The room was bare - a green-sheeted examination table pushed up against the far wall and a large desk, cluttered with papers, bisecting the room’s length. A lone poster fluttered on the wall, moving every time the door swung open or shut. The lack of other adornment so typical of Western medical offices was not uncommon here at the Ruhunda Health Center. More striking, however, was the absence of a sink or even a bucket in which health center staff and patents could briefly wash their hands.
The general consultation room at Ruhunda routinely sees an average of 60 patients each day. This is where Juvenal Niyomugaba, the Vice Titulaire at Ruhunda, practices. Beginning at 8:00 each morning and working until 4:00 or 5:00 each evening, Juvenal consults with patients, treating them for a wide assortment of illnesses and conditions including respiratory illnesses, malaria, pre and postnatal consultations, and general wounds and skin infections. As they enter the room, he congenially greets them with a handshake and then proceeds to investigate their aches and pains or dress their wounds. Despite the otherwise professional nature of the visit, the health center’s lack of running water made it difficult for Juvenal to wash his hands between consultations except for the few moments when he was able to take a quick break.
“I am busy every minute of the day - in consultations with new patients, meeting with past patients, and performing administrative tasks,” said Juvenal. “I am a professional, so I know the importance of hand washing between patients, but how can I do it when there is no sink and no bucket to wash my hands with and I have to go outside to fetch water? It’s not possible.”
Unfortunately, this unsanitary and poor clinical practice was not singular to Juvenal’s service. Rather, it was an intolerable condition shared among all rooms and health professionals at the health center. Most notably, neither the delivery room nor the pediatric and adult consultation rooms at Ruhunda had access to running water. That any doctor would be forced to deliver a child without immediately washing his or her hands before and after performing procedures is unfortunate and reveals the sometimes perilous risks inherent to both practitioners and patients when water is not available.
Ready and reliable access to water is critical in determining the quality of care offered at health centers in Rwanda. Rwandans face a daily onslaught of pathogens and parasites which threaten their health in both small and large ways. Soil transmitted helminths, amoebas, and general bacteria and viruses exploit the country’s poor hygiene, resulting in increased morbidity and lowered productivity among both working adults and students.
Water is an easy remedy to these problems, especially in health centers where people are most vulnerable. Not only does water enable equipment sterilization equipment and hygienic care, but its presence in health centers also allows health professionals to role model good hygiene and hand washing.
Unfortunately, many health centers must operate without this basic service. According to the 2008-2009 Ministry of Health Annual Statistical Booklet, only 59% of health centers nationwide are connected to either the local or national water grid. The rest must rely on a combination of rainwater harvesting, surface water from nearby lakes or rivers, and wells and boreholes. Even those health centers already connected to a water grid must struggle to bring water inside their health centers; they are often forced to carry water in buckets from an outside tap on to the grounds of the health center. Before local Access Project Peace Corps Volunteers applied for and received water grants from Appropriate Projects, both Ruhunda and Musha Health Centers were among Rwanda’s many health centers without internal running water.
The villages of Ruhunda and Musha are both located in the Rwamgana District in the Eastern Province of Rwanda. Ensconced in the folds of gently rolling hills in rural Rwanda, they both host small communities of small scale and subsistence farmers. While both Ruhunda and Musha are relatively close to the nearest regional capital, Rwamagana – a mere 20 and 30 kilometers, respectively - the cities remain largely untouched by modernity. Although electricity and cell phone coverage are available, few in these largely agricultural cities use these resources.
But in March and April of 2010, the Ruhunda and Musha Health Centers took a critical step in their path towards modernization and improving the care they provide. With assistance from Access and its Peace Corps Volunteers, funding from Appropriate Projects, and the initiative and leadership of the health center titulaires, sinks were finally installed and connected to running water at both health centers, thereby eliminating previous practices of hauling water by bucket and sporadic hand washing.
The projects were organized and executed by Peace Corps Volunteers Colleen Laurence and Kara Rogers in coordination with the Rwamagana District Health Advisor, Charles Ngirabatware. The volunteers worked with Appropriate Projects, an initiative of Water Charity, to coordinate the funding of each project. According to the description on their Website, Water Charity aims to complete small but critically important water and sanitation projects working exclusively with Peace Corps Volunteers serving throughout the world. They mandate that each project present a complete solution to a problem, use appropriate technology, finish quickly, and cost no more than $500.
