Post 21. Over and Out

August 9th, 2011 by Chantelle

In just a few hours we will be cramming into the car and driving 2000km due north to the Yukon for 3 weeks of hiking in a tiny corner of Canada’s immense northern wilderness. 20kg of dehydrated food, 4 topographical maps for route finding and brand new neoprene socks for river crossings.

Needless to say, we are not in Kansas anymore. Or Chad, as the case may be.

Grant and I finished our mission and arrived home one month ago and it is amazing what a little time and distance can do. For Grant, he has been able to catch up on his sleep, finally calm his reeling mind, and gradually inch back up to his pre-MSF fighting weight.

For myself, this perspective has helped to put a more positive slant on all that I saw in Chad. There are a few major points that remain insoluble in my mind – the perceptions and practicing surrounding the role of women, the quality and accessibility of education, and the increasingly harsh and inhospitable natural environment, for example. However, I can now look back on my 9 month and see glimmers of hope. We worked with some incredibly competent senior national staff – both male and female. We also collaborated with very motivated and engaged Ministry of Health representatives. MSF is now partnering with a local organization to address female genital mutilation. Outside of our own projects, we witnessed a presidential election that, although effectively had only one party, was calm and uneventful. In fact, the overall security context was calm throughout the entire 9 months. That in itself is a fundamental precondition for any other development or progress and represents a major change from previous years.

Grant proudly describes his time in Chad as intense, challenging yet satisfying and is bolstered by the continued good work that MSF is doing in the country. On the other hand, when I was asked about my favourite moments in Chad, I replied tongue-in-cheek with “mango season, discovering the epilady and a cycling vacation in France”. Fortunately, time and distance has eased my cynicism and revealed to me threads of hope that I am slowly weaving together.

There is no Wizard of Oz to magically provide all the country needs to be successful, but there are some amazing individuals and organizations – insiders and outsiders – that have the heart, the brain and the courage to try.

Post 20. FGM

June 28th, 2011 by Chantelle

It kills me to have to write this blog.

On a personal level, the whole reason why I am here is to chip away at my own ignorance and try to understand all the perceptions and misconceptions, realities and reasonings that make up this place that so kindly hosts me.   Both in my own mind and in the minds of whoever has the patience and interest to follow my bumbling journey, I want to break stereotypes and foster understanding.

In this particular case, however, I remain eons away from any sort of understanding.

Female genital mutilation.  Those three words should never be found in the same paragraph, let alone neatly abbreviated to the common acronym of FGM.  Sorry – I can’t abbreviate it.  FGM rolls off the tongue too easily; but the words “female genital mutilation” slap me in the face every time I read/write them.

According to the Female Genital Mutilation Network, the practice is most common in counties such as Somalia, Guinea, Egypt, Sudan and Mali, all of which have a prevalence of over 90%.  The WHO reports that worldwide, between 100 and 140 million girls and women are living with the consequences of female genital mutilation, with 3 million new cases per year.  Most often girls from 4 to 14 years of age.

WHO describes 4 different categories of female genital mutilation:

  • Type I: Clitoridectomy – partial or total removal of the clitoris
  • Type II: Excision – partial or total removal of the clitoris and the labia minora, with or without excision of the labia majora
  • Type III: Infibulation – narrowing of the vaginal opening through the creation of a covering seal, formed by cutting and repositioning the inner, or outer, labia, with or without removal of the clitoris.
  • Type IV: Other – all other harmful procedures to the female genitalia for non-medical purposes, e.g. pricking, piercing, incising, scraping and cauterizing the genital area.

You can only imagine the list of health risks that accompany this mutilation.  Immediately following the procedure there is risk of infection, severe bleeding, tetanus, and urine retention.  Not to mention pain.  In the longer term, there is the risk of recurrent urinary tract infections, cysts, infertility, childbirth complications and newborn deaths.

Female genital mutilation obviously has no health benefit for the girl whatsoever; rather its justification is purely cultural.  UNICEF lists the following factors perpetuating the practice:

  • Sexual – to control or reduce female sexuality by reducing libido and sexual enjoyment; to ensure virginity and fidelity.
  • Sociological – as an initiation for girls into womanhood, social integration and the maintenance of social tradition and cohesion.
  • Hygiene – where it is believed that the female genitalia are dirty and unsightly.
  • Health – in the belief that it enhances fertility and child survival.
  • Religious – in the mistaken belief that FGM is a religious requirement.

Increased sexual pleasure for men, family honour and an income source for those performing the procedure are also frequently listed as contributing factors.

A survey in Chad in 2004 found a prevalence of 45%.  Type II was found to be commonly practiced across the country, while Type III was limited to the border area with Sudan. However, in the MSF supported maternity ward in Am Timan, seeing a woman without mutilation is the exception, suggesting that the prevalence might be higher in Am Timan than reported by the 2004 survey. Most often just the clitoris is removed, but the remaining scar tissue is so thick it requires significant incisions to deliver the baby.

As MSF, we treat the medical consequences, but we are aware that actions going beyond the medical sphere, involving all the local leaders, are required. This limited role is hard for the team here in Am Timan to swallow, particularly those of us with our own clitorises, perfectly intact. As an innovative initiative to rectify this impasse, MSF is planning to partner with a well established Chadian NGO who will train, sensitize, and inform in an attempt to reduce the phenomenon.

Many of my male Chadian colleagues openly balk and laugh at me when I suggest the possibility of equality between men and women and are appalled when I tell them Grant makes pancakes for me on Sunday mornings.  While I am amused by this light-hearted banter, the profoundness of their sentiments strike me silent whenever I think of that simple little abbreviation,  F.G.M.

References
UNICEF
World Health Organization
Measure DHS
Female Genital Mutilation Network

Post 19: All about ME!

April 29th, 2011 by Chantelle

Well, enough about all the wonderful things that everyone else is doing here in Chad….let me tell you about all the wonderful things I have been doing lately.

As you may recall, I am the Watsan for the mission – responsible for water, sanitation and hygiene.   Burning garbage, emptying latrines, surveying drainage paths, testing water pumps, “training” (ie. begging) people to wash their hands…..not what you think of when you think of ”Médecins Sans Frontières”, but nonetheless an important part of MSF’s activities and what I do every day.

In 2010 there was significant flooding in the Am Timan area and a many latrines in the community collapsed and have not been rebuilt.  As part of the flood response, MSF is working with the community to construct 120 latrines to replace the fallen ones.  So, let me walk you through it…

The beneficiaries themselves provide the manual labour…starting with the digging of the pit.  120cm across and up to 350cm deep.  If it is hot and sweaty standing at the top of the pit looking down, it is a million times worse standing at the bottom of the pit looking up!  I can attest to that.  44oC in the shade.  Not 44oC in the sun!

I have hired a small but growing legion of local tailors to sew sandbags to use to line the latrines…..about 12000 of them.  They are making a mint off this program!

Of course the sandbags then need to be filled with dirt (NOT sand, as you may logically think)  Young and old – fun for all!  About 150 bags per pit.

….and then pounded into the walls of the pit.  This lining will make the pits more resistant in the rainy season and prevent their collapse.

We usually attract quite a bit of attention as we labour over our latrines…. Women, children and the odd camel caravan gather around to watch us work.

Myself and Hamza, one of my three community supervisors, after a long, hot, sweaty day of laying sandbags.  (I’m the one on the right.)

We have set up a small latrine slab fabrication site where our chief mason and his 4 assistants make 8 concrete slabs per day.  It is a 150cm diameter self-supporting dome-shaped slab with no rebar.  I know, I know – I was hesitant at first.  But we test them with 6 people standing on them and if they don’t break, out they go!  All according to the do-it-yourself latrine book.   Incha’Allah!

Then we load the slabs one by one onto a horse cart, complete with wood and fencing, and send them off to be installed.  This very persuasive cart driver somehow convinced me to pay him 3500 CFA, or 7 dollars, to haul one load to a particular neighborhood.  Sure, it is farther than the other neighborhoods and you have to cross the sandy riverbed…..Am I getting ripped off????  I’ll never know.

And voila!  Happy, happy latrine owners!

Post 18. More Fistulas!

