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 three 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 three 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 five villages decided that their three largest villages should each have a community health worker, and the final region, made up of seven villages, determined that two community health workers in the main village was the best idea for them. For every community health worker desired, the community had to nominate two 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 two 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 posting with MSF, 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.
Image shows a mother with her daughter at the Massakory feeding programme for malnourished children under five years old, 2012.