At Ruhunda, the project outfitted both the general and pediatric consultation rooms as well as the delivery room with sinks. Similarly at Musha, the consultation, pharmacy, surgery, and pediatric rooms received sinks and were connected to the local water source. From start to finish, the projects took on average two months to finish, and the positive results were visible immediately. A combined population of 22,167 people from the cities of Gishari, Munyiginya, and Ruhunda (all served by the Ruhunda Health Center) and 15,432 people within the Musha Health Center catchment area now receive a higher standard of care when they visit the local health center. In follow-up visits after the conclusion of construction, nurses and technicians applauded the improvements and noted an unexpected benefit from the water project – namely, their health had improved as well!
During the application process, Gerard Kaberuka, Titulaire of the Ruhunda Health Center, said, “Everyone knows that water is the source of life. If we receive water, then we receive life. Water will decrease disease prevalence and improve the quality of services offered at the center.” Now, thanks to Water Charity, water flows freely and life blooms in a healthy environment at Ruhunda and Musha.
Since first writing, several other projects to install internal running water in health centers have been organized and completed by Peace Corps Volunteers in conjunction with Water Charity. Jessica McGhie facilitated projects at three separate health centers in the northern Musanze District to install running water in the hospitalization, consultation, and pharmacy services at two centers and pipe in and treat the water at another. Similarly, Colleen Laurence has just completed her second project at the Murehe Health Post in Rwamagana District which installed sinks in the maternity, consultation, and laboratory services and connected them to the on-grounds water source. Her colleague in Rwamagana, Jenny Boyd, is currently working with the staff at Rubona Health Center to install water in their maternity, consultation, and laboratory services. The combined impact of these projects will affect the over 125,000 people who seek care at these health centers.
Friday, July 9, 2010
Sunday, April 18, 2010
Cow Eyes, Intore Dances, and Searching for Milk - The Untold Story of Cows in Rwanda
A copper cloud of dust kicked up from the tires as our truck pulled itself up the steep hill towards the Muyumbu Health Center. Every few minutes, Anatole, our driver, would swerve to avoid the gaping potholes in the road and the yawning precipice which bordered it. Originally, these drives to rural health centers were a bit of a bother, but, by this point, I was unfazed by the constant jostling and, instead, used the time to catch up on sleep or debate politics with Charles. In this sense, the day was like any other.
It was a Wednesday morning, and we were running late as usual. I was dozing in the back seat as we zoomed over the steep terrain. Suddenly, the car lurched to a stop so quickly that my head banged into the front seat. As the dust settled, I rubbed my forehead and hastily scanned the perimeters of the truck. Did we run over something? A goat? A small child? “Charles, what happened?” I asked, still looking around. He was unresponsive, gazing out the window. “Charles, qu’est qui se passé?” I demanded, wondering if he had understood my harried question in English.
“Look.” That was all he said. I followed his gaze to an adjoining pasture which I hadn’t noticed in my frenzied search. There, over 30 long-horned, Ankole cows grazed in blissful ignorance of our white truck and its gawking onlookers. “We stopped for cows?!” I asked, not meaning to shriek in the process. The higher octave must have caught Charles’ attention because he then turned to me and proceeded to patiently explain the merits of each respective cow, noting their color, the size and shape of their horns, and their thickness and breadth. While this educational session didn’t calm me as Charles had perhaps hoped, it did serve another purpose, as a useful introduction to an element of Rwandan culture to which I previously hadn’t paid much heed before our drive-by cow-gazing that day.
This episode took place about three months ago, but since then I have been witness to several other moments when Rwandans displayed an almost undue reverence for cows. Instead of going to a country home or lake house for the weekend, I visit people’s pastures and cows; neighbors offered me gifts of cow butter when I first arrived in Rwamagana; and when lusty men try to woo me, they call me “cow eyes.” (Charming, right? You boys in the US could learn a few lessons from your African counterparts :P) In any case, through conversations with Charles and other Rwandan friends, I eventually came to appreciate their attitude towards cows and how it developed.
Long-horned cows or inka are woven into the fabric of Rwanda’s history, culture, and language even though they are actually an exotic species to region. Cows were introduced to the fertile Great Lakes region early on by traders and thrived in the environment, unique in Africa for its ability to host grazing livestock. Inevitably, cows became important fixtures of life in Rwanda, and their significance continues to this day. Not only do they provide milk and other dairy products critical for sustenance, but they also have symbolic importance in Rwandan culture. It’s difficult to e
scape them; cows are everywhere, physically and figuratively. When visiting a friend or family, you often sit down to share news over African tea (milk and tea with ginger); in dances performed at religious and cultural events, the women rhythmically sway and throw up their arms in a graceful V-shape, palms outward to mimic the slope and curve of cow horns; and, when I first arrived in Rwamagana, old women routinely asked me, “urushaka amata?” (Do you want milk?), sly smiles playing over their lips. I was always hesitant when responding to this question but, out of politesse, usually said yes. At this point, the women would always throw up their hands in a “Thanks be to God” salutation and call for their eldest son. I eventually figured out that “urushaka amata?” had a double meaning – are you looking for a husband? Needless to say, I don’t accept milk as often as I once did now.