April 11th, 2011 by Chantelle

In our last mission in the Democratic Republic of Congo, I wrote extensively about our fistula campaign. A vaginal fistula results from prolonged and obstructed labour, when the baby’s head pushes against the wall of the vagina for an extensive period of time, cutting off circulation to the tissue, which then dies. The resulting hole, when left unrepaired, leaks a steady stream of urine, leaving the woman wet, stinky, and prone to infection and a host of medical complications. They are often abandoned by their husbands and isolated from their families and communities.

In the DRC, 80 women were rounded up from surrounding villages and brought to our swelling hospital to undergo surgery to repair their fistula. Many of the women we treated had suffered for years with this condition. This was the 4th fistula campaign MSF had conducted in the region, and due to overwhelming need, it was followed by a 5th and perhaps 6th.

As a non-medic, I was first of all quite surprised how entire dinner conversations could focus on female sexual anatomy without the blink of an eye. As the campaign got underway, I was awed by the precision and technical wizardry of our German surgeon who could reach into the depths of a patient and stitch up a hole or rebuild the vaginal wall, essentially by feel alone. However, what most impressed me and what moves me to this day, was the instant, profound, and permanent change this surgery has for the woman, her disposition, her spirit and her life. It is really like giving her back her soul. The tents where the women stayed for 3 months were a haven of solidarity, hope, anticipation and rebirth.

Here in Chad, the problem of vaginal fistulas is no less severe than in the Congo. There is often little provision of health care and many births take place at home. It is frequently too late when, and if, women try to come to a health centre or hospital. This is compounded by the young age of many of the mothers and the prevalence of female genital mutilation.

Poster for the MSF fistula program in eastern Chad

Poster for the MSF fistula program in eastern Chad

MSF’s strategy in Chad, however, differs from that in Congo. Instead of an annual campaign, MSF has a permanent fistula program, housed in a regional Ministry of Health hospital. A team of outreach workers is constantly combing the countryside looking for women with fistulas. Patients are brought to MSF’s “Women’s Village” in the hospital where they prepare for surgery, undergo the procedure, and spend weeks in physiotherapy, relearning how to control their bladder, for example.

All of this had absolutely nothing to do with Grant and I until the fistula outreach workers came to Am Timan to train our own community health workers and our maternity staff how to identify and refer fistula patients to their hospital. This sensitization was so successful that within 24 hours they had 7 patients to take back to the hospital with them. In the 3 weeks that followed, 7 more patients were sent and another 6 are lined up and ready to go. Grant now spends a small part of each week coordinating transportation to fly patients to the hospital and we just had a dozen pairs of ultra absorbent underwear fabricated by a local tailor to make sure they travel in both comfort and style. Go ladies, go!

Post 17: The Wizard of Chad

March 28th, 2011 by Chantelle

On a 7 hour car ride straight north into the expanding reaches of the Sahel desert, I try in vain to snooze in the back seat.  Every now and then, I open my eyes to the marvels of a camel caravan as it crosses the sea of sand, methodically and purposefully.   Both the method and the purpose are lost on me and leave me in awe.

Kodjo sits in the front seat, staring out at the same sand dunes.  However, while I am in and out of awestruck slumber, he is mentally elaborating a project proposal to turn our little nutrition tent in the desert into a fully functioning, secondary healthcare project, complete with a hand-over strategy for the end of the 2-year project period.  A full proposal is at headquarters in Berlin by the time Kodjo goes to bed.

He warns the team that the plan may not be approved by headquarters….but everyone knows the power of both his conviction and his persuasion.  We collectively dismiss his caution while digesting the implications for both our personal work load and the impact of the project on the neglected population it aims to serve.

Mothers registering their children outside of our little nutrition tent in the desert.

In the past 6 months, our MSF team has completed 2 emergency nutrition projects, 2 emergency cholera interventions, and an emergency meningitis vaccination campaign, as well as the development and expansion of 3 longer-term primary and secondary health projects, and the closure of a remotely operated project in the more perilous east.  The expat team has swollen at one point to over 40 people and the total 2011 budget tops out at over 5 million Euros….and growing.

And the man behind it all…Dr. Kodjo D Edoh, Head of Mission for Chad.

Kodjo (right) with the president of the MSF International Association, addressing national staff at the annual Field Associate Debate.

Kodjo is from Togo (between Ghana and Benin, if that helps you at all) and was working as a General Practitioner in the public health sector in mid 90s; a time when healthcare was fully subsidized and free for all.  However, the Togolese healthcare system was not spared from the wave of neo-liberal economic policies that swept through parts of Africa, slashing social programs and implementing user-pay systems.  He now had to charge his patients for what used to be free care, and refuse those who could not pay.

Unable to rectify these economic constraints with his moral medical obligations, he left Togo to pursue a Masters Degree in Hospital Administration, in New York, with an eye to future employment in the UN or WHO.  An MSF flyer in his mailbox successfully tempted him to take a break from his studies; a 6 month stint in Uganda to boost his resume and serve as a stepping stone to the both noble and well-paid positions of the international health organizations.

8 years later, he is still in the field with MSF and now uses his position as Head of Mission to lobby those same UN agencies he once aspired to – pressuring them to respond to the needs he sees in the field.

To call him ambitious, passionate and inspirational would be a hat-trick of an understatement.   He says his role as Head of Mission is to inspire his team and indeed any meeting you have with him leaves you feeling excited; like an important piece of something much greater than yourself.  He also says that MSF’s greatest asset is passion; the passion of its people.  This is what defines us and allows us to achieve anything that we achieve.  As for ambition, what he likes most about MSF is that anything is possible.  Strategies, projects and programs are all driven by the people on the ground and based on the needs that they see.

So with all that at the helm, we will just see what happens to our little nutrition tent in the desert.

 

Post 16: Congolese Courage

March 17th, 2011 by Chantelle

Guillaume is one of five Congolese expats currently working in our Chad program – two doctors, two nurses and our interim Medical Coordinator.  Like the Canadians, the Congolese easily outnumber any other nationality here.  Unlike the Canadians, however,  these stats results only because MSF has had a long, expansive history in the Democratic Republic of the Congo, responding to waves of conflict in far-flung corners of the vast country.  The Congo has long claimed MSF’s largest presence in any country.   The upside is that MSF has had the opportunity to recruit, train and expatriate numerous highly competent, French-speaking doctors and nurses, to the benefit of many other missions.

Guillaume (left) and fellow Congolese doctor, both receiving Chadian soccer outfits in the Am Timan Christmas gift exchange

Guillaume was privy to much of what has justified MSF’s presence in eastern Congo.  He is from South Kivu province, which borders with Rwanda and is home to the continuing aftermath of the 1994 Rwandan genocide.  In the chaotic years that followed, Congolese villages were attacked by rebel groups, child soldiers recruited and women raped, causing much of the population to flee into the forests.  They eventually organized themselves into militia groups to defend their villages, but also used the pretense of self defense to commit rampant banditry and further terrorize each other.

Guillaume himself walked 900km in 20 days to escape the first attack on his city in 1996.    After returning home to looted property and destroyed neighborhoods, the residents vowed never again to leave.  In 2004, the city was again controlled by rebels for several weeks and Guillaume’s own home unsuccessfully attacked.  Blocks of houses were surrounded by rebels and everyone within systematically raped.  As a doctor, he was working in an HIV clinic and counseled those same rape victims who showed up in his clinic for testing.   Some of them, his neighbors.

Guillaume began with MSF in 2005 as a consulting doctor in a 3000-patient HIV project , worked his way up through the Supervisor and Medical Team Leader positions and ultimately became the Assistant Medical Coordinator in 2009.  Having already assumed many of the responsibilities normally given to an expat, he was a likely candidate for expatriation and, in 2010, he completed all the necessary steps.  He joined the Am Timan project in Chad in October as a medical doctor.  As the “first missioner” status is obviously in theory only, his experience and expertise has quickly cast him into the role of Medical Team Leader and among other things, he is overseeing the development of our own TB/HIV program.

What Guillaume likes most about working for MSF is that the priority is on quality of care and availability of resources for the patient.  After this mission, he would like to gain further MSF field experience in a large TB/HIV project, and then aspires to future posts as a Medical Coordinator.  If MSF is lucky, he might just be a lifer!

Guillaume doing rounds in the Am Timan pediatrics ward

Post 15: International Women’s Day

March 8th, 2011 by Chantelle

Is it really International Women’s Day if you have to wear a skirt to
participate??

