Bear-ing witness

Although it has gotten easier over the years, my transition back to home life is never graceful. Although I know to expect overstimulation around every corner, I am still overwhelmed by it. My only respite is my home, the ‘Chaled’ – an elegant cross between a chalet and a shed, without any electricity or running water, deep in the Northern Canadian wilderness. It is my sanctuary. Where I can hide from the chaos and uncertainty of the rest of the world.

Every year when I return home it usually takes a few weeks to reconnect with my environment, to truly feel at home and to not wake up confused as to where I am. This year, however; the reconnection was practically instantaneous – thanks to a bear.

My first night home, I excitedly went for an evening walk with the neighbor’s dog down an old forest trail. As I wandered along the trail I was lost in thought, with my mind more in Chad than in Canada. I was suddenly ripped from my daydreams by the sound of a stampede coming towards me. I jumped off the trail, with the dog in tow, just in time to not be trampled by a huge bull charging down the trail with a look of sheer terror in its eyes. For half a second I contemplated how cows look so different in Chad than in Canada, and how thankful I was that the bull didn’t have horns like those in Chad. I was thrown back into reality as I realized that the bull must have been running from something – and that something took only a moment to materialize. And that something was in the form a very large brown bear. For one quick moment I had no fear. The bear had something to chase. Why should I be afraid? When the bear saw the dog and I it came to a roaring halt. Why should it chase the bull when there were two stationary objects standing before it? And suddenly I was 100% in Canada. I was there. On a path. With a bear five metres away from me and staring me down. Yet another not-so-graceful transition to home!

In the end all went well. I did what one is supposed to do when one sees a bear. The dog behaved appropriately, and the bear responded accordingly. I am still, however; wondering where the charging bull came from and where it ended up.

I returned to the Chaled, and went to bed smiling and feeling lucky. I was home. And I am so lucky to have this home. There are risks associated with every environment. In the Yukon (Northern Canada) the risks are mostly related to the wilderness and to being in a remote context. How lucky I am that these are my risks, not malnutrition or access to basic human rights.

Although the bear instantly reconnected me with my environment here, I am not quick to forget where I was. As malnutrition rates were rising in Chad, I had the luxury to leave – my thoughts and hopes stay with those that have no choice but to remain.

As this is my final blog entry, I would like to take the opportunity to say thanks. Thanks to everyone I met in the field that shared their stories with me, and allowed me to pass them on. And thank you to everyone that took the time to read them. It has been an honour and a privilege to have the chance to share them. Thank you.

 

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Take two

Today I leave Chad. It has been a hectic ending, and I will work until I board the plane tonight – but even in all of the craziness I have had time to  reflect  on my last few months here, and the impact that we have as a humanitarian organization.

At one point in the week I took a break with our local health promoter. We were sitting outside a tent of the malnutrition hospital, sipping painfully sweet tea, when we heard the cries of a mother who had just lost her child. We live in the hospital compound, and these are the cries that often wake me at night. Youssouf, the health promoter, said, ‘She cries, and then with all of the other mothers she will pray. Pray that the child will return as a bird or as a tree, but not as a human.’ I pondered the cultural significance of this, wondered if it is bad luck to return two consecutive times as a human – and in the end I asked for clarification. ‘No one’, he said, ‘wants to have to do this again. No one should ever have to be a human in Chad – better to be a bird or a tree.’ The words stayed with me. They gave me a better insight into why mothers refuse to have their children transferred to the hospital.

As long as there are places in this world where life is perceived as so painful that parents pray their dead child will return as anything but a human, there is work to be done. On days during the mission when I have stressed about the children in our project who die, my manager has reminded me that for every child that dies in the malnutrition program, there are hundreds that are saved – and if we were not here most of the children in the program would end up dying. Now we just have to work towards making life more bearable once a child is saved…

Leaving Massakory was hard. Leaving missions is always hard, but this time it was particularly hard knowing that I am going to school and won’t be on a  mission again for two years. As we pulled away from Massakory I wondered about the future of our national staff and of the children and mothers in the malnutrition hospital. I wondered about the overall future of Chad. I hope for the day that when a child does die, the prayers of the mother can be different. I can hope, but hope can only do so much.

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Locked in the outhouse

For as long as I can remember I have always had to go to the bathroom 3 times in the night. I have no idea why, but it happens every night without fail, unless I am moderately dehydrated (which has happened on a number of occasions recently). Over time I have become somewhat of an expert in navigating myself to the outhouse/bathroom, wherever that may be, doing what needs to be done, and then returning to bed, without ever having really woken up.

One night this week I woke up  at 1am for my second trip of the night. As is often the case, I don’t recall the trip to the outhouse. Once finished my business I turned the door handle of the metal door – I clearly remember this because the door didn’t budge. I am sure that our outhouses have been created to withstand serious attack. In addition to their heavy metal doors with slits for air vents, the outhouses are solid concrete from floor to ceiling (minus of course the hole to squat over).

I tried to turn the handle again – absolutely no movement. It took about 30 seconds before I fully woke up and realized the extent of the situation – I was locked in a concrete outhouse in the middle of a very hot night in Chad. Trying to be self-reliant I frantically fiddled a little longer with the door before calling out loudly for the night watchmen to come help me. He desperately tried to free this outhouse captive, but to no avail. He eventually went off in search of the hospital night watchmen. The second night watchmen had no more success than the first. At this point I started to really feel the 45 degree night heat, and I noticed the extremely large camel spider on the ceiling. I am not easily squeamish, but I find camel spiders frightening. They are generally quite large, and can be very aggressive. I decided that considering the context of the situation, it was best to ignore the spider and pretend it wasn’t there.

A camel spider, with cat for scale

 

The night watchmen and I eventually decided that the project’s logistician had to be woken up. The logistician seemed to take it in stride that his sleep had been disturbed to save the expat locked in the outhouse. He too tried unsuccessfully to turn the door handle (I decided it was not in my best interest to point out that if it was just a matter of simply turning the door handle, I would not still be in the outhouse). Once he was quite sure that the door handle would not turn, he left for the hospital, wrapped only in his towel, in search of a hammer.

Upon his return he began banging the door handle and lock off the door. With every loud bang on the metal door the spider got more agitated, and I got more worried. For the proceeding 45 minutes, I squatted in the corner of the outhouse, hiding from the door handle I was sure would be projected towards me at any moment, as the handle and lock were continually beaten/hammered. Eventually, drenched with sweat, I was freed.

Freedom seemed precious, and my bedroom which on occasion seems like a cell in itself – appeared spacious and luxurious. Oh relativity. And thankfully I had dehydrated enough during my time in captivity that I did not need to go to the bathroom again in the night…

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Community

Three months ago, just before I arrived in Massakory, a significant percentage of children being admitted into the malnutrition program had complications due to untreated or poorly treated diarrhea. This is the country where cholera has its own season, quality of water is always questionable and access to health care is limited. We had a choice – we could continue treating children suffering from diarrhea induced malnutrition, or we could choose to treat the diarrhea at the community level before the child became malnourished.  The answer seemed obvious – and Project ORS was conceived.

Except for the fact that it was MSF who decided to implement the project, Project ORS is the essence of a community based project. The idea of Project ORS is that trained community members treat children that have simple diarrhea in the community, with Oral Rehydration Salts (ORS) and Zinc. Children who have any complications, are malnourished or have an additional illness are referred to the health centre / malnutrition centre.

At the outpatient malnutrition program in Massakory, we noticed that children with diarrhea-induced malnutrition were coming from 3 distinct regions. These were the areas we targeted for the project. The setting up of the project has taken weeks. First we wanted the community to decide for themselves that they wanted the project. We discussed the project with the community leaders – we explained why we thought the project was important. We also explained that it was for them to decide if they wanted to have the project in their villages. The community leaders then presented the idea to the village chiefs, and in the end all 3 regions agreed they wanted the project. From the start it was clear that the community member trained to treat diarrhea would not be paid by MSF and that it would be left to the community to  choose how to show appreciation towards the community member. In collaboration with the community we created criteria for the community health worker. He/she had to be able to read and write in either French or Arabic, and had to be someone that was often available as mothers would have to be able to find him/her when their child had diarrhea.

Each area where we proposed to set up the project was made up of 5 – 7 villages within a 2km radius. Each region chose a different approach. One area decided they wanted a community health worker in each village. One region made up of 5 villages decided that their 3 largest villages should each have a community health worker, and the final region, made up of 7 villages, determined that 2 community health workers in the main village was the best idea for them.  For every community health worker desired, the community had to nominate 2 people. We then went into each region, met with all of the nominated people, and the village chiefs. We described the program, the role requirements, and did some simple exercises to demonstrate the skills required for the position of community health worker. After this meeting, the nominated community members returned to their villages, with their village chief, to explain to the project to their village and to determine collectively which of the 2 people would be the community health worker.

Setting up community health projects requires time, patience and some degree of passion. Three months ago we started this process, and it was only this week, my final week in Massakory, that we were finally able to assemble all of the Soon to be Community Health Workers  together to do the day long training required for the position.  This is my fifth mission, and I will never fatigue of the excitement in bringing community members together to learn to treat simple illnesses. The 10 men, dressed in white robes and turbans, arrived early in the morning, full of energy, excitement and motivation. Having been a part of this process since its inception, I felt strongly connected to each one of the community health workers. Throughout the day the energy in the training room, despite the suppressive heat, was inspiring.  These are people with very limited literacy skills – but we all shared the same objective. They helped each other fill out the simple consultation forms. They taught each other how to write certain words, and how to recognize the words ‘oui’ and ‘non’ in French (if we just had Arabic keyboards it would be so much easier!!!). We will not pay the community health workers for their work, so it was important to me that throughout the training day we made them feel valued by MSF. For the day they were treated like royalty – fed meat and bread  at lunch – a delicacy in this part of the world, and during breaks we served peanuts and dates.

At the end of the training I thanked everyone for having come. For having spent the day with us. I thanked them for being willing to be the pioneers of this project. I then explained that unfortunately I will soon be leaving Chad, and that I am sad not to see the evolution of this project. After I had spoken, one of the community health workers, a village chief who believes so strongly in the project he asked his community to nominate him as a community health worker, stated, ‘Medecins Sans Frontieres has brought medicine from Europe to Massakory. We were grateful for that , but it was still too far for us to go to get treatment. And now you  have given us the chance to treat our own people in our own village. The only way to thank you is to do a good job. Don’t worry, we will make you proud.’

And this week, Project ORS was officially launched. In the end it is not me that needs to be proud, it is them. I hope that soon that the community health workers, and their fellow community members, will be proud that they are helping reduce child malnutrition and death rates. I hope with all of my heart that it is a success.

 

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Hawa

It is amazing what one can become accustomed to. Somehow we have become accustomed to the oppressive 45 degree heat. Lack of personal space is challenging, but I am more or less used to it. We each develop our own coping mechanisms whether it is sitting in buckets of water or searching out small corners for a moment of personal space. I don’t even blink at the fact that there are no outhouses in the villages and that the desert is used as a pooing field. I know the risks associated with it, but I am no longer shocked by it. Unfortunately, over the years I have even become accustomed to the fact that malnourished children exist.

There are, however; things I will never become accustomed to. Last week Hawa, a 3 year old severely malnourished girl, died at home. She was in the outpatient malnutrition program. During her weekly consultation the nurse noticed that she had a fever and had lost weight. The nurse told the mother that Hawa needed to be transferred to the malnutrition hospital for treatment. The mother refused to be transferred. She had 4 other children at home. She had never been more than 10km from her village in her life. I imagine the thought of going somewhere where she would have to interact with people she did not know, where she did not know what was expected of her, what would be fed to her, and how long she would have to stay, was overwhelming. After an hour of negotiating, the nurse called Hawa’s father. He too refused the transfer. He was worried about who would watch and cook for the other children while the mother was at the hospital. Who would collect the water and the firewood while he worked in the fields? And how would he communicate with the mother? He had a cell phone, but she certainly did not.  In the end Hawa returned home with her mother.