Cows are also used as an informal currency in Rwandan culture, and the number of cows attributed to an individual is often used to gauge that person’s stature in the community. Once, towards the beginning of my service in Rwanda, Charles shyly admitted that he had over 20 cows at his pasture in Gisenyi and invited me to come visit them sometime. As I made more connections, I met more individuals who seemed similarly abashed while divulging the number of cows to their name. Eventually, I realized that these seemingly modest admissions of wealth were not modest at all, but a way to slyly establish their position and power in relation to others without overtly bragging.
In a culture which so glorifies cows and the stature they confer, it’s easy to see how this system could be manipulated to create and/or sustain a hierarchy. In fact, this is exactly what happened when Belgian colonialists assumed control of the Ruanda-Urundi region from the Germans in 1923 following the conclusion of World War I. Before Belgian’s began their governance, ethnic identity was a much more fluid concept. The Tutsi-Hutu distinction was not determined based upon physical appearance, as the Belgians preferred to believe and eventually instituted, but rather by the number of cows one possessed. The prevailing class system featured a minority Tutsi upper class and lower classes of Hutus and Tutsi commoners; however, one’s Tutsi-Hutu designation could change depending on the number of cows he or she acquired. For example, a Hutu pastoralist who attained a significant number of cattle would come to find himself and his family considered Tutsi.
The Germans and Belgians co-opted this economic system to create puppet rulers of the Tutsis, using Hamitic theory as its religious support. Individuals with 10 cows or more were labeled as Tutsi, issued an identity card, and educated through the public education system creating an educated Tutsi elite. Conversely, all those with 9 cows or less were labeled as Hutu and systematically disenfranchised by Belgian colonialists and the Tutsi class of rulers. In 1926, the Belgians also abolished the local posts of “Land Chief,” “Cattle Chief,” and “Military Chief” which further stripped Hutus of any local power they might have had over the land. Eventually, the labels which were originally economic in nature (akin to our labels of blue collar and white collar perhaps) became forever attached to physical traits.
It’s April - Genocide Memorial Month in Rwanda - and during this time of searching reflection and remembrance, I can’t help but wonder how the genocide would have been different or even if it would have occurred at all had these labels not been manipulated. Would the original economic divisions between Hutus and Tutsis have fomented into mass genocide as well or might they have found outlet in some of the socialist movements which gripped Africa in the wake of independence? But these “what if’s” are useless in retrospect. They do not heal the physical and mental wounds left by genocide nor do they address the very real issues of living and working in this developing country…of preventing this still very stratified society from shattering yet again.
Some believe that cows could still help this divided society even as many revile them as part of the problem. In 2006, President Kagame instituted a program to distribute cows to 250,000 of the poorest households at absolutely no cost. His hope and that of the Ministry of Agriculture and Animal Resources is that the cows will help support low-income households through milk and manure production. Heifer International also has an active presence in Rwanda and, since 2000, has been working to distribute cows throughout communities as part of their “Fight For Peace” initiative. When Heifer provides a family or household with a cow, they also educate those individuals about zero-grazing technology, better breeding practices, and conflict mediation techniques.
And yet while some, like Paul Kagame and Heifer, seek to increase Rwandans’ access to cows, others aim to limit it. It’s interesting to examine some of the compelling efforts at present to modernize Rwanda’s economy. The organization One Acre Fund is working in several districts to measure the actual worth of cows – the foodstuffs which they produce, their social value, and their monetary value at the time of sale versus their buying price. Though they are still in the process of conducting their evaluation in several districts, the results from some completed surveys reveal that, in general, “cows are not worth their fat.” The money which people use to buy, feed, and keep cows is not equivalent to the money and stature received in turn, especially for those small-scale and subsistence farmers who are only able to keep one or two cows at most. One Acre Fund argues that the money spent on cows would be better spent on education, health, and improving agricultural practices. One of my closest friends here, an English Education volunteer in Cyangugu, is working with Once Acre Fund’s campaign to educate Rwandans and help them to reevaluate the worth of their cows compared to health insurance, school fees, and nutritious food. It’s difficult work, she confessed to me, but she has faith that the “right” priorities will eventually prevail. Honestly, I’m a bit conflicted on the subject of livestock aid and am inclined towards the skepticism of One Acre Fund till proven differently.
Some of my language facilitators during training seemed similarly convinced that owning and obsessing over cows was a passé practice and that the importance of cows in Rwandan culture would fade as individuals confronted the necessities of modernization. Perhaps there is some merit to their claims, but, in speaking with my best friend, Janet, she seemed equally insistent that Rwandans would never fully free themselves of their ties to cows. I also asked Janet, who was recently engaged, whether she would accept money in lieu of cows at her dowry ceremony. She seemed affronted by the idea and immediately nixed any possibility thereof. According to her, when a family gives the bride’s family money in exchange for her hand, it is akin to selling her whereas if they give cows, they honor her and her family. Not being Rwandan, both practices seem terribly antiquated to me, but a small part of me (the anthropologist inside) wishes that Rwandans still practiced their previous custom in which a male member of the bride’s family took a spear and threw it as far as he could in the bride-groom’s pasture. According to tradition, all the cows between that male and the place where his spear landed would be apart of the dowry and herded from one pasture to another in an elaborate ceremony involving both families.
Alas such ceremonies are untenable now, but, at least for the time being, cows remain entrenched as both figurative and literal presences in Rwanda, and I hope this doesn’t change any time soon. Honestly, I’m not ready to wave goodbye to this cow-crazed culture just yet. I mean, where else can I use the insult I just learned? Kunnywa cy’inka. Roughly translated, “shit on your cows.”
Friday, February 12, 2010
A Different Battle Cry for Aid
Ensconced between folds of gently rolling hills in rural Rwanda lies the Ruhunda Health Center. This clinic is fairly typical by African standards. Cows graze in the adjoining pasture; mothers and tired children wait in negligibly clean, open air sitting areas; and staff members support operations in the maternity and general consultation wards by running buckets of water from a pump outside. It’s no Beth Israel or even Patient First in America, but it is suffices, meeting the needs of the 22,167 people whom it serves in the villages of Gishari, Munyiginya, and Ruhunda. To them, the clinic is merely an extension of their daily reality - poverty - and there is little which they can do to change that.
At Ruhunda, patients can access a range of services, including maternity, general consultation for children and adults, minor surgery, family planning, vaccination, and voluntary counseling and testing for HIV, among others. The center also runs a successful community health worker (CHW) program which trains Joe Schmo Rwandans to go into communities and conduct information sessions on a range of health topics.
A cursory review of the facilities and programs in place at Ruhunda would yield a positive review in the eyes of many a Rwandan health official. They would interpret the above description as evidence that Ruhunda is a self-sustaining health center. But they would be wrong. Oversight and planning of any kind is minimal. Reform is needed to improve the quality of care offered at Ruhunda and the countless health centers like it, but change won’t originate in top down Rwandan reform or by peasant uprising. Nor can we entirely rely on staff members who are too consumed by processing patients quickly and day-to-day survival to be the whistle blowers. There can be no doubt that the Ruhunda Health Center is in great need of additional reform and aid. The real question is what type of aid do they need most.
Different people would answer this question differently. Jeffrey Sachs might visit Ruhunda and proclaim the need for increased bed net distribution to allay the high prevalence of malaria, one of Ruhunda’s most frequently-treated afflictions. If Bono trekked out to Ruhunda, he might lobby for increased ARV monitoring and distribution as the keys to success. Scarlett Johansson would probably talk about malnutrition, kitchen garden demonstrations, and maybe a de-worming campaign. And me? What is my recipe for improvement at Ruhunda? An annual budget plan, drug requisition formulas, and a modem to update antivirus definitions on the center’s three out of four functioning computers. This, my friends, is the less sexy, but equally important aspect of development work.
Allow me to clarify. I say “sexy” because concepts like financial management and data processing do not pull at the heartstrings like AIDS orphans or school fees. Terms like these will never grab headlines and will forever struggle to grab the attention of most development workers. And yet these issues are equally as important and influence the quality of service for patients with illnesses like malaria, AIDS, and malnutrition. How can a health center with no annual budget in place afford to plan vaccination campaigns, buy or replace equipment, or even pay its staff? If the pharmacy is stocked out on mebendazole, how will they treat 5-year old Esperance who has contracted ascaris worm and subsequently suffers from malnutrition? Indeed, how can a center expect to achieve progress on any front if they fail to accurately record and analyze monthly data? This is what The Access Project and I, as a member of this organization, strive to improve each day.
Peace Corps assigned me to The Access Project – a project run out of Columbia University and The Earth Institute - in early December. In the beginning, I had only a vague idea of the organization and its goals. “They focus on macro-level management and infrastructure issues,” I told people, not really knowing what I meant by those words. But my friends seemed to buy it, nodding their heads knowingly in response. I bought into this hazy idea too, intrigued by the prospect of working on big picture issues after concentrating so heavily in health education on the ground in Mauritania.
After a few weeks in “the field” - traveling to remote health centers, interviewing staff members, and surveying record books and general conditions - the heretofore fuzzy objectives of The Access Project became increasingly defined. Suddenly, I was cross-checking health metrics data, brainstorming methods to streamline insurance information, and admonishing health center directors to purchase internet modems. In between, practicing English with every other Rwandan, of course. Suddenly, I understood how useful a business mentality could be if applied to the health system. Each of the centers I visited was functioning below its optimal capacity because of poor management and/or lack of obvious incentive to change its current practices. Believe it or not, the resources and money were there; all they needed was a little training, a push or, more likely, a shove in the right direction, and, most importantly, a change in mindset about their responsibility to provide the best care possible…which is where my work begins.
Each day, my fellow team members and I drive 30 minutes, 1 hour, 2 hours out to health centers tucked away in remote corners of the district. Our team of four consist of Anatole The Hun, our driver; Charles “The Strongarm” Ngirabatware, former politician and head of Access in the Rwamagana District; our resident number cruncher and erstwhile bookie, Pascal; and yours truly, the supposed tech guru (laughable, I know). You’ll have to pardon the nicknames; I like to pretend that our cadre is a highly-specialized team akin to the one amassed by Ethan Hunt in Mission Impossible, just without the marshal arts and bloodshed. It spices up long drives.
When we arrive at the health centers, the act ends, and we all set to work on our respective tasks. Pascal meets with the accountant and/or the insurance manager to discuss budget plans, review financial records, and check insurance enrollment. Charles discusses necessary improvements in infrastructure, planning and coordination, and human resources with the center director. He also steps in whenever Pascal or I need help applying pressure or, in my case, translation in one of our sectors. Officially, I split my time between data management and IT, but, more often than not, I end up teaching Excel 101, virus prevention, and how to use System Restore to rooms crammed with administrators.
Crowding around a beat up laptop, we wile away hours on end, experimenting with different formulas, plugging data into graphs, and reveling in the mystery that is file creation. On slow days, I start scanning all computers at one time and reward the staff member with the lowest number of infected files. They love to mock the person with the most computer viruses; it’s an interesting spin on peer pressure. In those sectors which record information electronically like Finance, Data, and Insurance, I stress weekly and quarterly data back-up. I never thought I’d derive as much pleasure from IT as I did from health education, but I do. The joy on Victoire’s face when she master’s graph creation in Excel is the same as Aminetou’s when she learns how to convince others not to use skin lightening cream.
Some might perceive my IT and data management lessons as a drop in the bucket in terms of effectiveness, but I know they’re not. I’ve seen the results – the spike in efficiency and tech comfort, the greater care afforded equipment at the center, the increased awareness and response to predominant health issues among health center staffs. This is the less sexy side of aid at work. If you’d like learn more about the efforts of The Access Project, you can read up on them at www.theaccessproject.com. I am also in the process of applying for a grant to install running water in the maternity and general consultation rooms at the Ruhunda Health Center. If you’d like to donate to my specific project, wait a week and then look for it at http://appropriateprojects.com.
Applying MBA practices to health care management is not a revolutionary thought in the world of international development. In the wake of massive, billion dollar aid programs which produce mediocre results, academics and practicians have long hailed the need for increased oversight and application of a business-like mentality to development work. “Reward results, not grandiose plans!” they cry. I get it. Now, I understand their arguments in a very real sense. Only, my battle cry is a bit different and, again, not as catchphrase-worthy. If I yelled, “Improved efficiency, monitoring, and management!” into the LiveAid crowd, I would probably get a few polite claps, some confused shrugs, and the overwhelming sound of crickets. But it’s true. We need to focus on the managerial and systemic roots of certain problems in order to improve the overall quality of care and response to those big name diseases. (In America too!)
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