Post 14: Wise Woman

March 1st, 2011 by Chantelle

The French word for midwife is “sage femme”, which translates literally as “wise woman”.  Nothing could better describe our sage femme here in the Am Timan, the expat supervisor for the maternity department.

Born in Kenya in 1956, Marisa considers herself of the “post-colonial generation”, having witnessed both the triumphs and tragedies of successive post-independence governments.  Of these, she sees the provision of free primary education in her home country to be a major triumph; its annulment in the late 1970s a far-reaching tragedy; and its reinstatement in 2003 an absolute necessity.  She herself benefited from free education, as well as from parents who valued it enough to ensure all 8 children, including the 3 girls, went to college.

After studying nursing and midwifery, Marisa spent 13 years working with the Kenyan Ministry of Health in various national, provincial and district hospitals and health centres.  In 1993, feeling frustrated with the lack of resources available to provide a minimum level of care to her patients, she left the public sector and moved into the NGO world.  She worked for 10 years with different international organizations in Kenya, vaccinating babies and training traditional birth attendants.

Unlike many African expats, Marisa did not work as a MSF national staff prior to being hired as an expat.  She clearly had an abundance of experience and was hired directly as an expat through the Nairobi recruitment office in 2003.  She was promptly sent to Congo-Brazziville for her first mission and has been catching babies for MSF ever since.

And somewhere along the way she became an outrageous Micheal Jackson fan.

Marisa doing the moonwalk at the Christmas party.

Marisa pours her mind, heart and soul into all her work, whether cradling newborns or making the schedule for her hygienists; however, a piece of each remains in her home village in Kenya.  For the past 5 years, Marisa has been personally sponsoring the education of 10 girls – 1 in primary school; 7 in secondary school and 2 in university!

Her recently started foundation was inspired by her mother, who, at 77 is one of few women of her generation who can read and write.  Her mother keeps close tabs on the girls in the community, identifying those who may need assistance and advising Marisa about their progress.  Marisa says that she is blessed to be a woman in an African country who has received education and wants to give that chance to other girls.

There are three “Western” women in our project – myself, a quirky Quebecois and a bubbly Brit.  The stories from Marisa’s delivery room that she quietly recounts baffle us, stupefy us, and more often than not, evoke the raging feminist within.  Stories of young women with numerous children, having undergone female genital circumcision as a child, and suffering from various unnecessary birth complications.  Like the rest of us, she deeply laments the suffering of many of the women she sees every day.   Here in Chad, she can ensure they have a safe delivery and send them on their way.  Back home in Kenya, she is cutting deep to the root of the problem.  Her project to educate the girls of her village is the hope that I so often fail to find here in Chad.

Marisa may not be a raging feminist, but she is one hell of a sage femme.

Marisa at work in the maternity ward.

Post 13: Meet our African Expats!

February 14th, 2011 by Chantelle

In MSF, we are thrown into situations that, in the short slice of time that we witness, seem quite bleak and often hopeless.  I am slowly understanding that this outlook results more because we automatically compare what we see to what we know, whether that is the comforts of home or previous international abodes.  We are usually not capable of comparing what we see to what we would have seen 2, 5 or 15 years ago, or what we might see 2, 5 or 15 years into the future.  These comparisons just may be a bit more uplifting.  While I can appreciate this intellectually, human instinct prevails and I have to consciously seek out sources of progress, of change and of hope, in order to keep positive.

One thing that always provides a source of hope is our African expats.  These are doctors, nurses, logisticians and administrators that have worked with MSF as national staff in their own countries.  After several years, they were hired as an expat, given much more responsibility and a managerial role, and sent off to other hot spots to work with the international MSF teams.

The profoundness of this didn’t strike us until we arrived in Chad and found ourselves surrounded by African expats.  Congo, Burundi, Ivory Coast, Togo, Guinea…..our colleagues represent a chronology of conflict and humanitarian aid across this continent.

This wealth of African expertise and competency lies in stark contrast to what we see here in Chad.

Within MSF, Chad is known for “challenging HR”.  Among a litany of other grievances, the difficulty in finding qualified national staff plagues many of our projects.  Here in Am Timan, we struggle to run a hospital with a perpetual shortage of local doctors and midwives.  But what is a practical challenge for MSF is deeply troubling issue for the country as a whole.  A poor education system and lack of professional capacity does not bode well for the country’s future.

