An Inside Look at Global Health Activity at USC

Giving Thanks for an Amazing Trip

2012-01-09T02:28:00.001-08:00

I've had some time to decompress after my trip from Cambodia and there's a lot of people that I wanted to give thanks to for making this trip happen. These sorts of events don't happen in a vacuum and if it wasn't for the support that I got from everyone I know that my winter break would have been much less eventful.

First and foremost I'd like to thank Christian Basa, my co-troublemaker in this endeavor. It was his idea to head to Cambodia to work on this project and if I hadn't had the good fortune to meet him this trip never would have occured.

I'd also like to thank Christian's wife, Idang, and the family for putting up with me the entire trip. Without Christian's in-laws there to provide context and translation for what I was seeing, the trip wouldn't have been as meaningful for me. Special thanks goes to Seng for taking the time to hang out and go on adventures with me in Siem Reap and Phnom Penh.

Of course, the USC Institute of Global Health and USC Marshall School of Business were instrumental in making this trip a reality for Christian and myself. I am very glad to be in the company of such amazing people who are doing such incredible things.

The support of Don Fetherman and Dr. Gerlinda Lucas of the Sihanouk Hospital Center of Hope was matched only by the enthusiasm that the lab staff showed towards us. Mr's Teav Syna, Kham Chun, Che Yanith, Chan Krisna, and all the hospital staff made living and volunteering in Phnom Penh a phenomenal experience.

Mickey, our tuk tuk driver who took us out for nights of fun.

Our volunteer-in-arms, Dr's Varadhan and Li, who kept life outside of the hospital enjoyable.

The staff of the Golden Gate Hotel; a place that I'd recommend highly for all those travelling to Phnom Penh.

My new friends from Siem Reap, happy new year and hope to see you again soon.

Everyone I didn't list, it's late and I sincerely apologize for not typing your name down. Rest assured that your support and contributions were felt and greatly appreciated.

I'm looking forward to the start of the new semester!

Project Summary

2012-01-03T18:41:00.000-08:00

I haven't talk about my project much. Therefore, I am going to write a summary about my whole experience in this blog.

What is my project about?

The incidence of infectious diseases occurs in many tourist destinations and is increasingly imported by tourists due to increase in global travel. For example, dengue disease is the most common arboviral (insect-borne) disease in travelers (Other than the fact that mosquito can carry diseases, they are the most annoying thing in Thailand too). However, with the lack of intervention and research focusing on tourists, the infection rate of dengue and infectious diseases among tourists remains high and is growing (A lot of people thought dengue is transmitted by food and water. Some people thought there is a vaccine against dengue). The purpose of this study is to assess the knowledge and behavior of tourists about disease and prevention. The study will be conducted through cross-sectional survey of tourists using one stage cluster sampling in the area of Ko Chang, Trat, Thailand, where dengue is endemic. Through Likert-scale, multiple-choice and open-ended questions, I will assess disease prevention knowledge, perceived disease susceptibility and severity, level of compliance, and the knowledge of dengue specific information, including, means of transmission, signs and symptoms, prevention methods and their level of compliance. I will attempt to survey 500 tourists that enter the island of Ko Chang with a milieu of tourists from various parts of the world. Inclusion criteria will be those who are over 18, speak English or Thai, mentally stable, and can give verbal consent. Those who are under 18, cannot understand English or Thai, mentally altered and are unable to give consent will be excluded (I ended up with 400+ surveys. I had to throw out 50+ surveys because it was not complete). The results of this study can potentially inform intervention strategies and health policy change for disease prevention among global travelers.

First day

I decided that recruiting people to complete a survey is not my favorite thing to do. However, it is the majority of work for this project. Initially, I interviewed the participants one by one. The process was too slow. At this rate, I would not finish the project on time. Also, the rejections was a bit of a shock for me. I realized that not everybody would complete the survey. I also know that I will get reject. Regardless, to get reject in a row was a sad situation. Later on, I learned to let go and did not take the rejection personally.

Later days

Later on, I developed a recruiting technique. The technique was a success. I finished 500 surveys as expected. Basically, I would pass the survey out before tourists walked into the boat (I asked for their consent first. Or else, it wouldn't pass the IRB, right?) Then I would give them incentive when they finished the survey (I walked around the ferry to collect the survey).

It was easier to survey people on their way back from the island than on their way to the island. My theory is that they are less excited about leaving. Therefore, they tend to have more time to complete the survey.

Something to keep in mind/interesting facts

- There are a lot of Russian tourists. However, they came in a big group and refused to speak English. Therefore, I could not get enough representatives from this group. To my surprise, they could speak perfect English when they hit on a girl(Maybe life is not so bad for global health women after all.) In order for the tour guide to identify the russians apart, they put a little round sticker on their shirt, which was also how I tell them apart. I would spend less time recruiting this group of people (i would first ask them if they speak English.)

- In the questionnaire design, I overlooked repeated traveler. They usually get vaccination for their previous trips. Therefore, for this particular trip, they do not get any vaccination. Something to keep in mind for my other project.

- I pre-tested the questionnaire with 10 people from the state before I came to Thailand. However, I realized now that pre-testing with the exact population I will be working with is important. Not only for questionnaire improvement but also for the recruiting technique. There are a few questions I would change, but it was too late to resubmit the IRB. So I decided to stick to the original questionnaire.

- Data input was a pain. Initially, I wanted to use iPad as a survey tool. So I wouldn't have to input the data by hand. However, the program was expensive. With iPad, I can only survey 1 person at a time. It would be impossible to complete 500 surveys in that amount of time. Therefore, I decided to go with a traditional (paper) method. (Also, the iPad survey program is extremely expensive.) Someone please develop a student version!! After inputting all the data, I have to recheck them again because there were a few errors....must be from looking at too many numbers for too long. Next time, I will hire someone to do it.....

To sum it up - - -

Ko Chang is not as underdeveloped as I expect it to be. However, Ko Chang is facing bigger problems many tourist destinations face in second and third world countries. The development is going up too fast without a good plan. There is no affordable clinic on the island, no sewage system, no clean water for the public, no trash management system, and no development plan. I think the whole island need to act quickly on these issues before this tropical paradise turns into another one of those ugly tourist spot in Thailand. I truly want to stay longer and work on those issues but my time here is up. I have to pack and get ready for my flight.

See you back in California...

Decoding in Chile

2012-01-02T20:59:00.000-08:00

This is my first blog post for my project on the ¨Medical Analysis of the Chilean National Forensic Database from an Emergency Medicine Perspective.¨ Actually, this is my first blog post ever, so hopefully it´s good! First, I´m going to give a brief introduction on the project. Then I will describe the 10th revision of the International Classification of Disease (ICD-10) and its importance in my project.

The Chilean doctors involved in this project work at the Pontificial University Catholic University of Chile.

My research project is a descriptive study on mortality rates due to injuries in Greater Santiago using the Chilean National Forensic Database from 1997 till 2010. Over the past couple months I´ve been working with Emergency Medicine physicians from USC, Dr. William Mallon, and the Pontifical Catholic University of Chile (PUC), Dr. Pablo Aguilera, Dr. Oscar Navea, and Dr. Marcela Garrido, to develop the project. The database includes the external cause (motor vehicle, gunshot, poisoning, etc.); the victim´s age, gender, and alcohol level; the nature of the injury (fracture of skull, third degree burn of hand, traumatic pneumothorax, etc.), the commune of the victim´s residence and the commune where the incident occurred (commune is an administrative division--it is comparable to a county); the origin of the victim´s body (hospital, street, jail, etc.); and the date of the incident. Essentially, we are looking to create a statistical description of deaths in Santiago of who, when, where, and why. It may not seem like we are looking at a lot, but we are looking at nearly 25000 victims in the database.

Marcela (left) and Pablo (right) in the office after our first meeting in Chile.

The sections on external cause and nature of injury (in our case death--all the entries in the forensic database are mortalities) are coded using the 10th revision of the International Classification of Disease (ICD-10). More specifically, the external cause of injury is coded using Chapter 20 of ICD-10 and the nature of injury is coded using Chapter 19. The dataset we are using has 850 unique codes for external cause and 500 codes for the nature of injury (however, we are not interested in the nature of injury for this study). These codes are used to facilitate the comparison of disease statistics between different countries. As I already mentioned, I´m only interested in one chapter of ICD-10: chapter 20. The codes used in this chapter are broken down into several groups including: transport accidents (car accidents, airplane crashes, etc.), other types of accidents (Falls, poisoning, etc.), intentional self-harm, assault, legal intervention and operations of war, complications of medical and surgical care, and a few others. This database only includes codes from the first 4 groups. These groups are further broken down based on the type of transport accident, the type of non-transport accident, and the method of self-harm or assault.

Pablo (left) and Osacr (right) with another doctor (middle) at the private Catholic Hospital. Oscar is my current host in Chile.

To give you a better idea of what information is included in the ICD-10 codes, and what I am doing for this research project, I´m going to take a few sample ICD-10 codes and decode them. Lets start with V03.12. The main code is ¨V03¨ while ¨12¨ is a subdivision. The ¨V¨ tells us that this was a transport accident. The other letters used in Chapter 20 include W, X, and Y. Our dataset only includes V´s and X´s (X´s can be used for non-transport accidents, intentional-self harm, and assault). For transport accidents, the first number also helps group the accidents: 0 refers to pedestrian victims, 1 refers to pedal cyclists, 2 refers to motorcyclists, etc. So, what does ¨V03¨ mean? It means that the victim was a pedestrian injured in a collision with a car, pick-up truck, or van.

Christmas Eve with David Acuña, a emergency medicine resident at PUC. I stayed with David´s family for my first week in Santiago.

Now you may remember what that the code was V03.12, so what about the .12? As I said before, the numbers following the decimal place are subdivisions (NOTE: from what I understand different countries and different sources can present the subdivision characters differently. They can present them following a decimal place, or they can present them separately). For transport accidents, the meaning of the first subdivision number varies depending on the first three characters (in this case V03). In our example, V03, the ¨1¨ means that it was a traffic accident (a ¨0¨ refers to non-traffic accidents while a ¨9¨ means that it was not specified if the accident was traffic or non-traffic). Let´s say that our code was V44.12. The first three characters, V44, refers to a car occupant injured in a collision with a heavy vehicle or bus. In this case, the fourth character, ¨1¨, indicates that the occupant was a passenger injured in a non-traffic accident. For all types of injures other than traffic accidents, the fourth character refers to the place of occurrence, which I´ll address later in our next example.

Finally, we have the 5th character. Remember our code is V03.12. Fortunately, the fifth character is the same for all types of injuries. It is the activity code and it tells us what the victim was doing when they were injured. A ¨2¨ means that the victim was injured while working for income (other codes include ¨0¨ for sports, ¨1¨ for leisure, etc.). So, in conclusion, V03.12 means that that victim was a pedestrian injured in a traffic accident involving a collision with a car, pick-up truck, or van while working for income.

New Year´s Day at parque los dominicos.

Let´s try one more code (because I know you are enjoying this so much). This time the code is X45.51. The X45 indicates that the victim suffered accidental poisoning by exposure to alcohol (it includes ethanol and other types). Meanwhile, the fourth character ¨5¨ means that the poisoning occurred in a trade or service area, such as an airport, restaurant, or supermarket. Finally, the fifth character ¨1¨ tells us that the accidental poisoning occurred during leisure activity.

Now if you are still awake, and if you enjoyed learning about disease coding, you can learn more about it at the WHO website, which includes an online version of ICD-10 and an online training program. http://www.who.int/classifications/icd/en/

A view of Santiago from Santa Lucia Hill with two emergency medicine residents: Catalina (left) and Valeria (right).

Wrapping up Cambodia

2012-01-02T02:26:00.000-08:00

Happy New Year to everybody! It's quickly approaching the end of my last full day in Cambodia and I must admit that I'm sad to be leaving so soon. There's so much left to see and do in this country, but most importantly, there's so much that can still be done at Sihanouk Hospital. Christian and I plan to keep working with the hospital in the future and we're really optimistic for the future.

I spent New Year's in Siem Reap on "Pub Street." I'll say this, they know how to throw a street party. It was awesome meeting people from all over the world and celebrating New Year's in true international style. Also, it's weird to think that I was celebrating New Year's 12 or 15 hours ahead of my friends. Siem Reap and the Angkor Temples were fantastic; I'm planning to return to explore the ruins more.

Christian and I returned to Phnom Penh by Sunday evening and today we spent the morning at the hospital conducting our final wrap up meeting with the lab supervisors. On the Thursday before we left for Siem Reap Christian and I had presented to the Executive Director and senior leadership team of the hospital on our report. It was very well received and I feel very blessed to have been part of this project. You can read Christian's blog on that day here: http://uscglobalhealth.blogspot.com/2011/12/finishing-touches.html.

We spent well over two hours discussing our activity-based costing model and template with the lab managers. The model that we created better captured their direct costs (labor & material) associated with their lab tests and provided instruction on how they could continue to develop the template without our assistance. Utilizing a combination of time/motion studies, analysis of procurement data, and information technology, we were able to verify and display their data in a more effective and useful manner. Now, Sihanouk Hospital can better determine the effect that fluctuating materials costs will have on their test costs as well as determine whether or not certain tests are unprofitable for them to run. This will go a long way toward shifting the laboratory from a cost-center to a revenue generating unit, allowing the hospital to better serve its patients.

I think both sides walked away from this experience with a lot of lessons learned. Syna challenged me to speak Khmer the next time I came back to Cambodia; I'll have to take him up on that challenge! I mean, I've already eaten tarantulas... how hard can Khmer be?

You can stay updated with my photos by checking out the public album link.

Happy New Year!

2012-01-01T21:01:00.000-08:00

Happy New Year!

It is finally 2012. It also means, the winter break is almost over.

WORK: I finally collected enough surveys (450 - my original goal was 300) from tourists. Majority of the tourists can speak English. They are mostly Eu

ropean from Sweden, Russia, Denmark, and the UK. I came to a conclusion that American prefers Bangkok civilization over this island (Ko Chang). I have to thank many people for helping me out with this project, without them I do not think I will be able to complete my project on time.

PLAY: I believe in "work hard, play hard" motto. Therefore, on Dec 31st and Jan 1st, I went out!

The picture above was taken during my snorkeling trip. The water was so clear and warm. Something I can never get in SoCal. I also fed sea monkeys (picture below/not the type that we grow in a jar of water).

Finishing touches

2011-12-30T17:10:00.000-08:00

I finally had a chance to upload some pictures from my camera. So let's begin.

The first image is a glimpse of our "office" while at the hospital. We found a nice, breezy, thatched-roof loft on one of the buildings. The hallway connects to the hospital administration staff and the staircase leads right into the laboratory. Space in the laboratory was limited and so we managed to stay mobile wherever the work needed us to be.

The next two pictures showcase our work gear. We used a large role of butcher paper and post-its to track out progress. This helped us present information to our project team members versus having to use too many words--language was a slight barrier still. And since there was no shortage of work to be done, this helped us stay focus.

I wish I could write more, but our driver is waiting for us as I wrap up this blog. Enjoy!

Developing Connections in Oudang Village

2011-12-27T16:20:00.000-08:00

This morning we went out to visit the Sihanouk Hospital Center of Hope's mobile clinic out in Oudang. Oudang was formerly the capital of Cambodia until it was moved to Phnom Penh at the behest of the French. It also seemed to have missed the modernization boat. It's pretty close to the city and the hospital provided us transportation to take a look at the work that they're doing in the outskirts of Phnom Penh.

I'll admit that there was a bit of culture shock when I got to Oudang. Phnom Penh is pretty modernized and not too far of a jump from western civilization, but Oudang was really just a country village. Apparently the government relocated many people here two years ago to make room in Phnom Penh for real-estate development. A real tragedy.

The mobile health clinic sees about 35 people each morning. In the afternoon, it switches over to become a medical education center for the residents. The clinic can only provide general care so for more specialized cases they are referred to the hospital. We were only there for the morning so only got to see them treating patients who were eagerly waiting for care (note that this clinic does not charge for its services).

While walking around the village an old lady kept beckoning me to come over and take pictures of her house. I walked over to her to oblige, but as I wandered over I realized something... I could understand her! Had I suddenly picked up Khmer during my few days in Cambodia? I wish, but it was really that she was speaking Cantonese. Oddly enough, her family was the only Cantonese speaking family in the village and by random happenstance managed to run into me, the one volunteer who spoke Cantonese. I spoke to her at length about living situation in the village, how she got there, and life in Cambodia. It was an amazing moment for to be able to shatter the language barrier even being across the world. I realized how much can be lost in translation and I appreciated the opportunity to connect and learn from someone who's lifestyle and outlook on life was so different from my own.

We also had the opportunity to visit the village's English school. Despite a lack of facilities, the school soldiers on and the village children are given a rudimentary education in English.

I spent the rest of the day reflecting on what I'd seen and starting the time studies in the microbiology lab. Our report out to the CFO is due tomorrow; we're pushing hard to get everything done but each direction we turn we keep finding more work that can be done, more training that could be completed. I hope Christian and I will be able to keep working with the Sihanouk Hospital over time and return to continue training their lab staff and IT department. There's just so much that can be done.

You can stay updated with my photos by checking out the public album link.

Merry Christmas from Phnom Penh

2011-12-25T07:41:00.000-08:00

Merry Christmas and Happy Holidays to everyone back home! Although it's just morning time of Christmas for those in Los Angeles and Vancouver, it's nearing the end of the day around 10:30 PM for me here. It's been an interesting Christmas Day though, and I'm glad to have the opportunity to blog more about it!

This is the first Christmas that I've spent away from my family in Vancouver, Canada. Many years ago, my family went on vacation to Thailand, and Santa came by to drop gifts off in our hotel in Bangkok. No such luck for me this year. Regardless, I jumped onto the day bright and early by starting out with the Christmas Church service with the Phnom Penh Church of Christ.

The service was held at the Ministry of Education because of the enormous size of the congregation. Singing, dancing, rapping, and break dancing were all featured by the kids. I wish I had a video of it to post up because it's so hard for me to accurately describe Christian rap combined with break dance (the visual is still strange in my head).

After service we went to grab lunch at a place called "The Living Room." Highly recommended by the Fetherman's, who I talked about in my previous post, the place had a definite western feel and served westernized cuisine. I had chicken pesto spaghetti with homemade pesto sauce - it was delicious. Sitting under the balmy weather and palm trees made it a great little spot for lunch. Additionally, the place serves as a social enterprise that "aims to offer employment, training, and fair working conditions to Cambodians graduating from NGOs working with vulnerable and at risk groups."

I took the afternoon to visit Tuol Sleng Genocide Museum. Visiting the site where so many horrific atrocities took place was definitely a deep experience. It was really similar to what it felt like to visit Dachau in Germany, except the events at Tuol Sleng took place very recently. The Khmer Rouge regime had taken meticulous photographs and records of their victims during their reign; this served to help identify exactly what each prisoner went through at Tuol Sleng. Additionally, they've got harrowing pictures of each victim posted - absolutely incredible what was done there on the grounds of an old high school.

Although I took a tuk tuk to Tuol Sleng, I decided to be adventurous and take a moto back to the hotel. A motel is basically a motorcycle or scooter that you ride on for transpiration. In the traffic of Phnom Penh, this becomes a trickier prospect given the traffic conditions and lack of adherence to driving rules. Regardless, I made it back to the hotel in one piece, and I wasn't turned off from the experience.

I went over to the Russian Market with Christian and his wife Idang where I ended up haggling for and purchasing a new belt. I'm looking forward to going back and getting some souvenirs and maybe another belt & wallet. Across the street from the Russian Market is a Kentucky Fried Chicken. KFC has several stores here in Phnom Penh, which really surprised me. I walked inside the restaurant and took a look at the menu. Yes, they've got the Colonel's secret spice, but their value menus included rice and fried egg. I wish they had that option back home! It also looked like Yum! was doing a lot for the World Hunger Programme, donating a fair amount of money to sustainable food and access to food. It was great seeing a company that recruits heavily at USC Marshall doing cool things all the way on the other side of the world.

I had dinner at a place called Samaky near my guest home. I returned to Khmer cuisine and ordered Amok for dinner, which is a meat dish served in a coconut (pictured above). If you come to Cambodia you have to try this dish out, it's fantastic. This was the second time that I had this dish and I do not regret having ordered it twice.

It's nearing 10:30 PM now and I'm about to sit down to crank out work for the hospital. I'm looking forward to settling in tomorrow for Day 2 and starting our time & motion studies of the microbiology lab. Hopefully what we're doing will help them bring down their costs in the long run. Talking with the hospital staff during Day 1 and seeing many of them at church service today really reinforced for me the importance of effective hospital administration. It's my hope that they see a few more volunteers looking to come and take on hospital administration rather than more doctors/nurses/medical students. There's just so much to be done here!

You can stay updated with my photos by checking out the public album link.

Healthcare Consulting Abroad

2011-12-23T09:37:00.000-08:00

Today was our first day at the Sihanouk Hospital Center of Hope (SHCH). Christian and I were picked up by the hospital at 8:30 AM in the morning from our guest house in Phnom Penh and driven over. Even in the morning, driving through the streets of Phnom Penh is an experience unto itself. I'm in awe that nobody was hit during the morning rush hour...

First order of business when we got to the hospital was a tour of the facilities by Sideth Chhin, the International Volunteer Coordinator. SHCH also serves as a training hospital for the area - one of the issues that Cambodia faces is that there is no formal residency program. As such, many of the doctors don't have clinical experience when they get out of medical school. SHCH has several international doctor volunteers that serve in the area helping to train the local doctors, making it possible for them to get supervised medical experience. In the past, SHCH ran on a lottery system for non-critical cases, so it would be the luck of the draw as to whether someone would get treated. Nowadays, they've moved to a triage system that prioritizes based on urgency. Additionally, they've made a conscious decision to focus on the poor, turning away those who can pay to one of the SHCH run medical clinics in the city that are fee-for-service. It's been a strategy that's been working, as in the past they've had patients dropped off by their families in Lexus's. Despite not charging for its services, SHCH is known for its quality, hence the large number of patients that swing by the hospital for services. SHCH has been around for 15 years, treating over one million patients during its time of operations.

We also learned that due to budgetary issues (less donations coming in than expected due to natural disasters elsewhere) the hospital had to shut down its surgical ward and limit its emergency department operations. It's a tragedy that they've had to do this because many of the people that come to the hospital have no other means of accessing healthcare. Hopefully the work that we're doing with their lab will help lower one of the hospital's most expensive functions, making it possible to reopen some services to the public.

We met with Don Fetherman, the CFO of the hospital in the morning to discuss the scope of what we're working on and how we could best help the hospital during our stay in Phnom Penh. There was no significant changes to the project described in my previous post "On the Other Side of the World," which is good. After meeting with Don, we went to the lab and met with the lab director Teav Syna to confirm our project and meet his team. I think there's a huge opportunity here for us to do some small changes that will result in big gains for their operations.

Some of the things that I've realized just in the first day is how difficult a consulting project on the other side of the world can be. Language and technology are two big barriers that we already encountered and are in the process of surmounting. Although Don speaks English (he's American), Syna learned English by himself on the fly and much of the hospital staff members don't speak English at all. Even though we were able to narrow down the scope of our project to focus on microbiology lab tests and developing a marginal test cost template for Don and Syna to project costs, we were still faced with issues in data collection. Christian went to work with the Director of IT while I went off to find Tea Eang, the Director of Procurement to source data. Luckily for me, Eang grew up in San Diego, so we were able to communicate without a problem. I can't imagine what it would have been like if I had to describe procurement reports in pictographs...

Christian and I got down to working with the lab team as soon as we gathered all the information. We found there were a couple of areas where we could quickly contribute, most of them centered around Microsoft Excel and reporting functions. It was great to be able to demonstrate value early on in the process and build a working relationship with the Lab team.

Some of my key takeaways from the first day:

As in any consulting project, it's critical to have an executive sponsor to act as the project champion and then a project manager to help implement the consulting project. In this case we were lucky to have the support of Don the CFO and Syna the lab director.
Again similar to consulting projects, scoping is key. There's so much to do here and the more we talked with Don and Syna the more things that needed fixing were brought up. It would be amazing if there was a hospital administration volunteer that could just help streamline operations for SHCH.
Data gathering, deciding what you need and getting it, is tough. Deciding what types of data we needed wasn't bad in this case given that we've done similar projects in the past, but concerns over the iffy IT structure and data integrity led to us not being sure whether we could complete what we promised to complete.
Sometimes, analysis means it needs to be done over Christmas. Despite the fact that it's Christmas Eve (ALREADY?), Christian and I are still working late into the night on getting a costing model done so we have a template by Monday to populate and test. Then again, whoever said this was going to be a walk in the park?
Clear and constant communication with stakeholders is critical. Although we're only here for a short while, we're looking at meeting with Don every day to provide updates on our progress as well as e-mailing Syna our updates daily (he's travelling out of town for training). We'll also be immersed in the lab so that we can better understand their professional culture and integrate with the team.
The Lab Team wants to learn! I have been super-impressed by how dedicated everyone here is to the work that they're doing. Many of the hospital team, especially in administration, are self-taught and internally promoted. Not many people want to come to work with a nonprofit free hospital that serves the poor, so SHCH has had to promote from within for a long time now. This has resulted in team members lacking the necessary knowledge to carry out their positions. It's not for a lack of desire to learn, but rather a lack of opportunity.

The first day has been exciting and filled with revelations for me. Christian and I are hard at work over the next week developing a marginal test cost template so that Don and Syna can have a better sense of how much the lab is costing the hospital to run, and how it might reach break-even point or possibly even turn a profit. Make no mistake, this is definitely an aggressive consulting project given our timetable. I can only hope that we can make a difference and provide sustainable long-term impact with the lab team.

Yes, we are working in a hallway. Necessity is the mother of invention, and there is much necessity here. You can stay updated with my photos by checking out the public album link.

Working in Ko Chang, Trat - Thailand

2011-12-23T03:38:00.000-08:00

Ko Chang is a beautiful island on the eastern coast of Thailand. The island has waterfalls, rainforest, salt marshs, wetlands, beaches, mountains etc. Basically, everything a person could ask for. It is a major tourist attraction, especially European tourists.

My job here is to survey tourists on a ferry to Ko Chang. The research is about tourist disease prevention. The tourists were very friendly. There were not many rejections, so far. To my surprise, I already surveyed 50 people/day, which was a lot more than my prediction. At this rate, I should be done in about 10 days. More time to explore Thailand!!

I also ran into 2 USC students. GO TROJAN!!! We bonded and had dinner that evening. Too bad, they only stayed for a night.

Phnom Penh Hustle

2011-12-22T05:57:00.000-08:00

After months of dreaming about it, I'm finally here--Phnom Penh, Cambodia. I just had dinner with Cristian a few hours ago after we rode around town in the bed of a pick-up truck. Piggy-backing on Cristian's earlier post, we got a new perspective (and perhaps a deeper appreciation) of the crazy driving skills required to navigate through the streets of Phnom Penh--it's not quite the same when you're in the middle of the action as opposed to standing on the sidewalk.
Fortunately for us, a family friend had graciously offered to pick us up and give us a tour of the city. Phnom Penh is definitely full of surprises and timeless splendor.

Well in less than twelve hours, Cristian and I will be visiting the Sihanouk Hospital Center of HOPE for Day 1 of our project. We don't have much time to lose and there is plenty of work ahead of us. I know the hospital has done, and continues to do, some amazing work in the country and I am truly humbled and thrilled to serve in such a small way.

Stay tuned, pictures are one their way....

Exploring the Kingdom of Wonders

2011-12-22T00:21:00.000-08:00

I'm waiting for the imminent arrival of Christian at the Golden Gate Hotel. Theoretically his flight landed two hours ago, so I'm hoping that he's made it in to Phnom Penh without incident. In any case, I took the opportunity this morning to take a walk around Phnom Penh and get a sense of bearing around the hotel.

Phnom Penh is a city of motorbikes. The streets are filled to the brim with them and I wouldn't want to be driving a car in this area. I'm definitely more cautious crossing the streets here, there seems to be reckless abandon regarding driving. I did notice an abundant use of high-beams by cars to warn motorcyclists of their approach. Pretty interesting traffic dynamic here especially when compared with that of North America.

Obviously I have internet here. It's spotty and unsecured, so as long as I don't go around doing online banking I imagine I'll be alright. There's a fair amount of wireless cafes here but what's really interesting is that there aren't that many landlines around. I've heard that it is because of the destruction of infrastructure during the Khmer Rouge era, but that's unconfirmed still (haven't Wikipedia'd it yet).

The primary reason of why I'm in Cambodia is to explore their healthcare system. To that end I've been wandering around looking at wellness clinics, pharmacies, and hospitals. I found an excellent blog by an ex-pat living in Phnom Penh about the healthcare system here: http://about-cambodia.blogspot.com/2011/09/when-you-need-doctor.html. I think tomorrow's visit to Sihanouk Hospital will be very enlightening.

A note on photographs. I am using three methods of photography to keep up with everything here. A digital camera, my cellphone, and a digital SLR. I am going to be posting photos from my cellphone as the trip goes along whereas the other photos will most likely wait until after I return stateside. I hope that's alright!

You can stay updated with my photos by checking out the public album link.

Sihanouk Hospital Center of Hope

2011-12-21T09:23:00.000-08:00

I’m heading off to Cambodia today with my classmate, Christian Basa, from the USC Marshall part-time program. The trip that we’re going on is supported by grant from the USC Institute for Global Health, and we’re headed to Phnom Penh to volunteer at Sihanouk Hospital Center of Hope (SHCH), a free hospital serving the poor of Cambodia. Because our background is in the business-side of healthcare rather than clinical, we’re going to be focusing on hospital operations, specifically their laboratory work. We’ll be here until January 4, taking a bit of time to visit Siem Reap and the temples of Angkor. You can stay updated with our activities by following my blog through the USC Marshall School of Business or through the USC Institute for Global Health.

Sponsored by the SHCH Medical Director and CFO, Christian and I will be evaluating the current cost model and capacity of critical laboratory test services that are offered at the hospital. We’ll be reviewing historical tests and usage rates at the clinical laboratory and performing a detailed analysis of in-patient & out-patient test volumes, as well as performing a throughput analysis for critical tests. Because of the differences in illnesses seen between a hospital in the 3^rd world country and a hospital in the United States, it will be interesting to compare how test volumes differs between the two.

The origins of this project comes from a conversation between Christian Basa and the leadership of SHCH, who identified a clear need at the hospital to baseline and optimize the current operation activities in the clinical laboratory. The laboratory currently engages in joint-research work with private and corporate sponsors. This engagement provides the hospital with either lease-free or full-ownership rights to laboratory equipment with the condition that certain testing obligations are satisfied. In some cases, the laboratory bares the cost of materials and maintenance required by the equipment. Reagent costs alone could account for 70% of a laboratory test cost. Although several of these tests are essential to supporting hospital operations, the laboratory is uncertain to the degree of profitability or loss incurred by providing the test services. We’ll be performing an activity-based costing analysis to assess the revenue model of the hospital and because cycle-times and test demand can be estimated, a throughput assessment can be performed on current laboratory equipment and labor capacities. Where appropriate, rapid improvements (i.e. kaizens) will be made to improve performance, safety, quality, and cost.

This project is going to draw upon both Christian’s experience as a lean six sigma black belt with project management experience in hospital and laboratory operations and my experience with business process management and my background with the U.S. Department of Health and Human Services. The classes we’ve taken through the USC Marshall School of Business will also be invaluable in determining how best to help SHSC.

Christian and I met through the USC Society and Business Lab Fellows program, a program that I’ve blogged about previously in my post "Changing the World with Business". We’re both keenly dedicated towards utilizing our business capability to have positive impact in the world. If you’re interested in social impact or healthcare, I invite you to take a look at the USC Society and Business Lab as well as the USC Institute for Global Health.

Reflection

2011-12-20T17:09:00.000-08:00

Hi all,

I have been back in the states for weeks now and definitely believe one last blog is in order. Upon arriving home I can't tell you how visually appealing everything looked and let me say, we really are lucky to live in a developed country where running water is not to be feared, electrical power outages come once in blue moon, and we can sleep easy knowing it is not extremely common to see children carrying newborns around begging for money. However, we have our own set of problems, one being our consumer culture, but lets not get into that.

I would like to take time to really thank the Institute for Global Health for making my trip to India possible. I believe the institute gives students from all fields the chance to fairly participate in a global understanding by traveling outside of one's comfort zone, and the institute advocates for students to explore different countries political, health, education, and cultural system. It is opportunities like these that really make a dent in students lives and really shapes our future career and personal directions. So really, from the bottom of my heart, thank you IGH!

I spent my last week meeting in India with the girls at Jamghat and teaming up with some researchers at PHFI. Here are some final pictures to end my practicum journey through India.

Spent some time playing games on the rooftop

Reading songs in Hindi

Pooja's masterpiece

Many many thanks to IGH!

Much love always,

Ellie

A greeting from Thailand.

2011-12-20T08:01:00.000-08:00

I arrived in Thailand about a week ago. And I completely forgot to

post a blog. Since I need to post 4 blogs, I should start now. While I waited for my IRB approval, I started out my trip by touring Bangkok and meeting my field advisor at Mahidol University, Thailand. I went to temples, malls, and other tourist traps. Mainly because my friend is also here with me in Thailand.

Wat Arun

On my way to this temple, I met exchange students from Germany and Austria. We joined force and toured the temple together. The temple was made with little pieces of china as you might be able to see in the picture.

Wat Pho

I visited Wat Pho the next day. It has the biggest reclining buddha. Thai massage is also originated from this temple. I did not get a massage in the temple. However, I got a 3 hours massage later on that day. IT WAS AWESOME!

Lastly, after three days in Bangkok, I got to my work place (Ko Chang, Trat.)

In the Working Zone

2011-11-21T05:41:00.000-08:00

Hi all,

This post will most likely be one of my lasts as time is ticking! I've been experiencing Delhi in the confines of my flat and at work. I completed my first paper, it turned out to be double the amount of pages I had expected. I meet with my supervisor tomorrow hopefully and we will plan out the next stage of the paper. He has a large database which I will be using to prove my points in a quantifiable manner. Again, I am working on a vaccination study trying to highlight the transition from old to new vaccines in developing countries and to see where policy is headed and where it needs to go. India is already in the scene for new vaccines but many critics claim epidemiological evidence is lacking to show vaccines for diseases like Hib or pneumococcal is essential at the current time. When you look at neighboring countries and developing countries many have been able to successfully adopt new vaccines which have been proven to be efficacious, safe, and cost-effective. The space is there for India, there just needs to be more studies and scientists out there ready to test the vaccines.

Where I spend my days - PHFI

As for my Ayurvedic survey, I have completed it and have passed it out to some people already. I am hoping to have more people fill it out this week and to at least create some sort of conclusion from it. I have been asking people at the ashram if they are willing to fill out my survey and many are open to helping. I am not sure I can get a large number of participants, but at least I will have some responses to work with.

Last Saturday I visited the girls at Jamghat and it was a great time. I bought a new cd for about 5 cents on the street and it had over 100 songs from bollywood movies, probably the best investment I've made so far. The girls loved the cd and we had a successful dance workout. After the dancing, I had a geography lesson plan and printed out maps of India for them to keep. I described the difference between what a map is, a state, a capital, and a city. The girls kept saying, "Didi (means sister), which map is this?" I repeatedly told them it's not map but a state, but it was funny to hear. They were really into this lesson and were focused the entire time. The previous week I had a lesson on oral health care and brushing, and next week I will probably create a lesson on nutrition and try to incorporate some songs in there. I'm really going to miss all of them!

The girls working hard!

I feel bittersweet about leaving India. I miss my family and friends, but really feel I am in a country where it is easy to explore, connect with others, and to reach out to those who are in need. I realize it does not matter where you are, that you can always help and explore, but I have grown pretty close to the way things operate here and the ease at which I feel I can grow as a person. The growth one can feel when being in the zone, whether working or spiritual, or emotional, is like a flame that keeps burning. I have no doubt that I will be back in India in the future and that the memories and stories will be with me forever.

This week, I will be making the most out of my time, working on my second paper, buying souvenirs, and checking out places which I haven't had a chance to see yet. My work friends and I will be celebrating Thanksgiving together. It will be the first time I will be away for Thanksgiving and my birthday, but I know it will be a good time! I plan on finishing my time here strong, so wish me luck!

See you soon!

Much Love,

Ellie

Negligence Toasted with Chai

2011-11-03T23:00:00.000-07:00

Hey friends & family,

It is November now, and time is whizzing by. I was in Kolkata for about 5 days, so I have a lot to share about my experience there.

A little bit on Kolkata:

Kolkata, formerly known as Calcutta, is the capital of West Bengal. Kolkata was a village before the British chose this place to rule in 1668. It also used to be the capital of India under the British in 1772, before it shifted to New Delhi in 1911. It is the only metropolis in Eastern India, and also the main business, commercial, and financial hub. It is widely known to be the birthplace of modern Indian literary and artistic thought. After Independence in 1942, Kolkata faced some challenging times. During WWII, millions starved to death during the Bengal famine of 1943. During the period of 1960s and 70s, there were strikes, severe power outages, and a violent Marxist-Maoist movement - the Naxalites, which hurt the city's infrastructure leading to financial stagnation. In 1971, when the war between India and Pakistan was happening, it led to mass numbers of refugees in Kolkata, which further hurt infrastructure. However, since 2000, information technology helped recover the economy and the city experienced growth in manufacturing. Many believe it is no longer associated with slums, destitution, and Mother Teresa, but has grown into the cultural capital of India. The climate is tropical with hot, wet, humid summers, and cool and dry winters. Bengali cuisine is delicious and the people are warm and friendly. Poverty still largely remains and Kolkata is said to house some of the largest slums with 1/3 of the population living in a slum.

Mother House

I arrived in Kolkata in the morning and went straight to Mother Teresa's House, where her Missionaries of Charity is located on 54a AJC Bose Road. I have always held high esteem for Mother Teresa and her charitable work, so one of my goals before leaving India was to see her house and volunteer at one of her homes. Mother Teresa lived in Mother House with the sisters and it is also where her tomb is. When I first stepped in, I met a few sisters, walked around in the mini museum dedicated to her, and chatted with some of the volunteers. The volunteer orientation was at 3pm so I had lunch and attended the meeting at Shishu Bhavan (the home for children) down the street. There were many volunteers of all ages and from far off destinations. I met volunteers from England, Switzerland, France, United States, Japan, and Ireland. Some have left their families on a volunteer mission, while others were there for a short time to give a helping hand.

Mother's Tomb

We were given some background information on the homes that we could volunteer at, some of which are: Kalighat - The home for the dying, Prem Dan - A home for women who were abandoned by their husbands, beaten, or suffered from various mental and physical illnesses and Daya Dan - A home for disabled children. Before our placement meeting, we had to read a paper written by a previous long-term volunteer. The paper demanded that volunteers not engage in any relationships or friendships with families and children in the neighboring streets (where most volunteers live). It emphasized the grave reality of sexual abuse which happens with these friendly gestures to help a child, and by giving money to these beggars, it is in a sense advertising and feeding into the cycle of an unlawful business. Most of the children who beg are hired or bought into this trade to make money for their owners. What looks like a mother and her children, are all just actors who are forced into this trade. There are reports of children on the streets being drugged; by giving them money, we are supporting the culture and abuse.

After the preliminary reading and logistical explanations, I met with the sisters in charge of placement. They asked me which house I would like to volunteer at and I told them to place me where they need me, since I was only there for a few days. The sister placed me in Prem Dan, where I was actually hoping to be placed.

And so the experience unveils itself:

I woke up for morning mass at 6am and prayed with the sisters. After mass, we went downstairs to the volunteer area where we had a breakfast which consisted of toast, chai, and bananas. As a group we engaged in some morning prayers and sang a cute farewell song to the volunteers whose last day it was, and off we went to our homes. As a group we hopped on a bus, paid about 5 cents and reached our destination.

Once we arrived, we went straight into our volunteer day. No instructions were given, I just followed the volunteers who had the routine down. First, we hand washed loads of clothing, bedding, and linen. Two volunteers were situated at a sink, all lined up like an assembly line: pre-wash, wash, rinse, and finally wring. Then we took turns taking full buckets upstairs on the rooftop to dry. After laundry, some of the volunteers and I went up into the home where we met the women and began to put ourselves to use. I cannot tell you some of the conditions these women were in (more on that later). I saw lotion being passed around, so I put my gloves on and began to lotion the bodies of the women (mostly ones who could not do it themselves, do to physical impairments). More so than lotion, I saw it as an opportunity for touch, which is so important to receive from other humans. Many of them were stiff, frozen and internally cold, with no sense of life. One young girl in particular who was mentally not all there kept coming back to me over and over to give her more lotion, I tried to tell her that was enough, but ended up giving her more to use because she could not understand. Once we were all through with the lotion and our time with them, we had a volunteer break, where we again ate bananas and had some chai. My first day was hard, I was angry and upset to see the living conditions and the lack of warmth and care in the home, more like "ward." Once break was over, we helped get their lunch ready and I fed a handicapped women who I had met before. She was an absolute delight. I am not sure what her physical condition was, but she could not use her right hand, and was not able to speak (her mouth was just stuck open). She could not speak, but she sketched her name on the bed, and spelled out

P-A-D-M-A. Her spirit was so lovely though, and she was so bright.

The next day looked very similar to the first, but I felt more comfortable being around the women and actually started to form a bond with some of them. Before I left, I made sure to tell one of the volunteers I was with to put music on in the afternoon, and to try to get them to dance, as well as settled the anger of a woman who was walking around and hitting the others with a wooden stick she used to walk with. The women that I saw had a wide ranging of conditions - some looked completely fine, and were young, maybe they had more dormant mental conditions. Others had hunchbacks, were severely burned with their eyes bulging out with only their whites showing. Many were older and angry, unable to walk, and having to crawl around the cement floors. The place was soulless, and the sense of hopelessness was overwhelming. I did not think I could handle physically seeing some of the deformities, but to my surprise, I was not turned off or fearful of their appearance or impairments.

The women were lined up like cattle, sitting side by side on the outside area of the floor - there was an inside area with beds (cots) lined up next to each other, with no room in between, and outside there were cement benches, shelves, and grounds. Some of my observations: no use of underwear, bugs crawling up and down the premises, women arguing, rocking back and forth, and threatening each other, cuts, bruises, and sores all over their bodies, abuse, and absolute neglect. I am not sure whether being at Prem Dan is better than the streets. There were no activities for them, basic hygiene, or emotional support. Many express their desire to go "home" to their "families," and by this they mean the streets. However, the sisters will not allow them to leave, especially the women (there's another section for the men) because they are afraid they will be sexually abused. And so they are ultimately held captive.

As a young girl in high school, and even until recently, I always had this grand view of Mother Teresa and her Missionaries of Charity. I am not about to criticize or make harsh judgments, but I am severely heart broken at the lack of care for the people who they have taken in and the way the workers treat the individuals at the centers. Many were rough with them, mocked them, and even pushed around the volunteers. Yes, the sick are off the streets, but are the better off emotionally? Are they receiving the medical attention that they need? Are they able to express themselves? Are they really safe, or do they FEEL safe?

After my experience, I did further research on Mother Teresa and her selfless goal to help "the poorest of the poor." To my dismay, I now know she believed strongly that suffering brings you closer to Christ, and did not believe in pain relievers or alleviating the distress of the people in whom she was helping. I have read stories where people were forced to defecate in front of each other, were denied medical drugs for serious conditions, and electroshock therapy was used as a form of punishment. Much happens behind closed doors. I will not go into any more details, but I am not sure where all of the millions/billions of dollar donations are going? People are blindly giving money to the Missionaries of Charity with the notion that they are giving towards a humane cause. Little do most know, that the money is just being given to the church, or used to push the low-income towards converting their religion. I cannot pass judgement on that, but all I know is that much needs to be done at these homes. The people are stuck, with no hope, and the volunteers, who I admire so much, and who all were so kind hearted and wonderful, are not only putting their self at a health risk, but may not understand the severity of the problem. The burning images of the loss of hope in the eyes of some of those women will forever be in my heart.

This experience was life-changing. More than that, it showed that there exists many forms of realities in this world. Additionally, saints may really be sinners in disguise.

Well, I have exhausted my capacity to write any further. I miss you all and love you all.

We were not allowed to take picture inside, but I will show you what I was able to capture.

MUCH LOVE,

Ellie

At Shishu Bhavan

Mother Teresa Pilgrimage Walk

Where some of the sisters are buried

Mother Teresa's school

Where she took her final vows as "Mother Teresa"

The wonderful volunteers @ Prem Dan

Interconnectedness

2011-10-22T03:38:00.000-07:00

Hi all,

I know it has been quite a while since the last post. Being here in Delhi for over a month now, I have really become accustomed to my new lifestyle. The thought of the temporary nature of this journey saddens me, but that is how life goes. It's one journey after the other, and what matters the most is that you enjoy it while it lasts and keep setting new goals and aspirations to strive for.

Recently, I have come to see how connected we all are. The people who I have interacted and met here in India have all had some distinct purpose along the journey and I could not be more thankful to have met such inspiring and courageous individuals. From my flatmates, to my co-workers, to random individuals I meet, I could not ask for more kind and soulful humans. I have become quite fond of my day to day here and feel like there is a purpose and place for me. Even if it is just one encounter, a weekend experience, or a deeper connection, whether it lasts or is destined for a short period, there is something to be gained and learned. Gushy stuff aside, I do believe we are all put on this earth to interconnect, share, and guide each other, however big or small.

Of late, I have been reading articles, papers, and journals for a literature review I am working on. The topic like I mentioned before is on vaccines. I am navigating through what is considered "old" vaccines, and pinpointing which "new" vaccines have priority in the developing country context. Six basic vaccines under India's universal immunization program (UIP) are tuberculosis, diptheria, pertussis, polio, measles, and tetanus. Recently, the government in Delhi high court created a policy draft strongly favoring the inclusion of new vaccines. There is much controversy around this because critics and health scientists believe the draft is flawed due to the lack of proof showing there is a need for particular vaccines, without a cost-benefit analysis and substantiating it with proper scientific evidence to suggest the prevalence of the diseases. So my main purpose is to take a look at the new vaccines which are trying to be pushed into immunization programs and to see where they fall in terms of cost-effectiveness, efficacy, and safety. It's been quite a task, sorting out all the existing data and findings, but through casting a large net, a key target policy will come of it.

In addition to the policy paper for PHFI, I've created an Ayurvedic survey to be disseminated to individuals receiving treatment. Some more background on Ayurveda: Ayurveda is a holistic national system of medicine that emphasized the mind, body, and spirit. The ultimate goal is self-realization or spiritual healing. Ayurvedic medicine is a connection between the microcosm and the macrocosm. Human beings are said to represent a small proportion of the universe, and the interconnectedness of human beings and their surrounding world make it impossible to understand one without the other. Ayurveda believes, we as humans are born in a state of perfect harmony and balance, but lose the perfection through improper diet or a lifestyle that does not suit our natural constitution or temperament. The purpose of Ayurveda is not just to cure diseases but to prevent disharmony, enhance health, create growth, and well-being. Every aspect of a person's lifestyle (diet, personal habits, work and home life, spirituality, relationships) are assessed. This makes treatment highly individualized and personal.

The skilled Ayurvedic doctor or practitioner has to identify the person's type to determine where the imbalance lies, and to balance the individuals doshas (bioenergetic forces that determine your constitution). In Ayurveda, there are three types of doshas (or tridoshas) which determine your composition (prakriti). An excess or shortage of a dosha can result in disease. The three are: Vata - which governs air and space. Pitta - which governs fire and water, and Kapha - which governs water and earth. We all have three but one dosha is dominant, sometimes two are. It's really fascinating to find out which dosha you are dominant in, it can help connect the dots in your life decisions, mood, diet, relationships, strengths, weaknesses, and health.

I have had the pleasure of connecting with an Ayurvedic ashram and have seen for myself the nature of cleansing, detoxification, meditation, and healing. For my research, I am specifically looking at how various Ayurvedic treatments effect the overall health and well-being of people who undergo them (physically, emotionally, socially, and spiritually). Treatments can take form of herbal drugs, oil massage, sweating, vomiting, purging, nasal drops, and bloodletting. These purifying techniques are used to remove toxins and undigested, unabsorbed, and unassimilated food.

An experienced Ayurvedic practitioner must administer these therapies. Ghee, is also very commonplace, used to reestablish intestinal flora. Once your unique treatment plan is set, a strict diet and lifestyle suggestions are implemented for long-term health outcomes.

What I love about Ayurveda is that it gives you the options and understanding to take control of your own health. The practice gives you a sense of hope and its place is not to tell you how sick you are, but it shows you how to heal, and rebalance your whole self. I am a believer of the power of Ayurveda to heal any individual, if they undergo proper treatment and shift their unhealthy habits. The shifts are not demanding, and the diet changes and lifestyle plans are very manageable and fair.

So, I hope I have given you all a glimpse of what I have been consuming myself with.

As for interesting cultural updates - I was able to get to Old Delhi to see the Red Fort recently and went to my first mosque in India, named Jama Masjid, meaning world-reflecting mosque. Other than that, I visited the Dastkar Bazaar "Nature Bazaar" that happens once a year and lasts a couple weeks. NGOs, grassroots organizations, artists, come together to sell one of a kind products, like camel poop paper, wallets, statues, jewelry, natural soaps, just about anything you can think of. The money then goes towards the organizations cause. There are also really cool art exhibits happening this month.

Malik showing this guy who's boss (they sold him a fake usb stick the previous weekend)

Red Fort

Jama Masjid

Latitude 28 Exhibit- Persian artist (in the picture)

With the gang in front of the Nature Bazaar

India Habitat Center Art Exhibition

Right now, it is pre-holiday week, with Diwali coming upon Wednesday. Diwali is the festival of lights and it is celebrated all across India in the fall around October or November. Diwali is said to lead us to the light of knowledge from the darkness of ignorance.

A brief history: Diwali celebrates the return of Rama and Sita, in the story of Ramayana. The story shows good overcoming evil. Prince Rama and his wife, Sita are banished from their home by their father, the king and sent to Ayodhya. Rama's brother, Lakshmana joins them in the forest for 14 years. After many years, Sita is captured by a 10 headed demon known as Ravana and taken to an island. With the help of a warrior monkey, Rama rescues his wife. The people of Ayodhya light oil lamps in rows to guide them back from the forest to Ayodhya and crown Rama king upon their return. The festival is held in honor of Lakshmi, the Hindu goddess of prosperity and wealth.

Families generally celebrate together at home and offer sweets, dried fruit, and decorative items to friends and each other. The exchanging of gifts is believed to help strengthen relationships. The holiday lasts five days. People wear bright new clothes and pray for prosperity and happiness for the coming year. Everybody goes outside to watch fireworks and the sounds of crackers (firecrackers) consume the whole city. The crackers have been going off all week! I keep having to remind myself it's firecrackers.

I attended a lovely pre-Diwali festival at a local park last night, on the way there a dog followed us up until we found an auto (we named her Jubi), definitely the first highlight of my weekend.

Then at the festival we rode the rocking boat-ship (definitely the second highlight of my weekend). This week I am hoping my lovely flatmates and I will have a family dinner together.

I'll be traveling at the end of the week, so I'll keep you all posted!

Happy Diwali <3

MUCH LOVE & LUCK!

Ellie

Love is Here

2011-10-11T21:12:00.000-07:00

Hi there,

I have lots to update you on! I'll take it one thought at a time. The title of the post is irrelevant, I just keep seeing this graffiti art that says, "love is here" and keep missing my opportunity to take a picture of it.

I told you all I was going to start volunteering at an orphanage, so I'll report on some of my experiences so far. When I arrive at the flat, the girls are eager to dance and get on with the agenda for the day. I start with a warm-up, exercise - a combination of stretches and yoga, and then we go into a fusion of bollywood, belly dancing, and classical dancing. The girls are receptive and even the little ones pick up on the tough beginning exercises. We have a great time, and I make sure at the end, to have one of the older girls come up and teach too. I am trying to show them that they too can lead the class, they just have to stand up with confidence and give it a shot.

Front door of the orphanage

Beginning exercises

The girls dancing

Hanging out with Pooja

Made Ushma take the lead

After the dancing session, we go straight into a little classroom they have, with chairs/desks, and a chalkboard. The first icebreaker I set was an emotional exercise. I drew a scale, with a happy face on one end and a sad face on the other. I had the girls come up and place a mark on the scale to see where they are emotionally. Half of the girls were on the happy end, while the other were on the sad end. I had a hard time communicating "what makes you happy," because they just kept repeating words, like happy to me....so I figured I would let it go until the following week. The following week, I created the scale again, and most of them were on the happy end. I then in Hindi, asked, "what makes you happy," and the girls responses varied. A lot said, seeing the boys (they live in another flat), one girl said a rainy day, another said thinking about her past, and another said remembering her mother. At that moment, I felt I could better connect with them and could get a sense of where they stood.

With the classroom lessons, it is hard to get all the girls focused, especially the little ones, but I do my best to draw in as many as I can. The funny part is, when the time comes for the end of our session, all the girls flood in wanting homework. It is so hilarious to see them begging for homework! I did not go prepared with homework the first day, so I came up with something for them to do. It is interesting because most of us try and run away from homework, but I am glad they are for it. Maybe because it gives them something to work on when they are bored, or they really enjoy the task.

Once we finished the icebreaker, I set up a lesson on five senses, and had them touch various items and I repeated what they were in English so they could see what the words were, instead of just feeding them random English words. After that exercise, we did a lesson on hygiene and hand washing. I explained the concept of germs and when it is important to wash your hands. We moved around the flat together, so I could show them various situations when it is needed to wash, and we ended with a hand washing demonstration. I also showed them how to properly cover their coughs, and to make sure to wash when they are sick too. The demonstration took them step by step on how to rinse their hands first, properly scrub, and then we counted to twenty together to keep track of the importance of time it takes to wash. I brought the girls a lemon bar soap to keep, and they loved the exercise, wanting to wash and show that they understood. I plan to give a lesson on dental care and brushing next week.

Mumtaj washing her hands

This past week, I threw in a question on what they wanted to be when they grow up, and the responses were - a couple said doctors, one said dancer, another said teacher, caregiver, a couple said mothers, and one said model. That day, I happened to be going to Indian fashion week, and something just clicked in my head. The girl, who is the brightest out of the bunch, and really works hard at learning and helps me translate, wanted to be a model.....so my instinct was to ask her if she wanted to come with me. I didn't even know if I had an extra ticket, or how it would work, but I asked. She was shy, and acted like she didn't want to go, but she really wanted to. I asked Amit (the founder) if it was okay, and he told me it was fine, as long as one of the caregivers went too. So, I called up to see if I could get extra tickets and made it happen. It was a wonderful time, and although I wasn't advocating for her to be a model, it is definitely possible to be a model and also be educated. We all know our dream career can change a hundred times, but I just thought the timing was too good to let it go. All in all, I'm loving my time at the orphanage.

On the red carpet with Eram and Elizabeth (caregiver)

At India Fashion Week

With my favorite designer of the night, Nachiket

Last week, PHFI along with the Center for Disease Dynamics, Economics & Policy, and other organizations put together the 1st Global Forum on Bacterial Infections. It was a three day conference, with professors, doctors, and health care professionals, coming from across the world (Kenya, Chile, Sweden, South Africa, Thailand, Malaysia, Korea, and more) to be there. I attended some of the sessions and was there for the inaugural day. I saw the Minister of Health and Family Welfare of the Government of India, Dr. Ghulam Nabi Azad, make his speech, and gained some new insights on antibacterial resistance and current mechanisms in place to combat the problem. The Indian minister spoke about how with newer antibiotics, the problem still exists, and there are constantly new strains emerging. He recommended to exclusively regulate antibiotics, and to procure availability of antibiotics within the market. He also urged the need for institutions/universities to invent new antibiotics with comprehensive surveillance. He emphasized how India is unique because not only are you dealing with a large population, but the size and spread of India makes it difficult to combat antibiotic resistance. Problems like the lack of doctor availability, and lack of medical facilities/personnel in places where it is needed is missing. He ended with stating that although antibiotic resistance is a global problem, solutions should be local, since there are different health systems in place across the country. He also proceeded to advocate for Indian tourism, by pushing for us to shop while we are in India because it is so inexpensive.

India Minister of Health - Dr. Ghulam Nabi Azad

Another, really interesting session I attended was based around pharmacists and informal drug dispensers. A very well educated and speaker who is an Indian pharmacists clearly explained how 80-90% of consumers receive their drugs through informal drug dispensers, and about 60-90% of people live in rural areas.

He went on to explain that the number of pharmacists in India = 1 million, while the number of informal drug dispensers are 1.5 million. He also shared how the number of registered pharmacies are 700,000 - 800,000, while the number of unregistered outlets are 1 million. Informal drug dispensers are a leading cause of antibiotic resistance, because people don't comply with the appropriate duration, there's self-medication, and there's weak health care delivery. Counterfeit drugs are also high, with cases of veterinary products mixed in and "natural medicine" which contain steroids in them. He suggested we get rid of informal drug dispensers, get professionals in the public and private sector, and train them. This has been tried, but it's hard to fill the void with a formal health sector. It's difficult to recruit professionals; revenue is low in rural areas, and it's harsh conditions for people to live in. So he ultimately believes if we give incentives to the informal drug dispensers (training one head person), and give them more money if they do less harm, refer people to the right primary care centers, and distribute appropriate health goods, this will be a successful and scalable strategy. I found this session the most interesting, because it was the most practical and proactive discussion. Overall, the conference was definitely a great experience, and I was fortunate enough to attend.

Pharmaceutical session

So, currently, I am working on my own research and have narrowed it down to the topic of vaccines. I am also working on a side study on Ayurvedic treatments and have connected with a center who will be assisting the study. I'll fill you all in more as the week goes by.

Right now, I'm just sitting in the living room, thinking about all I have to do, and hoping the power doesn't go out again. The power has gone out more times than I can count today. Okay, I'll write back very soon.

MUCH LOVE,

Ellie

Universal Oneness

2011-10-06T08:38:00.000-07:00

Hi family & friends,

Happy Durga Puja! The month of October is a very festive time in India and there's lots of rejoice and unity in the air. The past 10 days have been a particularly important holiday for many, so I figured I would share the story and mythology to you all.

Mother Goddess Durga

Durga Puja is an annual Hindu festival that celebrates the worship of goddess Durga. The dates of Durga Puja are set according to the traditional Hindu calendar and is largely celebrated mainly in the states of West Bengal, Bihar, Assam, Jharkand, Orisa, and Tripura, which consist predominately of Bengali Hindus and is considered the biggest festival of the year. Goddess Durga is considered the deity of power. She was placed on the earth in aims to kill the demon Mahishasura, who was set to conquer the world with his tyranny and invisible power. Significant Lords known as, Lord Vishnu, Lord Brahma, and Lord Shiva (her husband), summoned her as an avatar to save the earth and living beings from the monster-demon Mahishasura. Ultimately, with the weapons provided to her by the Gods, she was able to push forth and conquer his invisible strength as a beautiful warrior, sitting on her lion. She is seen as the mother goddess, with her ten arms, and her name in Sanskrit means invincible.

The last day is today, and common rituals that occur during this time are fasting, feasting, prayers, and offering of various items such as food, water, various powders, clothes, plants, and more. On the last day, known as Dashami, she is placed in the river or lake for a farewell. For 10 days, she leaves her husband Shiva to visit her parents on earth, and then returns to her heavenly abode.

I visited several different sites today in Durga's honor, and felt at ease knowing everyone was there to celebrate the victory of good over evil in unison. I offered some sweets to the Gods and had kumkum spread on my forehead for the first time.

I'll share a story I read about the Divine Mother, Durga Puja:

Goddess Durga and Lord Shiva's son, Lord Ganesha, came across a stray cat while playing. Little Lord Ganesha was thrilled about the animal and began to manhandle it. He even resorted to pulling its hair, scratching it and beating it up with a stick. The frightened cat ran for its life.

After his play, little Ganesha went home. He was shocked to find his mother, the Divine's hair disheveled with scratches on her face. He was horrified to see her limp as she moved about.

He burst into tears, "Oh Mother! What has happened to you? Who beat you up?"

The Divine Mother Durga replied, "It was you who beat me up, a little while ago"

Little Ganesha was perplexed. He claimed to be playing out and hence was not responsible for his mother's affliction.

Divine mother Durga replied, "Do you recall the way you ill-treated the little cat? You thought you were hurting it, but you were actually hurting me!"

The truth immediately dawned on little Ganesha that the Divine Mother Durga is the inherent being in all beings of the manifested world. The manifestation of the world is nothing but the manifestation of Durga.

When I read this story, it really hit me that the actions you place on others do end up either hurting or helping the collective whole. There is a universal oneness we all share, but often forget. What you place on others, in one way or another gets returned to you or someone close, coming into a full circle.

Well, tonight, I've been missing lots of you and the states, but am really thrilled to be here for the wonderful season.

I'll be posting again shortly with some updates!

Here are some pictures from the day -

Even the dog has a bindi!! (too cute)

Bengali sweets!! (YUM)

MUCH MUCH LOVE,

Ellie

It's Best to Remain Calm

2011-09-27T06:29:00.000-07:00

Hi everyone,

As I'm sitting here on the couch, sipping on some hot Taj black tea, my mug reads:

NEVER GIVE UP

Never give up-

no matter what's going on,

develop the heart,

Too much energy in your country

is spent on developing the mind

instead of the heart,

Develop the heart,

Be Compassionate

not just to your friends,

but to everyone,

Be compassionate,

work for peace

in your heart and in the world.

And I say again,

never give up,

no matter what is happening,

no matter what is going on around you,

Never give up

- Tenzin Gyatso, XIV Dalai Lama

It's interesting that I just realized the mug had this written on it. Oddly, today I had the Dalai Lama and Tibet on my mind. I was just thinking about Tibet and read about how two Tibetan monks set themselves on fire while protesting against Chinese policies in the area (not the first time). It seems the monks have given up... or have they? The oppression the Tibetans must face daily probably makes them feel helpless, like they have lost all control and a way out. Chinese occupation in Tibet has resulted in deaths of hundreds and thousands of people, the destruction of monasteries, nunneries, temples, and imprisonment and torture of thousands of Tibetans. Peaceful Tibetan protests driven by the desire to be a sovereign nation, are causing aggressive arrests and punishment by the Chinese army. The ruthless rapes, murders, attacks, and cruelty are too much to even imagine. As someone put, "today they all have only one hope, one dream and one voice. A free, independent Tibet." And so it seems never give up, for justice will one day be served. Until then, develop the heart, be compassionate, not just to your friends, but to everyone (irrespective of the circumstance).

Tonight has turned into a calm night. I got to my flat after work, rested a bit and decided to go on my balcony to try and hear the catcalls (from actual cats) outside. Well, little did I know when I shut the screen, it locked me out. Here I am in a tank top, thinking i'm going to get bitten by mosquitoes, but all I could do was laugh. I just kept laughing and realized even if my flatmates were home, there was no way they could hear me from upstairs. I sat for a second, and then began to shout their names....no response. So I sat some more and shouted some more, until I realized, it's easy to get all worked up, but harder to just stay calm. So, after about 12 minutes, I got up again and realized the other end of the sliding door could possibly be open, and sure enough the door opened, and I felt free from confinement. Although, at the end of the day, it wouldn't be the worst thing to be stuck out there all night....i'm just glad I wasn't. To unwind, I ordered some boneless chicken kabob and buttered out naan.

As for productive updates, I met with an amazing NGO called Jamghat (means "a lively gathering") this past weekend that deals with homeless street children. The founder, Amit, singlehandedly built a place for street kids from all walks of life to have a place of their own. The children have a flat/floor to themselves and have care 24 hours, 7 days a week. The age range of the 10 girls who live in the flat is between 5 - 14 years old. Amit's main goal is to keep the number of children who live there small, in order to give them appropriate nurturing, attention, resources, and to avoid spreading himself and his mission thin. What makes this NGO so unique is its range of possibilities. Amit has created a place for children and adolescents to learn vocational skills, like hand bag making, and to be self sufficient. He is also known for putting on theatre productions bringing awareness of issues like HIV/AIDS, global warming, and even emotional plays. His theatre productions have been performed for King Charles, World Bank, various universities, WHO, etc. This man has put his heart and soul into Jamghat and it shows in the children's faces and in their presence. After speaking to Amit, he has allowed me to come and volunteer at the home with the girls. I will be teaching them some dance, public health lessons, and english because they are really interested in learning. I meet with them this Saturday, so I'll update soon.

In the meantime, here are some pictures -

Vocational Training

Amit with some of the girls

Alright, until next time! By the way, Happy 16th birthday again Omid Afshar, you're my world!

MUCH LOVE,

Ellie

Anxious to Get Down to Work!

2011-09-25T23:54:00.000-07:00

Written on August 21, 2011:

HI!

It’s almost time for me to leave and I have yet to complete my survey! I’m getting a little anxious as Dr. Pan’s schedule seems quite heavy and everything depends on when he can get me in to survey people. He suggested the end of August to my collaborator here, Dr. Duan, but she informed him I’m leaving on August 25 so he scheduled me in for August 23 (just two days before I leave!)…but he insists that I can survey 30+ people in one day, and there is really nothing I can do about it at this point, so I just have to trust that this will get done. I’m glad that I had a full 5 weeks here, which I had imagined to be not enough time, but apparently this entire time was needed as Dr. Pan’s schedule is quite full and he keeps making revisions to the questionnaire. His suggestions are good so I’m not complaining but again, the time frame does make me a little anxious. I guess I just have to learn to be patient and learn how to deal with "China time" (translation: delays). For now, I’ll leave you with these beautiful pictures of Gǔlóu Jiē (Old Drum Tower Road) and the Beijing Art District. Just when I think I could never live/survive/cope in China and I’m feeling overwhelmed and frustrated, I'm reminded of how beautiful, fun, and quirky this city is. The Drum Tower Road pictures were taken on my way to eat lamb skewers—a popular street food item. Enjoy!

Trying to Buy More Time

2011-09-22T20:51:00.000-07:00

Hello hello,

It's been over 2 weeks now, and I'm trying to make use of the time I have left in India. I have been spending the past week at PHFI reading up and brainstorming measurable research possibilities, and have been familiarizing myself further with health systems economics, medicines, and universal health care coverage in India. I should have a set topic by the end of next week or following week (the latest). I am also drafting my case management paper on the health voucher scheme and will have that completed by early next week.

An area i've been spending a lot of time reading and understanding is access to medicines, vaccines, and technology. Medicines are a major component of modern health systems and have been developed to reduce death and diseases around the world. India produces enough drugs to meet domestic consumption, and is one of the largest exporters of generic and branded drugs, it has been deemed the 'global pharmacy of the south.' Many life-saving drugs to developing countries and supplies of quality drugs to rich nations at decent prices come from India. Nonetheless, millions of Indians themselves do not have access to drugs; cost of drugs and lack of public health facilities are factors contributing to the problem. About a third of drugs prescribed in hospitals during the mid-80s were given for free. Free drug supply has dropped from 18 percent to around 5 percent in outpatient care. Not to mention, Indians rely on private chemists for medicine purchase. This raises a thought....many chemists (essentially a shopkeeper of drugs) you see on about every corner, give away drugs without prescription, guidelines for dosage, and there seems to be a natural culture of self-medication. I guess that's not too far off from the states, I mean a lot of us use WebMD or treat ourselves, but I see it more of a way to know what's happening to you, and then you have the doctor confirm the medication/diagnosis. We also have many restrictions to accessing drugs, we need the proper referral and there's a gate-keeping mechanism to follow. I'm curious to see if self-medication is commonplace for many.

Another factor that plays into to barriers to medicines is a lack of regulation of drugs and diagnostics. There's poor enforcement of the Drugs and Cosmetics Act of 1940, making regulation in the health sector ineffective. The Central Drug Standard Control Organisation (CDSCO) of India has the task of approving new drugs and clinical trials, importing controls, setting standards, and overall coordination of state drug control authorities. State drug control authorities are only responsible for regulating the manufacture, distribution, and sale of drugs. Inadequate drug regulation leads to the production of forged and substandard drugs. The quality of drugs is also touched and the medicine on the table is questioned on whether or not it is efficacious or safe. There were recent deaths of pregnant women in the city of Jodhpur due to contaminated IV fluids brought on by the manufacturers. Drug quality has really become an issue in India in recent years with claims of ineffective drug production administered and produced by small drug manufacturers. In 2005, drug manufacturers in India became tied to a mandate which made them abide and comply with Good Manufacturing Practice (GMP) regulations, and harmonious global standards to create quality drugs. Yet, quality of Indian drugs is still questioned over and over again.

PHFI has several data sets in the area of medicine and vaccines, so I will be working with the evidence they have accumulated to write a research paper within the realms of drug regulation and barriers to accessing medicine.

Moving away from my research possibilities, I'll update on some new happenings. Last weekend, my roommate, a couple of her friends and I went to Kashmir. Kashmir is in the northwestern region of India and today is part of the Indian-state of Jammu and Kashmir, the Pakistan regions of Gilgit-Baltistan and the Azad Kashmir provinces, and the Chinese-administered regions of Aksai Chin and Trans-Karakoram Tract. Kashmir is really one of the most beautiful places in the world, but it has been troubled by disputes. Kashmir wants to be an independent state. Maharaja Hari Singh, the ruler of Kashmir from 1925-1952, was Hindu while his people were mainly Muslim. Therefore, he was unable to decide which nation Kashmir should join, making Kashmir a neutral region. In 1947, Pakistan sent Muslim tribesmen to the capitol, Srinigar, and the first war over Kahsmir began between India and Pakistan. India took the dispute to the United Nations, the UN called for Pakistan to remove its troops and for India to withdraw its forces. Once this happened, it allowed Kashmir to have the freedom to decide their future, but that did not play out as planned. Pakistan ignored the UN mandate and continued fighting for part of Kashmir. In 1949, there was an agreement made with 65% of the territory given to India, and the rest to Pakistan. Again, fighting broke out regardless of many more agreements. In 1989, there was a massive genocide which drove out all the Hindus in the valley before the troops reached them. The ongoing fighting and bloodshed has been going on for more than 5 decades. In 2002, credible elections took place which favored negotiating with the separatists. A couple years later in 2004, the prime ministers of India and Pakistan held a meeting and discussed steps their countries are taking to ease the conflict. Since the 2004 peace talks, violence has lessened, but the tension over whose territory it belongs to still stands. It really remains an unresolved conflict.

When we arrived to Srinagar, the capitol of Kashmir, it was absolutely gorgeous - it has been compared to the Swiss Alps.It was quiet, the air was fresh and felt like somewhere far off. My roommate has a family friend who had us over for breakfast - his cooks made us delicious omelettes, and he spoke of his shawl business. He sells very expensive pashmere and wool shawls that run up to $7,000 US dollars. After breakfast, he drove us to the houses where the shawls are made (both hand made and machine) and we saw the workers in the room quietly sewing and weaving, it was really something. Mid day, we drove to where we were going to stay, which was on Dal Lake and were given a house boat for the weekend. The house boats at this place are well known, and many prominent people have stayed there including Ambassadors and musicians like George Harrison. The house boats were surrounded by Kingfishers and Maple trees and a staff that made the place feel like a home. One of the mornings we woke up at 4am to take a shikara (boat) out into the water to engage in the morning market. We sat in the shikara and bargained with the local people who were selling saffron, vegetables, jewelry, and sweets. It was so interesting to buy and sell goods on water. We also stopped and watched bread being made for the morning round. I really loved Kashmir and didn't feel any of the political unrest that has had such a history there. We went to the countryside and had a horseback ride in Phelegum through the mountains - I missed riding. Overall, it was pure beauty and I felt lucky to have had the chance to be there. Kashmiri people are known to feed you and feed you and feed you!! So, even if you're full, they will put more food on your plate. Kashmiri's are incredibly hospitable and warm. In Kashmir we were surrounded by lots of mosques, being that the majority of the people are Muslim. It felt comforting hearing the prayers at 5am and they have someone live on the loud speaker 5 times a day, so no matter where you are you can hear it.

Anyhow, I've said a lot. I intend on reading more this weekend and I attended a German-Indian outdoor music festival with an Indian star percussionist (who was amazing, his name is Sivamani) and a German solo percussionist at the park last tonight. This festival was part of a series of events to celebrate the year of Germany and India. On a side note, it was interesting to find out that government public elementary schools here teach their children how to speak German. They also teach them Spanish too. I think we should really require Spanish to be taught to our elementary kids.

I'll write again in a few days to update you some more. MISS you all!

MUCH MUCH LOVE!!!

Ellie

Enjoy the pictures ---

Breakfast at Mr. BishirJ's

Seeing the shawls being made

This man's picture was in the National Geographic

Patience

Antique Austin Car

Lovely Kingfisher

More FOOD!

View of Kashmir from Parimaha (The palace of Fairies)
Bread being made underground at around 430am

At the morning market

The house boats

Bulletin from Beijing

2011-09-22T19:36:00.000-07:00

Written on August 10, 2011:

I’ve been in Beijing for a little over two weeks now, and I’m really starting to settle into life here. I have a studio apartment which I am leasing on a day-to-day basis from a family friend and it’s much nicer and cozier than I expected (albeit rather expensive).

On my second day here, I visited the Chinese Research Academy of Environmental Sciences (CRAES) and met with my collaborators, Dr. Duan and a PhD student who insists that I call her what her friends call her, Zhenzhen. I presented my research topic and questionnaire to them and Dr. Duan is going to arrange for me to meet with a physician from the Beijing Maternal and Children’s Hospital (BMCH), who will facilitate the administration of the survey. Dr. Duan has made some minor revisions to the survey which I composed before my departure as I had to submit it for IRB approval. I then asked a relative to translate it into Chinese for me and Dr. Duan is helping me refine the Chinese version so it is easier for participants to understand. I hope that I can start administering the survey soon, but this really depends on Dr. Pan’s (from BMCH) schedule. In the meantime, Zhenzhen and I went shopping to purchase the gifts we’re going to be giving to the participants—packages of disposable diaper wipes. Dr. Duan believes the study participants will appreciate them and put them to good use.

Before arriving in China, Dr. Zhang had given me some interesting background in the population I'll be working with. He informed me that the average pregnant woman in Beijing is older and more educated than her American counterpart. Because of China’s strict one-child policy, women in urban areas of China do their best to make sure they are ready—in terms of family structure and finances—before attempting to have a child. There are also fewer teen pregnancies and single-mother pregnancies in Chinese urban areas in comparison to the States. I believe this places a lot of pressure on Chinese women to attain the right balance of success and stability before a certain age so that their one child will be born into the environment parents wish them to be brought up in. As you can imagine, the one-child policy—and the added pressures that come with it—have serious and far-reaching effects on social relationships and structures. It will be very interesting to see if the results reflect these demographics and how the average (educated) pregnant woman in Beijing views air pollution and its effects on her child.

‘Til next time,

Lily

Packages of disposable diaper wipes for the participants.

Zhenzhen "MODELS"ing our gifts!

The Chinese Research Academy of Environmental Sciences:

2011-09-19T18:44:00.001-07:00

It’s a big week for IGH!!

On Friday our first online course with the New York Times Knowledge Network launched focused on the Global Rise of NCDs and the UN High Level Meeting on NCDs. The course offers a great forum for in-depth discussion about how to manage the global rise in NCDs.

Today we spent the day dodging (heavy) security around the UN interviewing governmental, non-governmental, and industry delegates to the High Level Meeting and posting the interviews on the course website (see picture of the beautiful NYC day!). We have two more Live Classroom discussions tomorrow and Thursday. If you want to join in, it’s not too late!! Register on our website.

Tomorrow we are co-hosting a lunchtime side event at the High Level Meeting with the Ugandan Permanent Mission to the UN focused on the Rise of NCDs in Sub-Saharan Africa. We are expecting a good turn out and a great discussion.

Then on Wednesday we are attending the Social Goods Summit to launch our Facebook game ‘1000 Days’, developed with ABC News and the Global Alliance for Improved Nutrition. The game is live so go on and play and share it with your friends!! (apps.facebook.com/thousanddays)

Perhaps the most interesting part of the week so far has been in the incredible security at the UN and all over New York. It just so happens that the hotel I am staying in is also the hotel for the security dog teams…. Literally there are dozens and dozens of enormous dogs staying on my floor. Signs on all the doors say “DO NOT DISTURB – BEWARE OF DOG”!!

Am I Dreaming?

2011-09-16T02:52:00.000-07:00

Hello from India,

I was away without internet access for 3 days, so I could not write as planned. I've been in India over a week now, and there's so much to say. I'll try and spare you ALL the many details, but let's just leave it at every day is really a new day here.

I arrived in Delhi, the night of September 6th. I expected the airport to be flooded with people and hectic, but it was quiet and easy to get around. I did have an emotional breakdown when I thought my bag was missing, but it was just rotating around the carousal....typical.

When I finally reached the exit, I had a driver waiting for me with my name written in pencil on blank computer paper. On the way to my new apartment, I noticed how busy the roads were with cars and people out and about (even though it was past 9pm). I live in a sector of Delhi called Vasant Kunj, it is also where I work at the Public Health Foundation of India (PHFI). My flat is just the right size and my room is cozy. I have two roommates, both very down-to-earth and friendly.

The very next morning I woke up to meet with my research overseer at PHFI. I took an auto-rickshaw to work, and had my roommate accompany me the first day. I knew I had to learn quickly, because if you act too slow, you will get ripped off or lost. So, my first two days here really felt like 2 weeks. After the initial panicky couple days, I felt like I could really get used to it here.

At PHFI, I discussed my interests in the field of public health; mainly to understand the health care system that exists here and described my skill set background. My supervisor gave met a set up papers to read and broke down some important research he's involved with. He also explained to me how the health care system works in broad terms. The health care system in India is quite complex! I'm still trying to understand it all.

The country of India is the largest democracy in the world. The potential for public health debate to be put on the political agenda is huge. However, health is rarely a decisive political issue in national or state elections. Looking at the health care system, it is one of the most privatized in the world. Since almost all private services require money out-of-pocket at point of service, the poor bear a large portion of the financial burden. More than 40% of Indians borrow money or sell assets to cover their medical expenses, leaving more than half of Indian households to fall into poverty.

Public health expenditure accounts for about 1.10% of the GDP, and there's much variation of resource allocations between states and territories. Per capita government health expenditure in India is one of the lowest in the world - US$7,000 compared to US$2,548 in the United States.

You might be wondering if there is a place for health insurance? India's tryst with health insurance program goes back to the late 1940s and 50s when the civil servants (Central Government Scheme - CGS) and formal sector workers (Employees' State Insurance Scheme - ESIS) were enrolled in a contributory but largely subsidized health insurance program. However, these programs, especially ESIS were confined to a small part of the society, and enrollment remained low due to the fact that it was only for formal sector workers. The informal labor sector represents 95% of the population. CGS, ESIS and the private health insurance (which started in the 90s, for high income groups) took up about 5% of the population.

Notwithstanding, since 2007, a whole slew of initiatives have been created, both from the central government and state governments. The goal is to upscale government health expenditure to 2-3% of the GDP through innovative schemes. Consequently, this would enhance access and availability of health care services and protect households from financial risks. Two big schemes are the National Rural Health Mission (NHRM), and Rashtriya Swasthya Bima Yojana (RSBY) - there are also state specific initiatives, which really vary across the board. Research now is being done to have a more integrated model and have the 3 central government schemes under one umbrella which would ensure efficient allocation of funds, and expand access to better care and private facilities. There is also a lot of research and direction towards universal health care in India, and essentially a single payer system.

This past week, PHFI gave me the opportunity to travel with some maternal/child health researchers to the state of Uttarakhand. The purpose of the 3 day trip was to meet with various stakeholders and mothers/families in the community to monitor and get a feel for a health voucher scheme in place in 5 districts. In 2005, the government of Uttarakhand launched the National Rural Health Mission (NRHM) in the state to provide health care to the rural population, especially disadvantaged groups like women and children, by focusing on public-private partnerships (PPP). A voucher scheme system was created to give provision for reproductive health services to BPL families (families making less than a dollar a day).

Basically, mothers in rural areas were given vouchers that would give them an option to deliver and get reproductive services through either a public or private provider free of charge. As you may already know India has a really high infant mortality rate; 47.57 out of 1,000 live births. Many rural mothers cannot afford to give birth in private hospitals or simply do not give birth in a health facility, leaving them more vulnerable to such things as hemorrhage, toxemia, anemia, obstructed labor, and puerperal sepsis. Their newborns are at risk of pneumonia, tetanus, prematurity, and birth asphyxia. When mothers do deliver at the government hospitals are faced with overcrowding, poor quality services, lack of gynecologists, untrained nurses, and lack of resources. Therefore, this voucher scheme gives mothers who are BPL the opportunity to have their delivery, prenatal, postnatal and antenatal care, sterilization, and family planning services taken care of in a facility of their choice. The voucher itself gives them a sense of confidence to get their needs met.

The team and I visited two districts in Uttarakand - Haridwar and Dehradun. Haridwar is an important pilgrimage city and is seen as one of the seven holiest places for Hindus. Dehradun is located in the foothills of the Himalayas, and is situated between the Ganges and Yamuna rivers. The two districts really varied from one another in terms of the delivery and views of the scheme, but in a general sense the voucher scheme did contribute to about 16,000 deliveries in private hospitals. Some village mothers were clueless about the scheme, having been missed from receiving their BPL cards (you need it to receive the vouchers), but the second scaling up phase of the scheme will reap better results. The pilot scheme was an utter success, however the scaling up phase 1 faced some challenges with financial adjustments/financial cuts, but appropriate measure have been set for the scaling up phase 2. Overall, the mothers were open to talking to us, and it was incredible to see the state of living of the BPL families. I was shocked to see first hand the places in which these large families (extended families) lived in, but could see that even with the little materials they had, they were functional and some places were impeccably clean and efficient with their scarce resources. I felt so lucky to visit both places, and was able to experience the beauty of it. PHFI's main objective is to monitor the scheme and to also create a documentary on the findings and successes. I'll definitely share the final product when it is made. My role now is to create a case management paper for this particular scheme.

I've explained a lot so far! I really wanted to write earlier, but could not get around to it because I was traveling and busy getting myself together. I will really try to post more often!

Aside from my interning, I have been able to explore. I went to the Garden of Five Senses, and took in all the exotic flowers and plants. I also found out gardens are a really great place for young couples to hide out and spend time alone together. There was also a random dance off with awesome music in a section of the garden; a bunch of adolescents were hanging out and having a good time.

I was able to go to Agra last weekend to visit the Taj Mahal. It felt unreal being at the Taj Mahal and making my way inside; the architecture, stones, calligraphy, and carvings were beautiful - it felt very persian and familiar. I went with a co-workers friend, along with an organized toured called the "panickers." It was quite funny, because as soon as we thought we lost the group, the guide would say, panickers, panickers, come here. haha. So appropriate. We went to the Agra fort, Taj, and then a Hindu temple around 10pm. Right when we got off the bus to get to the Taj Mahal, it began to rain so hard, so we opted for umbrellas given by some young boys at the side of the road. Funny enough, later that evening, as soon as we arrived at the temple it started to pour again. I experienced walking through the wet ground completely barefoot, quite a trip.

Going back to Haridwar and Dehradun, all I could say is wow. Haridwar really is the hub for spirituality; there were Sufis, mystics, and pilgram types all around. I was lucky enough to get to see and put my hands in the Ganges river (don't worry, i'm still alive!), it was really something. In Dehradun, the Himalayas was on the backdrop, and it was so green and clean. The mountains were so quiet and peaceful and the families were generally happy and extremely friendly and hospitable.

Overall, I'm really getting used to it here. The cows, the dogs all around, the traffic, the quick power outages, the random rains, my new friends, and the every day uncertainty is keeping me on my toes.

Okay, here are some pictures --

An auto-rickshaw

The Garden of Five Senses - Prayer for Peace

Little puppies built a home under the wood

In front of the Taj Mahal

Random cow relaxing

Feisty Camel

First family we met with in Haridwar

Second family we met with in Haridwar

The families baby lamb (yes, that's a bug bite not a bindi)

Private Nursing Home (aka hospital) we met at - notice cervical cancer testing banner

Poster material bringing awareness of the voucher scheme

Peaceful Ganges

The Himalayas

Lovely family in the hills of Dehradun

Beautiful grandmother - she wanted her picture taken

The Accredited Social Health Activist community health worker (ASHA), mother and I

Put my hands in the Ganges River!

Well, I'll post again very soon! Miss you all!

MUCH LOVE,

Ellie

The USC Institute for Global Health has a new look!

2011-09-13T17:24:00.000-07:00

Today, we launched our redesigned website to better accommodate our growing presence at USC. We hope you find it easier to use (and easier on the eye).

We are currently featuring our Global Health Lecture Series, our new Program on Global Health and Human Rights (GHHR), and an online course on non-communicable diseases created in collaboration with the New York Times Knowledge Network.

On our new website, you can browse through up-to-date articles on global health and explore the projects we are involved in globally and locally.You can also find helpful links for job opportunities, scholarships, internships, and fellowships through our resources section. Be sure to mark you calendars for our Global Health Lecture Series events and check out the education and grant programs we offer for students.

Send any feedback on our new site to Larissa Puro, the web and media coordinator, at puro@usc.edu.

Stay connected with us through Facebook and Twitter as we work with you to fight on for global health!

Banana Village

2011-09-08T13:52:00.000-07:00

Day 12: It is our second to last day in Kiritimati. When I first arrived here I never thought that 2 weeks would go by so quickly. The days have been a success, one success after the other. We have received so much support by the hospital staff and the subjects. So many people have wanted to partake in our assessment and we have reached such a high number already. Today we have over collected over 450 subjects!

The goal is to get 500 participants. Luckily our last stop is in a village called Banana, they live under a fortress called a 'maneaba' which is a huge thatched made up of coconut wood and palms and concrete floors where people can sleep. Yesterday we visited the Protestant maneaba and had success so today we hope to have great success with the Catholic maneaba. Unfortunately this maneaba does not have electricity so we had to go back to get our portable electric generators to power our Piccolo Labs which is what we are using to collect lipid readings. And as we had begun setting up a nice tropical rainstorm hit. Everyone living in the area ran under the maneaba except the children who went playing, which left us to shuffle around the people and finish our set-up so we could get started. After the hour of setting up and the rain subsiding we began assessments.

During the next couple hours we were on pace. The people kept coming and the assessments, dietary recalls, and blood glucose was moving like an assembly line with people only waiting to get cholesterol testing done. By 1pm, we had taken a lunch break and decided to spend time with the kids who were quite the avid dancers and coconut tree climbers. It was great to see the children having fun and it was a reward to have spent some time with them. The nurse of the village took us for a tour of it. She showed us the new school being built and also where the old one was. After our lunch tour we got back to work. We had come close to our goal and tomorrow was the last day to get our final assessments and to do a mini preliminary analysis of our data before we left!

However, tonight was the little féte they were going to throw for us. And it was quite the party. They roasted a pig and made our beautiful flower leis for our heads. They had a wonderful song and dance they put together for us as well as a cake! I hadn't eaten sugar for two weeks so it was quite a delight! It had been a beautiful day and even better evening to spend it with our wonderful team of nurses, doctors, and their amazing families!

It's Hot in China

2011-09-07T18:04:00.000-07:00

Hi! It’s been a whirlwind trip and I have a lot to catch up on! A lot of blogs (and Facebook) are censored (blocked) in China so I’ve had to use the school VPN to access certain sites. As such, these blog entries were written while I was in China but I didn’t want to post them there since I’ve heard stories of people’s seemingly harmless blogs being removed. For the next couple of weeks, I will post my entries one by one, but I’ll let you know when they were written.

Written on August 1, 2011:

Hi from China! Or, I guess I should say “nǐ hǎo.” First, let me just start by giving a quick introduction of my project and background on Beijing. I’ll be assessing air pollution beliefs and attitudes among pregnant women in Beijing, China. My advisor, Dr. Jim Zhang in the Biostatistics department, is collecting data for his project to assess the correlation between air pollution exposure during pregnancy and adverse birth outcomes. My project will be an offshoot of this main project but has very little to do with actual data collection and analysis. Basically, I’m interested in understanding how pregnant women in Beijing view air pollution and whether or not they’re concerned about its health effects during their pregnancy. To do this, I will be conducting a short survey (~50 questions) among pregnant women in Beijing.

To give you an idea of what I’m working with here, you might need to have a little background information on Beijing. With a population of almost 20 million as of 2010, China’s capital city is one of the most populous cities in the world. Air quality has long been an issue in Beijing, and the government is taking steps to address this problem. A joint American and Chinese study in 2006 found that much of the city’s pollution comes from the areas surroundingit. Before and during the 2008 Olympics, the Chinese government billions of US dollars to attempt to improve the city’s air quality. More recently, the Chinese government has taken a strong stance on smoking and secondhand smoke by banning smoking inside buildings. This is an unprecedented and laudable policy since tobacco sales are State-controlled and China supplies about 30% of the world’s tobacco. Despite this great public health leap forward, many question the efficacy of the ban and wonder how and if it will be enforced. Indeed, since coming here, tobacco smoke seems omnipresent. Whether I’m sitting in a restaurant, walking down a street, or outside the Beijing Maternal and Children’s Hospital, there is the unmistakable smell of tobacco smoke if not actual cigarette smoke being blown in my face.

On the bright side, there is evidence of a growing awareness and improvements in this area are visible. While in a swanky shopping mall, I saw “No Smoking” signs in the restroom, and I’ve seen anti-smoking messages elsewhere—for example, at Subway. Granted, the shopping mall is known for having more foreigners than Chinese people, and Subway isn’t exactly a Chinese enterprise, but these types of messages were nonexistent when I was in China in 2007, and I believe they are a sign of more improvements to come.

Here's a photo from being a tourist last week in Beijing's Art District, called 798. Notice the lack of blue skies. This is what the sky always looks like in Beijing.

Poland, Here we come!

2011-09-07T13:39:00.000-07:00

On Day 4, the team of Kiribati nurses and our team headed to Poland which is the farthest side of the island. And right when we arrived there were already 20+ people waiting to be seen, it was definitely very rewarding and successful to see that many people waiting at 8:00am. The nurses and I had been working from the moment that we entered the clinic until noon nonstop. Things started out a bit hectic because when people see you they automatically want to begin their assessment. It took a bit of time to adjust our way of doing assessments to make it as efficient as possible for our subjects and ourselves. Needless to say that throughout the day I learned how to say thank you, here it is phonetically, “kor-aba”. And by the end of the day we had seen over 50 people which was a success, and in the past two days of beginning our assessment we had seen 100+ people. Each individual had done an assessment survey, a dietary recall, blood glucose, and a lipid test. By this time, I definitely had a sense of purpose and a new outlook on how desperate care is needed on this beautiful atoll. The women, men, and children were so appreciative and tried to show it in small gestures. During our lunch break, I had an extra Trail Mix CLIF bars that I gave to the children waiting around the clinic for their parents, which they shared among themselves. The Welfare Committee of that village had brought us food for the day which consisted of fresh caught fish that was broiled, papaya, coconut/coconut water, toddy, and rice or noodles. The day was a long one considering we left at 6 A.M. and came back around 7:00pm since it is about a 2-3 hour drive to and from but it was one of the most rewarding especially when assessments died down a bit in the afternoon. I spent some time interacting with the people of the village and their children. I learned a lot from them --there is something to be said about actions speaking louder than words. In this small island where I could not speak the language, I could communicate more than I ever have been able to communicate with someone speaking the same language as me.

India on the Horizon

2011-09-05T10:16:00.000-07:00

Hello all,

Mera nam Ellie Afshar hai (my name is Ellie Afshar), and I'm a recent USC Master of Public Health graduate (well almost). I started my practicum at the USC Institute for Global Health (IGH) in the spring, and am concluding my studies as an intern at the Public Health Foundation of India (PHFI). I will be stationed mainly in New Delhi, India, but will have the opportunity to travel to parts of southern India.

At the Public Health Foundation of India I will be working with the health systems team on issues relating to health care and equity in India, especially the dimensions of cost, and socio-economic inequities in health care utilization in India. Although India's standards of living have risen, there still exists pockets of terrible poverty and deprivation. Just to give you an idea - the ratio of hospital beds to population in rural areas is 15 times lower than urban areas. The ratio of doctors to population in rural areas is almost 6 times lower than the urban population. Looking at infant mortality, an infant born in a poor family is two and a half times more likely to die in infancy than a well of family. These stark statistics only solidify the need to move towards better improving access to health care (mainly in rural areas), system restructuring and strengthening on the financial, institutional and management ends, public-private partnerships, and outreach strategies to remote areas.

I am hoping to research the many factors that contribute to the health care dichotomy between the rural and the urban areas. Factors like health care access, economic and political contexts, and the role of private health care are some markers to understanding the 39 million people falling into poverty every year as a result of health care expenditures. I'm fascinated to finding out firsthand what it takes for individuals to seek and receive every day health care and their perspectives on the system on a whole.

Alongside my work with the Public Health Foundation of India, I hope to explore the many dimensions of medicine in India and the use of traditional medicine vs. allopathic medicine (the east/west uses of medicine). It's fascinating how many in the India use Ayurveda as a part of their life and I'm curious to see how it is practiced and how it contributes to health seeking and health outcomes. Ayurveda pronounced (aa-yoor-vay-da) is the oldest complete medical system in the world with recorded origins dating back 3,500-4,000 years to 1200-800 BC. It is a science in which the knowledge of the body (sarira), senses (indriya), mind (sattva), and soul (atma) are defined in one meaningful system.

Well, I think I've said enough. This will be my first time in India, so I am going to take it all in as much as I can. My nerves are all over the place, but I know I am doing what I have been set out to do. I would like to thank the USC Institute for Global Health - without your support, I do not think I could have made it here. I would like to specifically thank Ivette Flores, Heather Wipfli, and Jonathan Samet. Also, I would like to thank the Public Health Foundation of India for so generously offering me an internship.

Wish me luck! Until next post!

Much Love,

Ellie

The Beginning Of The Journey to Kiribati

2011-09-01T09:50:00.000-07:00

To start off the beginning of the trip the plane was delayed by about 3-4 hours from the initial flight thus United tried to make up time so we’d only arrive an hour late. So upon arrival to the airport there are 7-8 luggages and supply boxes waiting to be picked up. I had rented two of those little dollies because there were so many luggages and supplies coming off the plane. Nonetheless almost everyone at the airport was interested to see what we (Alexandra & I) had in our frozen boxes. It was great to see the support even in Honolulu. Dr. Beale (P.I.) came in to meet us and helped us out to the truck…we would not have been able to do it otherwise. So the rest of the evening comprised of going to the hotel in Honolulu checking in, getting our luggages upstairs and making sure we had the last bits of information and supplies before we headed out the next morning to Kiribati. Once we boarded the plane in the A.M. there was no turning back with one flight in and out once a week.

We had a dinner and called it quits for the evening. In the morning we were up early at around 5:45am starting to get ready for the day. The plane didn't leave until noon but we had to be at the airport at 9:00am and we were meeting with our P.I. at 7:00am for breakfast. It was a great morning although I had some stresses because no matter how many times you check a luggage you always think...maybe, just maybe I forgot something (which we did not forget anything). Nonetheless, after breakfast and checking out we were off to the airport. Had our last view of the Ala Wai Canal and next thing you know we are at the airport. I am really glad we did arrive their early because with so much luggage going through; it took quite some time for clearance. Next thing we know Air Pacific is calling our names in "Final Call" for our group. Once on board, I was excited! The flight felt like years even though it was a 3 hour flight. I wanted to land and get started. Once we did land, reality set in --this is going to be home for the next 2 weeks. Let the work begin.

From An Inside Look at Global Health Activity at USC

Pictures from Shirati

2011-08-17T20:52:00.001-07:00

In front of the Sota Clinic with Dr. Kawira and the nurses.

An old Burkitt's patient coming for a check-up

Getting to the Interviews

One of the families visited

Day before summiting Mt. Kilimanjaro

Looking back through the pictures, it's hard to believe that I've only been back to LA for less than 3 weeks. Life here is so much more hectic that I really miss the days in Shirati. Leaving Shirati was sad after being there for a month. The other guests we met there were staying until end of August or September, so I almost wanted to stay with them. Luckily, we had planned for some fun traveling after Shirati or else I might have just postponed my return.

After Shirati, we went on a safari through the Serengiti, and it was amazing seeing the abundant wildlife. We were even lucky enough to spot lions enjoying their kill. My favorite part of the safari, however, was the Hippo Pool. Our guide brought us to a pond where there were over a hundred hippos lounging around.

Kilimanjaro came after safari, and it was a huge contrast from the chill days riding on our jeep. Climbing Kilimanjaro was a feat. We took six days for the entire journey. While it was not a technical hike (there were trails along the entire way), it was definitely demanding. Each day required at least a 7 hour hike. Luckily, we were required to hire porters to carry our stuff because otherwise, I definitely would not have been about to do it. The toughest was dealing with the altitude. On summit day, you could not sleep because the air was so thin, and then you had to hike through the night with your altitude sickness. It took just about every ounce of our strength to get there, but we all made it to the highest point in Africa. :D

End of Trip

2011-08-06T18:56:00.001-07:00

The trip has come to a close. I was very glad to get appointments with the national department of health and the national treasury in the last week. As I look over the information I've collected, I think it can be safe to say that I will not be able to get a full list of the PPIs in South Africa. I have a rough list of about 20 that I'll be able to include in my report, but I think the most comprehensive part of my research will be the categories of PPIs in South Africa that I put forward.

I'll spend the next week reviewing the information I've collected, processing it, and typing up my report. I'm excited to see how the paper is received, and though it is more of a primer on South African PPIs than an evaluative study, I think that this report will be able to pave the way for future evaluative studies in South Africa. I'm going to contact a journal or two to see if they are interested in the paper.

Many thanks to the USC Institute for Global Health for supporting this trip!

Sunday, July 31, 2011

2011-07-31T13:45:00.000-07:00

It has been a busy month for the two of us! July creeped up on us quickly and there's been no shortage of things to do. Brooke's house became a mini-lab, full of lab equipment and Alex's house became a mini-print shop, full of paperwork and binders to be organized. One of the major things that we've learned about international projects from this experience is that sometimes you just have to play it by ear. Both of us prefer to be very organized and precise about having things completed and ready to go but this isn't something that we've been able to accomplish so far. Trying to coordinate with the Ministry of Health and doctors and nurses on Christmas Island only through email has been a challenge that has been further complicated by the cultural barriers between us. For example, during the IRB approval process, the IRB asked us what the Kiribati government's policy was on getting consent, does it need to be written or can it be verbal? When we relayed this question to our contacts on the island we were informed that this is a question that had never been asked before, there was no policy! So while they are trying to determine what their policy should be, our IRB approval is on hold. But despite all the craziness, we're excited to get on the ground in 2 days and start working with our team on the island. It's amazing to think that we're doing something that's never been done before!

Here's just a look at the huge amount of stuff we're taking with us!

Penultimate Week Update

2011-07-27T01:51:00.000-07:00

I've lost count of how many weeks its been. I think 4. But I know that it's my second last week, hence the title.

Last week I was in Durban, on the east coast of South Africa. Unfortunately, two of my meetings fell through, so I had a relatively quiet week. I met with the Department of Health as well as one of the largest Non-Profit Hospitals in the country (McCord Hospital, http://www.mccord.org.za/cgi-bin/giga.cgi?c=1285).

My trip to McCord was fantastic. Not only was it incredibly helpful to my research, but it was a place that I could see myself working one day after I get my training as a doctor. McCord allowed me to open up an entire new category of public-private collaboration in South Africa, the area of Provincially/State Aided Hospitals and Clinics through the country. These are Non-Profit Organizations that provide services just like a regular hospital or clinic, but get a portion of their funding from the government. They use the excess funds to develop the hospitals infrastructure and slash prices to make their care more affordable. It's a brilliant solution that only non-profit organizations can survive on.

This week, I'm in Pretoria, the administrative capital of South Africa. I've already met with someone from the National Department of Health, have set up an appointment with the National Treasury (they have an official PPP unit for funding projects), and am in communication with the National DoH PPP director. Unfortunately he is out of his office this week and will not be able to meet. I'm heading down to Jo-burg this afternoon to stop by a research institute and then I'll make a few personal visits before I head back.

I've spent the past week trying to understand the structure of the health care system here in South Africa and doing so has helped me understand the different categories of PPPs. One of my preliminary conclusions is that I've found three major types of public-private collaboration in South Africa, (1) official Treasury-sanctioned public-private partnerships, (2) funding of/collaboration with non-profit organizations, (3) contracting out of services to private health professionals. There are multiple theoretical systems with which to classify the different models for PPIs. One was even developed specifically for South Africa, however I've found that one of the systems developed at UCSF seems to be the most useful for both categorizing and then for going backwards and trying to get information on a project simply by looking at the model category.

I head down to Cape Town at the end of my trip to hopefully meet with someone from the Department of Health, and I'm hoping to get a meeting with the President of the South African Medical Association as well. We'll see how those stack up-but I'd be quite fortunate to get either!

July 26th, 2011

2011-07-26T02:10:00.001-07:00

We have met with all four schools that we will be working with to conduct research assessing girls' knowledge about physical fitness. In the two high SES schools, Seeta and St. Lawrence, the girls are open to sharing their thoughts and have a wide knowledge about health in general. They are relatively up to date on new findings in health (for example, the health benefits of red wine). Although they are hesitant to take on sports as a hobby, they were eager to learn yoga with me, and were pleasantly (hopefully) surprised by how tough it is to stand still. Because they come from families who can already afford their expensive education and their well-rounded education will most likely land them a good job, these are the girls that will have to battle overweight in the future. However, with encouragement their habits can be changed. They already look up to western celebrities such as Rihanna and Beyonce, they just need that extra push to also take up exercise habits.

The two low SES schools are a bigger challenge. The girls are reserved, quiet and painfully shy. In their traditional village culture, women are supposed to be reserved and do as they are told, so it is hard for them to open up with their own thoughts, especially to a foreigner. The answers that they were giving seemed to be "textbook answers." When asked about the importance of exercise, they said "to prevent high blood pressure," but none of them had any idea what high blood pressure means. After a few sessions, they have begun to open up and answer and ask questions more freely. We allow them to submit questions on paper if they are scared to raise their hands and ask. What seems to be the most immediate concern, however, is not physical fitness, but it is information about sexual health and safe sex. Even though their culture values virginity, many of the girls are having sex, but are not given the information about how to have safe sex. They are curious, and because it early sex is shameful in the community, they are too afraid to ask anyone but their friends about it. I want to share everything I know but I must wait until there is a curriculum that I can follow, to give them information that is culturally-appropriate and approved by the community.

Yesterday at Bulamu SEED, a government school for low SES high schoolers, we played a game where everyone sits in a circle called "I love my fellow girls who... (insert something about yourself that other people also share)" for example, "I love my fellow girls who have a brother." Then, everyone who has a brother must stand up and run to an open seat. They really loved this game and were laughing and being silly. I was excited to see them giggling and having fun, and we've made a lot of headway in getting the girls to share their personal opinions and questions.

Today, I will be visiting a health clinic in the village.

Till next time!

Stephanie's Gift

2011-07-25T07:59:00.000-07:00

Life in the Tanzanian village is hard. While it's not the kwashiorkor picture of poverty I had expected, people do work hard to get by. As a foreigner, you start to become desensitized to the poverty after a couple weeks, but once in a while, you come across a story that really tugs at your heartstrings...

I met a boy in the village today who became paraplegic shortly after the death of his mother (the reason for his paralysis is unknown). Hi father had left them long before, so he is now under the care of his aunt and uncle. They have cared for his basic necessities, but they do not have the resources to support his disability. As a result, he spends the day crawling around his house. His knees have become so rough from the crawling that you can't even straighten his legs for him. The one thing that the boy desires more than anything else is to go to school, but he does not go for shame of having to crawl the distance to school.

A couple of weeks ago, Stephanie (one of the guests at the hostel) found the boy and was moved buy a wheelchair for the boy. Because the wheelchair had to be delivered from another city, she left before she could give it to him, so my friends and I had the privilege to bring it to him. The smile on boy when he saw his new wheelchair was priceless. He was so excited to try it out for the first time, and all he could talk about was that he would be able to start school the following day.

Economics in Tanzania

2011-07-25T00:31:00.000-07:00

One day as we were riding back home from our interviews, we were met by a massive raincloud. Raindrops came pelting down on us as we found shelter at a nearby coke stand. While we waited out the rain, I had a very productive conversation with Killion, our translator. Interested in how financial prosperity affects a family's willingness to seek medical treatment, I asked Killion to explain how the local village economics work, but instead, I was given a brief history lesson on the economics and politics of East Africa. This is what Killion told me...

When East African countries gained their independence, they had one of two options: completely abolish their colonial political and economic structures and create a new country from the ground up or build upon the existing system and make gradual improvements. Kenya, a country that chose the latter, has thrived economically in comparison because it built its industries on top of the existing framework. Tanzania, on the other hand, is far more impoverished because it demolished not only the framework but also the infrastructure that colonialism left behind. The Tanzanian government didn't have the immediate resources to build a successful country from scratch, and widespread political corruption compounded the problem. As a result, Tanzania has become one of the poorest countries in East Africa despite its wildlife and mineral wealth. Some villages watch their agricultural surpluses go to waste while others starve because of the lack of roads connecting the country. Furthermore, the value of the Tanzanian currency has dropped below the Kenyan shilling in the past thirty years as a result of poor global monetary policy, affecting the buying power of basic commodities.

Killion's lesson ended here because the rain had passed and we needed to get back on the road. That was probably one of the best conversations I had with Killion. I wish I knew more about the regional history and the economics of developing countries to learn more from him, but alas, maybe the next rain.

A Wedding and A Funeral

2011-07-25T00:07:00.000-07:00

In our time at Shirati, I was invited to a wedding and a funeral, and they surprisingly shared many similarities. I was a bit disappointed with the wedding because I had imagined a traditional African ceremony, but instead, it was very much of a Western-style reception. The decor, format, and speeches followed similarly to that of a reception back in the States. The one unique thing was the procession of gifts. Guests floridly present their gifts because the culture says that the more you embellish on the opulence of the gift, the more you cherish the couple.

The funeral a week later was remarkably similar to the wedding reception in that it was more of a celebration than a somber event. Speeches were made and the achievements of the deceased were highlighted as the feast and bright conversation presided over the guests. Interestingly, funerals draw crowds of hundreds, even a thousand clan members, and can last for as long as a month of celebration, whereas weddings had much smaller audiences.

Picture Update!

2011-07-17T21:04:00.000-07:00

Sunday July 17th

2011-07-17T07:14:00.001-07:00

Had a whirlwind of a few days! I spent last Friday at the Larawatu Malnutrition Clinic again. Rainy (my translator) was sick, so Dr. David (the SF doctor) took her place. After passing out eggs and weighing the children, Dr. David and I searched the village people for eye cataracts. Cataract surgeons from Australia are coming in two weeks to perform about 100 surgeries. They only perform surgeries on mature cataracts and only on one eye of each of the patients. This way they can double the number of people who receive this surgery. We stumbled upon a very sad case. I noticed a small baby with reflective eyes-- the opposite of cross-eyed. Beyond that, the baby looked pretty unhealthy and was struggling to keep his head up. I called Dr. David over and he had seen this baby before for skin problems. He thought the baby may have TB which is becoming a big issue in the villages because it is contagious. After discussing the baby's situation with the 20-year-old mother, Dr. David learned that 1. the baby was 1.5 years old but looked like 6 months, 2. he cannot walk, talk, etc 3. his 22 year-old father was a drug abuser in Bali and contracted HIV. This was just heart-wrenching; staring at little baby who was so unhappy, fussy, no appetite. The mom was doing the best she could to keep him calm. This probably means the mother along with the baby both have HIV. I was in awe trying to take in this bad news. I know SF does not (yet) provide support to HIV cases. Although the government does have HIV drugs, I know that they are expensive and must be rotated often. The bottom line is that this case probably will not have a happy ending. I was just looking at the father as Dr. David put on his gloves and felt around his lymph nodes, thinking wow he is my age. The father had a very hoarse quiet voice and was skinny enough to be on the malnutrition program himself. The mom remained very calm. She obviously knew something was wrong with the baby, but I'm not sure she knows the extent of his issues. Interesting to observe the way Dr. David is so patient and gentle with his patients even as kids, grandparents and headmasters of the village rush to the scene. The village is much different from the sterile hospital room secluded from other patients. Rather, everyone in the village is taking note of the issue and listening in with eyes wide open. Probably a good thing after all as HIV can spread easily through Larawatu with sword fights, sacrifices and sexual encounters.

I woke up early Saturday morning to watch the baby turtles hatch and struggle to reach the water. It is amazing that they know exactly which way to go, minus one or two stragglers. We are not allowed to interfere in the process because it is natural and Nihiwatu wants the turtles to sense the smells and atmosphere of the beach. This way the turtles will come back to this beach and hatch more eggs. The turtles are just tiny--a few inches wide! It is actually quite hard to watch them hit the water because waves are pounding, white water is crashing. The turtles get washed up and smashed back into the water. Only a few make it because of predators. I spent Saturday running an eyeglass clinic in Rua village. We saw about 35 patients, all older. We have an Indonesian eye chart for far-sightedness. I learned the Indonesian words for the pictures on the charts so I can point to the picture and ask if they can see it. I really enjoyed working this clinic. I definitely needed Dr. David to translate a few times when patients had different problems--cataracts, one eye was worse than the other, or when they wanted to walk out of the clinic with their eyeglasses on instead of using them for reading only! One lady was quite funny. She was my first patient and stuck around to observe other people being tested. She watched which glasses they received. She looked a little unhappy and jealous almost! A few hours later, the lady came back with her bible (tiniest print) and said she couldn't read it which really bothered her. We then adjusted the prescription and she could read the bible! She was ecstatic. All of the Sumbanese patients came in their best-dressed clothes. The ladies wore lacy colorful tops, with stitched skirts, and hair in buns. They dress up when they go to the clinic. They were such sweet and gentle elderly people.

Yesterday afternoon Nihiwatu put on a traditional horse race on the beach! It was fabulous. We all had to be creative in making hats--many were banana leafs, floral headdresses and woven crowns. The horseriders are wild! None of them wear saddles. It looks like a nightmare trying to control untrained horses!! It was a lot of fun.

Dato took me to meet Margarita and her family in her village this morning. They were all smiles! They immediately laid down a woven bamboo mat for me to sit on. They brought out coconut juice, hot chocolate and peanuts on a big tray. We sat in a circle and I asked Margarita and her family many questions. Unfortunately, she does not speak English and I do not speak Indonesian. Dato told me it's easy and I must start. So that is my next goal! Maybe I will learn a few basic conversation topics so I can now call Margarita. Margarita, by the way, has a cellphone and facebook. This was all so bizarre to me. Here Margarita is living in a bamboo village with large funeral rocks, water buffalo, and no electricity. The irony is so interesting. Dato kept calling Margarita "the boss" because she is so educated now and living a good lifestyle. She supports her parents and makes good money working for the government hospital. I am so proud of her. It also humbled me to see how her life has changed for the better. It makes me feel very satisfied thinking that I paid for her nursing education and her life is forever changed. Her mom made me a woven ikat embroidered with my name. It is bright blue, green with a Sumbanese pattern. The Ikats are dyed with local plants and minerals. Ikats are worn around the waist or like a scarf. Ikats take a long time to weave and so many Sumbanese believe they have magical powers and strong symbolism.

Monday, July 11th

2011-07-13T00:25:00.000-07:00

Monday, July 11th

I spent yesterday afternoon with Dato, a Sumbanese man who has worked for Nihiwatu since it has opened. Dato is like the mayor of the West side of Sumba. He owns the reef on the Nihiwatu shore. Dato took me to his beautiful village where the children are healthy, clean and happy. There was a significant difference in Dato's village where the SF has helped them for several years. I even found a young teenage girl wearing an Irvine Laser's Soccer jersey, which is the team I played for in 7th and 8th grade! What are the chances!!! