Saturday, June 30, 2012

The Collective


I have never experienced a community like I have here. I say experienced rather than witnessed because I really do feel like I have been woven into the threads of this place, even if it’s only temporary. I’ve been sent on errands, I’ve been invited to houses, and people have cooked for me. They take care of me the way they would any other little orphan.

I had the unfortunate opportunity to attend a funeral this week. It was for the 7-year-old son of an intermittent pediatrician here. Technically, there is only one pediatrician, but from time to time others from Libreville or Europe will help out. This pediatrician lives in Libreville with his family, but has worked at the hospital for almost my entire time here. He was in France for a continuing education program this month. His wife was backing out of the driveway and didn’t see the little boy.

This man is one of the best people I’ve had the pleasure of meeting in life. He started his family later in life and is probably somewhere in his late 50s. He is kind, genuine, respectful, and extremely wise. He speaks slowly, calmly, and with purpose. There have been many times where I have disagreed with his viewpoints, but you have to admire someone who speaks with such unalarming conviction. Friday mornings are presentation day for the doctors, and whenever it is his turn, he speaks about professional and personal integrity, teamwork, and self-improvement, while the other doctors present case studies of pulmonary TB and abscesses.

One night when we had him over for Sunday night dinner, the conversation turned to relationships and marriage. He spoke with love and devotion as he recounted how he met his wife and started his family with her. He told us about a time a year or so into their marriage, where just like everyone else when the honeymoon phase is over, they started to experience each other’s faults. For a week or so he would wake in the middle of the night to his wife’s murmurs and find the light on in the room next to him. He realized she was praying. She was praying that God would help her change because she knew she was causing him pain. The doctor told us that in that moment he made a conscious decision to love her not in spite of her faults but because of them. Because she wanted so much for them to be happy and he needed to help make that a reality. It was such a beautiful story, and so when I heard about his son and how he passed away, I knew I wanted to be at the funeral. I pray that they can take each other back to that moment and recommit to their promises to each other.

The funeral was unlike any I’ve attended. When I think about it, I’ve actually attended quite a lot of funerals in my life, both for family members and acquaintances. My typical funeral experience includes the funeral home viewing, the church, and then the burial. In this case, I arrived at the morgue to meet the other hospital representatives (I can’t imagine what the taxi driver thought when a random white girl said “take me to CASEP-GA,” nor what my face looked like when I realized I had just been taken to a morgue) and then joined the procession to the family’s home. There we found probably over 100 people. They welcomed the body and the family in song, but it gently progressed to a collective moaning. The coffin was placed in the home, and we were called up group by group to pay our respects. The parents and siblings went first, and the shrieks and groans emanating from that cold cement building were enough to make your skin crawl. Our Schweitzer group was called next, which made me thoroughly uncomfortable, as I felt we should not be directly after the family. Various church groups, extended family, schools, etc were called after us.

At least two wailing women in every group doubled over in pain and were nearly carried out of the home. It seemed as though the farther we got from the immediate family, the louder the moaning and the emotional and physical distress became. I take this phenomenon to be the representation of the collective sense of mothering. I say: “they weren’t immediate family;” they would say: “I just lost my child.”

In life and in death the collective remains. In my second month here I was invited to a nurse’s home for Pentecost. She had me sit at the table and served me an enormous plate of food. As I ate I observed her setting an elaborate presentation of food and wine, assuming there would be others joining me. In fact there were others joining me: the ancestors. Here I was on Pentecost feasting with the ancestors while her children sat on stools on the kitchen eating friend bananas. I told her the table was beautiful and I wished I had my camera to take a picture. She told me I could come back later with my camera because all the food would stay until the next morning. Probably two days worth of cooking and preparation was on that table, and it was all going to the ancestors. No one living would eat that food (besides me which was both an honor and guilt-inducing all at the same time).

In Gabon you’re never alone.

Thursday, June 28, 2012

Limitations


It’s been a rough month. I’ve become more and more conscious of my limitations in this environment. In theory being your own boss is great. Make your own to-do lists? Take a vacation day without asking permission? Work out whenever you want? Sure, bring it on. Except there’s that little thing about me being my own worst critic, and turns out self-critics are also pretty harsh self-employers. Evidently self-accountability is even harder than accountability.

I’ve had three very distinct phases in my time here. Phase One I like to call Fred Flintstone, or maybe Chicken With Head Cut Off: a lot of movement and energy with relatively little result. Phase Two was cruising: smooth, confident, comfortable, progress, results. And Phase Three? Stuck in the mud; inertia; hesitance; self-doubt; discouragement.

I have a sinking feeling that my work here will amount to nothing in the long run. Personally, I have gained immensely from this experience, but I’m not sure I can say that my presence has had any effect on this place. Don’t get me wrong; I did not come here thinking I was going to change Gabon or even Lambaréné. But, I did come here as a professional with a specific skill set. I’m not a student anymore; I’m not writing a thesis or collecting data for some study. And this isn’t an immersion program where I soak in “culture” like a sponge and then go home. I have something tangible to contribute, but I’m starting to feel that the circumstances are such that this just isn’t possible. I’ve started to doubt the global public health system. Sometimes the mud is so thick you think, “What can anyone possibly do about this?” Short of devoting your life to one problem in one place, what can you do? And then I feel guilty about only doing a short 4-month stint and feeling like I’m taking without giving and the self-critique circle continues.

In a lot of ways, all of this is important to know early on in my career, but it’s also discouraging. I’m currently applying to jobs for when I come back to the States, which turns out to be difficult when you’re having a career existential crisis. It’s also a fine line between “just get your first job” and “I only want to work for an organization that I believe in, to which I can contribute, and with whom I can progress.” I’m not exactly in a position to be picky.

The next public health fellow arrives this weekend. I’m hopeful that she like the other new arrivals will bring a fresh breath of optimism and energy.

Sunday, June 17, 2012

La Cuisine

Long over due food post! Generally speaking, I like Gabonese food. The main proteins are chicken and fish. Vegetable-wise it's a lot of spinach-like greens, eggplant, tomatoes, and root veggies like manioc and taro. The mangoes and pineapple are out of this world, and I could eat fried bananas for the rest of my life.


The brown root things are manioc "tubercules" and the red things are "noix de palme" which means more or less palm nuts in English.









Lots of noix de palme



The manioc root is fermented and made into a stick form, then wrapped and sold in a leaf. It smells and tastes horrendous.

Typical meal at refectoire.

Also typical refectoire meal. Boiled bananas and manioc leaves with some sort of smoked fish. Some batches are really good, others are really oily. Gabonese food has a LOT of oil.


Unidentified meat, taro (like a more bland potato) and grapefruit.



The following are pictures from when I learned to make Nyemboue (unsure of spelling). It is a sauce made with the noix de palme. Arnaud taught me how!


First you wash the noix and boil them in water.

Then you transfer to the mortar. We borrowed my neighbor's mortar, which she had just used to make piment (spicey sauce). We decided to put a bag in the mortar to protect the nyemboue from becoming similar to lava.

And then you crush the noix!

Then you remove the pit of the nut and add water to make the sauce.

This was the entire meal from that day. We added smoked fish to the nyemboue. The bottom left is eggplant and top right is a spinach-like green with smoked fish also. Then of course, friend bananas.


Thursday, June 14, 2012

The Little Engine That Could


Optimistic realism is the name of this game. One would not bother with this public health business if one believed it were futile to attempt changing the status quo, yet one should also not assume people will roll over for you when you do attempt that change.

And so it is that I find myself attempting an evaluation based on the WHO “Adolescent Friendly Hospital” standards in an establishment riddled with financial concerns, disgruntled personnel, empty research, and need I go on? I had thought this project would be a natural and logical continuation of the school research. A sort of self-reflection on what the hospital itself can do to improve and promote adolescent health, particularly sexual and reproductive health, in the area. And so I researched the standards, how and where they’ve been implemented, how to evaluate the establishment pre and post implementation, and what tools and resources are necessary. I had a plan. I was armed and ready. Or so I thought.

Turns out optimists write “standards” and “evaluation tools.” Optimists say things like “provider feedback should be sought at every level of evaluation” and “include adolescents in evaluation process.”

Realists show up at doctors’ meetings shaking in their flip-flops and try to talk about “hospital evaluations” without sounding like La Blanche who will tell you everything you’re doing wrong.

That critique about not acting on research from my last post? Well, here we go again. Research is the easy part. I could waltz in to just about any school here and distribute questionnaires and hold focus groups and get people talking about adolescent health and everyone back home would think, “Wow she’s really making a difference.” But actually doing something about adolescent health? Actually giving out 200-page WHO guidebooks on treating adolescent health problems? Actually holding a training using WHO “standardized” training tools for health care providers who treat adolescents? I might as well suggest we all walk around wearing underwear on our heads.

And so this little engine will continue chugging along the precarious incline of La Blanche who goes to the people and La Blanche who pushes her own agenda for change.

Tuesday, June 5, 2012

Small Victories


I finished my study at the school about a week and a half ago. I presented the results to the Director and some of the professors. I also prepared a little “tool kit” of sorts for the professors to use in class based on my results and recommendations. Here is what I found:

Knowledge
Ø  HIV/AIDS transmission knowledge was very high, but knowledge of the exact mechanisms of transmission was low.
o   Students knew you can get HIV through unprotected sex, but not that HIV can be found in vaginal secretions and sperm.
Ø  Conception and contraception knowledge was low.
o   Majority of students did not know when a girl is most fertile and thought that the calendar and withdrawal methods were effective.
Ø  Condom knowledge high, but self-efficacy low.
o   Majority of students knew that condoms could prevent STIs and pregnancy, but they also thought that using an oil-based lubricant and using two condoms at once was okay.
Ø  Confusion over STI vs. pregnancy prevention
o   I asked students to list which contraception or STI prevention method they used the first time they had sex. Some people would say they used a condom to prevent STIs but used nothing to prevent pregnancy, and vice versa.
Attitudes
Ø  Family planning
o   In the boys’ focus group, the guys said that family planning was about more than spacing pregnancies. In fact, according to them, it’s about planning your whole life! They talked about needing to plan for your studies, getting a job, getting married, getting a house, and then also for kids. Not bad if you ask me.
Ø  Using condoms means you’re not faithful to your partner
Ø  It’s easy to get condoms but…
o   The good ones are expensive (lots of stories of inexpensive condoms breaking)
o   It’s embarrassing to buy them and people think you’re up to no good
o   If your parents find them, they’ll be pissed
Ø  Some parents talk to their kids about sex, but others say go ask your teacher
Ø  Sex happens early, often, and is frequently unprotected
Ø  When guys talk about forced sex, they talk about harassment and using sex to get something you want, but when girls talk about it, they talk about rape and incest
Ø  Reasons for not using a contraception method when you first have sex:
o   Most said they didn’t know about conception or were inexperienced and didn’t know how to use a condom
o   Only a small percentage said they didn’t want to use a method or were too caught up in the moment
Ø  Reasons for not using a STI prevention method:
o   Again, most said they didn’t know or lacked experience
o   A small percentage said they thought their partner couldn’t possibly have a STI
o   One person said he was in a hurry

Behavior

#
%
Already had sex
88
82.20%
       females
38
76.00%
       males
48
87.30%
Not had sex
18
16.80%
No response
1
0.90%

Average age at sexual debut
15.5
      females
16.8
      males
14.3
Minimum
7
Maximum
22
Mode
16
"Do not know"
1
No response
1
Contraception at sexual debut
#
%
Used method
45
51.10%
     females
25
65.80%
     males
19
39.60%
Did not use method
38
43.20%
Do not know
2
2.30%
No response
3
3.40%

STI prevention at sexual debut
#
%
Used method
44
50%
      females
22
57.9%
      males
19
39.6%
Did not use method
31
35.20%
Do not know
10
11.40%
No response
3
3.40%


This is just a sample of some of the questions to give you an idea of the general themes etc. Of course, the real challenge is going from research to action. Too often public health stays in the realm of research and planning and nothing ever really gets accomplished. We have all of these examples of “best practices” etc., and yet when it comes to actually implementing them, we’re sort of lost. I didn’t want to just hand over a mess of statistics and call it a day, so I prepared some in-class activities for the professors to use. The Director seemed very interested in the results and wanted more background information on adolescent health. When I returned to the school to give her some more educational materials I found through the WHO, she said she was planning to hold a camp this summer to talk with adolescents in the community about these topics. They frequently hold Bible study camps, but she said that the church needs to talk more about these issues, and she will talk to the Bishops about it. I’m going to help her prepare a curriculum she can use with the camp. I’m far from moving mountains over here, but I’ll take just about any movement I can get.

Sunday, June 3, 2012

Development


There was a time back in college, when I first became interested in public health, when I wanted to become a nutritionist, a maternal and child health nutritionist to be exact.
Then I found out I would have to endure awful things like calculus and physiology, and as the good Lord did not bless me with such talents, I settled instead on the behavioral side of health. Instead of studying how nursing moms and babies metabolize fat and protein, I studied behaviors associated with contraception and pregnancy.

But there is still that part of me, the part that has spent countless hours babysitting since I was old enough to watch my little brother, which is fascinated by child development. I love babies right around the age of 6 months when they really start to interact with and react to the world around them. Movements are voluntary, emotions are dependant on more than hunger and fatigue, and independence is knocking at the door.

I’ve seen many a well cared for child in Gabon. Mamans come to PMI dressed in their stylish panje and jewels, their baby or toddler securely tied on their back. They place their carnets on the nurse’s desk and immediately tend to the child’s needs. They breastfeed, they coo, they talk, they tickle, they play. If the toddler whines or fusses, it’s that ornery temper of a child who is used to being spoiled to pieces and loved to death. 



But every once in a while you see a child, and you know from first glace, he or she is not progressing. You have that sinking feeling that something is not right. Maybe there’s a copper tint to the hair, maybe the eyes are a little sullen, maybe you have trouble distinguishing the age because a two year old just can’t be that small. And when you try to engage him or her in play, you get nothing in return. The child cowers in on him/herself and looks utterly too exhausted or bewildered. On a recent overnight trip to the village of Sindara, my friends and I had a veritable feast of fish, rice, eggplant, and manioc, while the child of the people cooking sat in the dirt on the side of the road and stared into space. I first noticed him when we arrived some 4 hours earlier, and there he was during our meal in the exact same spot doing the exact same thing. No stimulation, no human interaction. I tried to talk to him at some point and he just started at me blankly. It could have been my accent, but either way he didn’t make a peep.

Research in the U.S. has shown that children from lower SES backgrounds hear on average 1 million fewer words by the time they are five than their higher SES counterparts, rendering them less prepared for kindergarten and beyond. This is why Boston has programs like Thrivein5 and Reach Out and Read, because the U.S. is not devoid of child development problems just because we are “developed.” But to some extent in the U.S. we have the “luxury” of spending time and energy on helping children learn to talk and read. Here you focus on giving parents bed nets (and hoping they don’t use them for fishing) to prevent malaria. When survival is your highest priority, development is equal to years lived rather than milestones achieved along the way. I can’t help but think that we perpetuate and exacerbate the “developed vs. developing” country divide when we spend all our resources on “higher” order needs.