However, my expat African colleagues also come from troubled countries that have at one time or another gone through terrible conflict, periods of economic stagnation and regression, often cursed by corruption and plagued by poverty.  But, out of that have emerged these amazingly competent, professional, dedicated, and passionate individuals.  They bring to the team a deeper understanding not only of the tropical pathologies and parasites our Western medics have only seen in textbooks, but a deeper understanding of the cultures, psychologies and contexts that the majority of us are completely oblivious to.  They indeed enrich all aspects of our work, and of our own personal learning.

So what I see in Chad is not representative of all of Africa.  And what I see now is not representative of what I may see in the future.  There is in fact hope and the MSF African expats are only one of surely many many examples.   So let me introduce you to them!

Post 12: Nutrition II

January 26th, 2011 by Chantelle

A nutrition program is a bit different that other medical programs in that the patients don’t necessarily feel sick.  They may not even feel hungry if there is something in their belly, nourishing or not.  So, in many cases we have to go find them.  We have teams of Community Health Workers who comb through the villages every day, visiting each house.  They round up all the children under 5 years old, poke and prod a bit, pinch their skin and watch it rebound.  Most importantly, they do the MUAC test: the Mid-Upper-Arm-Circumference test.   Apparently all kids under 5 should have roughly the same arm circumference and if it is less than 114mm, they fall into the “severely malnourished” category and are entered into our program.  114mm is about the circumference of an empty toilet paper roll.

Most children will be in our ATFC – the ambulatory therapeutic feeding program.  Each week they come to one of our mobile clinics where they are measured and weighed, vaccinated if necessary, given vitamin A, checked for malaria, and fed a hearty helping of Plumpy Nut – the high-energy, protein-rich, fortified, peanut-based power paste.  The mother is then given a week’s supply of Plumpy Nut and they head back home.

There are often complications that, for whatever reason, end with the child not recovering.   MSF has devised several creative solutions to mitigate them.   A “protection ration” is additional food given to the mother at each visit, intended for the family.  This is to ensure that the Plumpy Nut rations intended for the malnourished child are not shared among the other children.   A “discharge ration” is when a bag of grain is given to the family once their child is discharged from the program to ensure the child doesn’t relapse into a state of malnutrition after leaving the program.  These additional food supplements also help to motivate the mothers to keep coming each week and not to default, despite the long distances they have to walk in the scorching sun, the fields that need to be tended, the housework that needs to be done and the other children that need to be cared for.  On the flip side, they also provide enough of an incentive to NOT keep the child in the program intentionally so as to keep receiving free Plumpy Nut. Unfortunately, there are rumors that sometimes one child in the family is deliberately underfed so as to stay in the program and keep receiving free food.  Understandable for a mom struggling to feed all her kids.

There is also the problem of mothers selling their weekly supply of Plumpy Nut in the local market, and so MSF makes them bring back all the empty wrappers the following week to prove they didn’t sell it.  Unless of course they sell it to a conspiring neighbor….

Apart from these social complications, there are of course medical complications.  Malaria is a big one.  These children are admitted into the ITFC – the intensive therapeutic feeding program.  They are essentially hospitalized and treated for their medical condition as well as their malnourishment.  Once the medical condition is taken care of, they go to the ATFC.

Rows of mosquito nets in the ITFC.

A patient and his mother in the ITFC.

When the child reaches a certain weight and is no longer in the “severely malnourished” category, they are discharged from our program.  Unfortunately, they still often fall in the “moderately malnourished” category.  That, however, is a whole other can of worms that MSF does not usually address directly.  Rather, MSF would lobby other organizations, such as the World Food Program or Unicef, to do broader food distribution.  According to our nutrition expert, sometimes it happens; sometimes it happens too little too late; sometimes it doesn’t happen.

As the person brought in to install an incinerator in the health centres and hospitals that house our feeding programs,  I can hardly comment on what works, what doesn’t, or what MSF should or shouldn’t be doing for malnutrition.  Let alone what other organizations should or shouldn’t be doing.  I am left just to wonder about it all, grateful for that cherished afternoon dunk in the Nutella jar.