women in rural Senegal die in childbirth. Nearly one child in seven dies before the age of five and one in four suffers from chronic malnutrition, malaria, and upper respiratory infections.

USAID is providing financial assistance to several Non-Governmental Organizations (NGOs) that are collaborating with the Ministry of Health to support initiatives designed to strengthen the healthcare system though training and the provision of critically-needed supplies. I spent several days meeting with these partners and visiting the health centers and hospitals where their work is starting to pay off.

There are five diseases or conditions responsible for 70 percent of all childhood deaths in developing countries - pneumonia/acute respiratory infection, measles, malaria, malnutrition, and diarrhea. One of Direct Relief's potential new partners in Senegal is an NGO called Basics II. Basics II's work to improve the diagnosis and treatment of childhood illnesses illustrates the complimentary relationship between the Ministry of Health and partner NGOs. Basics II is training health providers to recognize and treat early warning signs for health conditions like dehydration in children, as well as providing education at the community level, where the diarrhea that causes dehydration starts, and by talking to parents about how to prevent diarrhea through simple measures like ensuring their children are drinking clean water and washing their hands after using the restroom. In addition, Basics II is increasing access to immunizations throughout the country; promoting exclusive breastfeeding to prevent malnutrition; and ensuring that all health facilities have a baby weighing program, as weight is an important indicator of a child's health.

Another example of NGO action tailored to support Ministry of Health measures is a project of Management Science for Health (MSH) to improve emergency obstetric care. Throughout Senegal, woman and infants often die because health centers are not properly equipped with lifesaving medical equipment and staff have not had adequate training in emergency delivery skills. MSH is working to reduce the number of maternal and infant deaths by providing emergency obstetric equipment as well as training for health providers. Topics include how to resuscitate a newborn, recognizing the early warning signs of women needing a cesarean section, and what to do when a woman begins hemorrhaging during delivery.

Inpatient room at health post
(photo by Kelly Darnell)

Unfortunately, many of the health facilities supported by the efforts of MSH and Basics II are still lacking the supplies and equipment needed to allow these trained health practitioners to implement their new skills. Many of the delivery rooms and neonatal ICUs I visited could benefit from a Direct Relief donation of basic items such as delivery instruments, vacuum extractors for woman who have miscarried, infant warmers, baby scales, needles, syringes, incubators, and neonatal ambu bags for resuscitating newborns.

At the end of my visit, representatives from USAID and I met with the U.S. Ambassador to Senegal, Allan Roth, in order to brief him on this new collaboration. Ambassador Roth discussed the fact that although USAID has long partnered with NGOs like Direct Relief, these partnerships are even more important today. In 1970, the US government provided 70 percent of American foreign assistance. Today, American citizens, companies and NGOs provide 80 percent of the assistance, while the US government has reduced its commitment to only 20 percent. Agencies like USAID are recognizing the enormous contributions made by American NGOs in addressing issues standing in the way of education, economic development, and health care delivery.

In summary, each of the NGOs with which I met during my visit to Senegal is well run by Senegalese professionals with backgrounds in community planning, education, and medicine. All are committed to improving the health system in their country. By supporting their efforts, Direct Relief can build on the strengths of this rapidly improving health system that is making it safer for a woman to deliver and for a child to be under the age of five.

U.S. Ambassador to Senegal Richard Roth
and Program Officer Kelly Darnell
(photo by Ann Veazey)