This week Hawa did not appear for her weekly consultation. One of our staff went to her village in search of her. The women in the village said that Hawa had died, after her uvula had been cut. Here it is a traditional practice to cut the uvula when a child has a sore throat or a fever. This is what the people know, and there is often more faith in this and other traditional practices than the medication that we offer at the malnutrition centre. Who is to say that is right or wrong. I just know that Hawa died.

And Hawa was not alone. 3 other children died in our outpatient program this week. The mothers of all 3 of these children had refused to be transferred. They either died of medical complications caused by the malnutrition, or because of the traditional treatments that were given to them.

I don’t blame the parents, the traditions or the community. And I don’t blame MSF. Honestly, I don’t blame anything. I am just tired and frustrated. Children dying at home, particularly of malnutrition and particularly when there is medical treatment available, is one of the greatest, if not the greatest, injustices in the world. Hawa, Adoum, Abdoulaye and Mahamat should not have been malnourished in the first place. They didn’t need to die. If they had not been malnourished, they might not have been so vulnerable to the effects of the traditional medicine given to them.

Someone I truly respect once told me that one of the greatest risks in working in humanitarian aid is that you become a cynic. I think that I am not cynical, but I do think that I am at a loss today. Sleep does not come easily, as I struggle with the challenge in front of us. I struggle with knowing that on the field we can not solve the problem of malnutrition. We can save some children’s lives today, but I seriously worry about tomorrow. I even fear for it.

Good bye Hawa. Good bye Adoum, Abdoulaye and Mahamat. I am sorry this is the reality that you knew and I am sorry we couldn’t help you more.

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The extraction of an expat

Intense heat is not something I have ever become accustomed to, maybe it is the Yukoner in me. This past week in Chad the temperature soared high into the 40s, even 48 C in the shade the other day! I was in Niger this same time last year and experienced the same oppressive heat, but at the end of the day we had bedrooms with solid walls, and air conditioners in each room. Here in Chad we have the straw  mat wall dormitory, where it always seem to be hotter inside then out and the fan simply seems to unrelievingly circulate hot air.

The heat does odd things to the body, the mind and energy levels. In the day I drink between 6 – 8 litres of water, and still only pee once or twice in the day. It is hard to concentrate, and I am so tired that I want to sleep, but no matter how many wet clothes I wear at once, sleep just doesn’t come. This past week I was searching desperately for a solution, or at least a coping mechanism. Creativity was necessary, but inspiration was lacking. Then I saw the buckets. Around our compound we have a multitude of rubber garbage bins filled with water, in preparation for the times that water does not come from a hose attached to a metal pipe coming from the ground (I constantly wonder where the pipe finds the water, but I am a nurse, not a logistician).

I am small, and quite good at contorting my body into an even more compact unit, so without any discomfort I plunged myself into the bucket – fully clothed. The relief was instant. The shocked looks on the faces of observing expats slowly turned to looks of envy as they realized my level of genuine relief.  3 others followed suit. Some had to work a little harder to transform into the compact ball form required for bucket entry, however; the effort was clearly worth it. 3 consecutive hours were spent in those buckets. Spirits were high, we sang, we drank our drinks of choice, those that smoke cigarettes smoked cigarettes. Life was wonderful. I started to envision being able to extend my mission if I could just have daily bucket time…

And then one of the bucket dwellers decided it was time to get out. Being much taller than I, she had used some force to plunge herself into the bucket. She had pulled her knees right up into a little ball and then dropped happily and heavily into her bucket of water, with a little wiggling here and there until she was covered in water right up to her chin.

But coming out was not quite so easy – some have theories that she expanded in the water, others say it was just a natural consequence of being a tall woman in a small bucket. For half an hour she tried on her own, it seemed shockingly similar to the beginning of the birthing process. She tried with all of her might for a few moments, and then she would take a number of minutes to rest and recuperate her energy before trying again. When she failed to extract herself independently, the cleaning woman became involved. With a serious, yet questioning look on her face the cleaning woman pulled, with no avail, on the expat stuck in the bucket.  Concerned as we were for the well being of the woman stuck in the bucket, us remaining bucket dwellers were unable to contain our hysteria.

Eventually our medical team leader stepped up to the plate. Amidst gales of laughter, she assessed the situation and announced that the bucket would need to be tipped over to be able to properly extract the expat. Fear penetrated the face of the stuck expat, shock penetrated the face of the cleaning woman. The expat shook her head emphatically, but it was apparent to all – all other options had been explored without success. The bucket was slowly and carefully tipped over, and the water poured out over the sandy ground. And with a number of twists and turns, a human ball finally emerged from the bucket, and unfolded into a standing human form.

Once the first expat was successfully extracted from her bucket, fear (and anticipation) developed amongst the observers and bucket dwellers alike, that the same situation would have to replayed 3 more times. As a representative of the remaining bucket dwellers, I am happy to say that we were each able to easily and independently remove ourselves from our buckets, with no help from external sources. And that night, once I stopped giggling every time I thought of the extraction, I slept better than I had slept in weeks.

I can only begin to imagine what the cleaning woman recounted when she returned home that evening, but one can be sure that her story was accompanied by the passing around of her telephone, on which she had taken numerous photos of the bucket extraction. The rest of the cleaning women team were already aware of our use of the buckets when they arrived at work the next day. They were rightfully concerned about their water reserves, which in case of water shortage they use to wash our clothes, and clean the latrines with. We made a compromise – I can use the bucket as my personal pool as long as I promise to empty it and refill it after use. The deal was done with a handshake – and my week improved from there. One daily soak in the bucket is the minimum standard for functioning now. No matter how hot I get in the day, I know that the bucket exists.

The extracted expat has still not returned to bucket life. I look forward to the day that she does.

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Notes

Somedays with MSF I feel that we are really making a difference. Other days I struggle with our limitations and the changes we don’t or can’t make. And most days I fluctuate between these impressions at lightning speed. This week was no exception, except that some of these impressions were formed while sitting, like royalty, on a pink frilly mattress.

The food security situation in Chad is never superb; however, it is particularly worrisome this year. Last year’s harvests were poor, and a variety of insects ravaged the crops that did manage to grow. In this region of the world where malnutrition, meningitis and cholera each have their own season, poor harvests only add to the complexity of potential problems. During the past week MSF embarked on a broad reaching nutritional assessment in the region in order to have a general overview of the current malnutrition rates. As my job involves coordinating and supervising all the activities conducted outside of the hospital, I was temporarily transformed into a nutrition assessment supervisor during the past week to help with the survey.

Conducting a nutritional assessment involves more than just arriving in a village and screening children. Village chiefs have to not only be notified and give permission for us to screen the children of the village, but the terrain in Chad is vast, and without a proper guide one easily becomes lost in the desert for hours. In one of the regions where we intended to screen, the Chief of the Canton was our guide. While an administrative position in theory, culturally the Chiefs of Cantons are considered as royalty, particularly in extremely remote areas.

The Chief of the Canton of Affrouk, our guide, was a young man of 37 with a princely appearance, particularly with his beautiful and impressively white booboo, turban and robes. The nutritional surveyors I was with briefed me that it is tradition for the Chief to sit in the front of a vehicle, with no one else but the driver – one would never want to crowd him. When this princely chief saw the absurdity of 9 people crammed into the back of the landcruiser in 45 degree heat, with all of the materials the team needed for a week in the bush, he insisted that I sit in the front with him. The team tried without effect to dissuade him of this, and eventually (and quite happily) I moved to the front.

We drove for hours through the desert in search of the villages randomly selected to be included in the nutritional survey. Sometimes more than an hour passed without seeing any signs of human life – no vehicle tracks, no villages, not even any livestock. In the 3 villages where we stopped to screen, we were treated as pure royalty. In one of the villages, the village chief had prepared his hut for the welcoming ceremony. Both my princely counterpart and I were provided with our own pink, frilly, satin covered mattress to sit upon.Sitting across from the Chief of the Canton, I felt a little like the paper bag princess, wearing clothes that failed to hide my lifelong inability to stay clean for longer than 2 minutes in a day – particularly in the desert where sand storms are a way of life.

After being served numerous rounds of tea, one of the nutritional surveyors brought forth a father carrying his tiny child – a baby of 4 weeks, who had been sick with diarrhea for one week, and now looked like an emaciated bird. The father sat on the edge of the pink frilly mattress, and cried while I asked questions about the baby’s illness. The father, speaking fluent French, described how days earlier he had walked 4 hours each way with the baby in search of help from the nearest health centre. The health centre had been closed, and he had returned home with the baby.

Once the nutritional survey was done in the village, and after a few more rounds of very sweet tea, we loaded the mother and the baby into the vehicle with us to make the very long drive back to the MSF hospital. That night, and for the following 6 nights, the father of the baby called me to receive an update on how his family was doing. With treatment the tiny baby progressed into a little baby, and eventually became a big enough and healthy enough baby that she was ready to go home. I had appreciated the phone calls from the father – they brought to life for me one of the reasons why we are here. They gave me motivation, and once the baby was discharged, I sadly thought that would be the end of my nightly phone call. The night after the baby and mother had been discharged, the father once again called. He called to let me know that the 2 had gotten home safely, and then he cried and said he didn’t know he could ever thank MSF for having come to do the survey in his village because it was what had saved his child.

I don’t know what the results of the nutritional survey will bring. I find it challenging to go into a village just to do a survey without being able to promise to do anything in future. Throughout my previous 4 missions I have realized that facing our/my limits is part of humanitarian aid (and part of life). Hearing from that father though made me realize that we do make a difference in people lives, and I guess that is why we are here.

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Seasons

The changing of seasons affects the lives of people differently throughout the world. For most of my life the changing of the seasons brought forth a sense of excited anticipation for whatever the upcoming season might bring.

In Chad the seasons can be divided by the weather, or by the epidemic. There is the meningitis season, the cholera season and the malnutrition season – all of which overlap to some extent. At the moment the meningitis season is here, and the peak season for malnutrition is slowly approaching. The signs of the changing of the seasons surround us, and the excited anticipation formerly brought forth by the changing of the seasons seems to evade me.

The numbers in Massakory’s malnutrition program grow progressively each week. Not only are the admission numbers increasing, but the types of admissions are changing. In the past month we started to see a growing number of children returning to the program. We can cure a child of malnutrition, but we don’t seem able to cure the country of the problem – children leave the program and go back home to the same problems that caused the malnutrition in the first place.

This week I met 22 month old Abdoulaye and his mother. Abdoulaye had been in the malnutrition program last summer. He was ‘cured’ in September, only to become sick with diarrhoea in January. He and his family live a 2 ½ hour walk from the nearest health centre. As his mother had to tend the fields to ensure that the family had food to eat, she was unable to take Abdoulaye to the health centre. He progressively got sicker, until he became malnourished again. He re-entered the ambulatory malnutrition program in February. This week when I met him at the malnutrition centre he had met his target weight and was yet again considered ‘healed’ or ‘cured’. When we told Abdoulaye’s mother that he was now healed, and she would not have to return the following week she became angry. ‘And what now – wait until he gets malnourished again?’ she replied.

MSF is currently conducting operational research in Massakory, on the use of Plumpy Nut’s brother ‘Plumpy Doz’, which is a supplementary food aimed at preventing malnutrition in children 6 – 24 months of age. For the next year, in the region where Abdoulaye lives, there will be monthly distributions of Plumpy Doz in the villages for every child that fits the age criteria. Mothers receive 4 pots of Plumpy Doz a month, and are instructed to give their children 3 spoonfuls 3 times a day. I reminded Abdoulaye’s mother of the Plumpy Doz. This did not diminish her anger. ‘And when the Plumpy Doz distributions are done. When you are done studying us? What do we do? Wait until our child gets sick and becomes malnourished again?’ she retaliated. I had no answer. What is the answer?

The discussion took me back to Djibouti and the first time I encountered mothers it seemed might intentionally be starving their children to be able to get access to free medical care. It reminded me of the mothers in Niger who seemed to keep one of their children constantly malnourished so they could receive a weekly ration of Plumpy Nut, with which they fed the rest of their children. I was reminded of the mothers in the Congo who had to make the unimaginable decision of whether to go harvest in their fields, where they would be raped, or to stay at home, not get raped, and have their families starve.

The causes of malnutrition are complex, as is its treatment. Clinically it is not complicated, but socially, politically and economically it is extremely challenging. Plumpy Nut and all of its brothers and sisters are not the long term answer. When leaving the centre with her final week of Plumpy Nut ration, Abdoulaye’s mother bade us farewell and cynically, yet realistically, called out, ‘See you in a few months’.

It reminded me of the end of the summer camp season when I was young. The end of camping season would bring tears to all of the campers and the shared hope that we would all see each again the following summer. The beginning of the peak malnutrition season has barely begun, but I already know that by the time the end appears, many tears will have been shed, and I will hope with every ounce of optimism that we will not have to see again at the malnutrition centre the children that we have treated this season. I can hope… but hoping has its limits.

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Redefining remote

Before even arriving in Chad, I had heard about the living conditions for the MSF project in Massakory. When ‘seasoned’ expats give the first tour of the ‘living quarters’ to the new Massakory arrivals, they do so with a sense of pride, disbelief and anticipation of the ‘newbees’ reactions. I am one who generally thrives more in discomfort than in comfort – I have always searched out ways to live that many others would never choose, and even I was dutifully impressed. The living conditions could definitely be considered challenging at the best of times.

For the next 3 months I will work with the community health aspect of MSF’s ambitious malnutrition project in Massakory. The community health component of the program focuses on treating severe malnutrition in the community. While there are the classic ambulatory programs for malnutrition set up outside of health centres, MSF is also trying a new approach to treating severe malnutrition in the remote communities.

Community members in designated distant villages have been trained to screen for malnutrition. The children screened as malnourished are directed to the local ambulatory program for a consultation. If they are considered to not have any complications they return home and receive their weekly ration of Plumpy Nut, which is the treatment for uncomplicated malnutrition, in their village. It is distributed by the trained community member who is ‘paid’ by his or her own community, either through money, food, or some other means.

This week I have been touring some of the villages that are involved in the new initiative. In the past 4 years I have had the great opportunity to work in some of the most dire and remote places in this world. I remember my first time heading into the ‘bush’ in Niger – I was blown away by the new definition of dire that was created in my mind. Today was a similar experience, not so much with the word ‘dire’, but with ‘removed’ or ‘remote’. We travelled by Landcruiser on sandy paths through the desert for 1 ½ hours from the already small town of Massakory to arrive in a smaller village with a health centre which has an MSF supported ambulatory malnutrition program. From there we drove 1 MORE HOUR, on an extremely uncertain ‘path’ through the most enchanting desert forest I have ever experienced.

We saw beautiful green birds, various type of raptors, hopping camels (their legs are tied together so they can’t run off), endless mules and slightly emaciated cattle. Elephants are said to pass through this forest, and to my great chagrin none were seen, but not for lack of incessant trying!! After 1 hour we arrived at a tiny village consisting of a few mud huts with straw roofs. Upon our arrival, an impressive quantity of children tumbled out of the huts as clowns do out of tiny circus cars. There were no signs of motorized vehicles in this village. I asked the village chief how they usually travel to the health centre, and how long it takes. He explained that usually one must either take a donkey and cart, which takes a number of hours, or walk – which takes an even greater number of hours. In most cases only medical emergencies head to the health centre, and women give birth at home with hope that all goes well. Standing in this tiny village, the importance of MSF’s new approach to treating malnutrition was beyond evident.

From our first stop we travelled to a number of other villages involved in the malnutrition program – each one equally small and remote. Village chiefs continually thanked us for making the treatment of malnutrition more accessible to them, and they told countless stories of the hardships involved in living so far from a health centre. In the last month the number of malnourished children in the entire MSF Massakory project has increased exponentially, even though the seasonal ‘hunger gap’, the months in which food insecurity levels and malnutrition rates rise in unison while waiting for the harvest, is theoretically still a number of months away. Throughout the world the causes of malnutrition are extremely varied, however; lack of early medical treatment for basic childhood illnesses is definitely one of the major causes. Seeing firsthand the distance so many families have to travel in order to seek basic treatment here, I worry about what the months of the hunger gap will bring when the effects of food insecurity and lack of access to early medical treatment are intertwined.

While the villages I visited today could easily fit into the stereotype of ‘quaint African villages’, it was clear their way of life involves endless challenges and difficulties. After an extremely long drive, I returned home, to the luxury of my tiny bedroom, which is part of a long row of bedrooms made of straw mat walls and a straw mat roof. I lay down on my bed, where in the night I can hear every movement and breath of every other person in the straw mat row. I listened to the chickens squawk in the henhouse which is closer to my room than the latrines or the outside showers. I turned on my fan, which circulates the hot air, the chicken smell and the sand throughout my room, and I was grateful for it all. Yet again, relativity humbled me, as I am sure it will for the next 3 months to come.

Posted in Chad, Community outreach nurse, Malnutrition | Tagged , , , , , | 8 Comments

Mission number 5: white bread and promises

The old stone building housing the MSF headquarters in Geneva is a constant hubbub and fury of activity. Information and people seem to move at rapid speed, with seemingly incredible purpose and motivation. During my first visit to the headquarters a number of years ago, I instantly became enamoured by the energy of the place, and the endless passion which seemed to emanate from everyone working there. Ever since that first briefing in Geneva, every visit to the headquarters fills me with an excitement and a belief that change is actually happening in this world, and that ‘we’ are all working together towards a common goal.

Chad will be my 5th mission with MSF. However; regardless of the number of missions I have done, I still have trepidations before setting off. Prior to every mission I question my abilities and my capacities. I wonder about my energy levels. I ponder whether I will connect with the team and the community. I worry whether I will find motivation and purpose. Briefings at headquarters, even if they fill me with energy and excitement, do little to relieve my concerns – I now know arriving in the field, meeting the team and actually seeing the project is the best prescription for clarification.

Still buzzing with headquarter-induced energy, I boarded the flight to N’Djamena, the capital of Chad. While reading a newspaper on the plane, I saw an advertisement for a European conference entitled, ‘The Promise of Africa’. I was intrigued. What does that mean? Does ‘Africa’ promise something, or was ‘Africa’ promised to someone? If so, to who and by who? The next line stated it was a conference where, ‘we focus on the promise of Africa, exploring its potential’. I imagined the phrase stopped there, and thought of all of the potential I have seen in the African countries I have worked in. I thought of the inspiring people I have met and worked with, who aspired to make change in their countries, change to the systems and policies that had failed them for so long.

I thought of Magaria, Niger, and the community health project where the villagers had enthusiastically embraced the concept that they were responsible for the health of their people. I thought of the Brown Bread Revolution baker, who was working to make change one loaf of bread at a time.

Then I read the end of the phrase, ‘Exploring its potential as a producer and consumer of luxury goods’… ’how can long established luxury brands remain relevant to a new generations of consumers?’. And with that, the excitement and optimism from the headquarters came face to face with another reality. Every mission so far has shown me how much more work there is to be done – on every level – in the field, in national and international government offices, and within ourselves – and this advertisement was simply a reminder of all of that.

As I sat pondering about the potential for change, the man next to me introduced himself. He was Chadian, and just returning from a conference in Paris. ‘What type of conference’ I asked, fearing a discussion based around luxury goods and the promise of Africa. Bread. He was returning from a BREAD CONFERENCE. His family runs bakeries in Chad and imports flour into the country. I asked the colour of bread he makes… white. When I told him I worked for MSF, he replied, ‘MSF has done so much for our country. I always wonder how I could every repay them, but I am just a baker’. I felt like I was in a movie. The moment was perfect. The discussion began…

And with that interaction, I knew I was in the right place. Change will come. One loaf of bread at a time.

Posted in Chad, Community outreach nurse, Malnutrition | Tagged , | 3 Comments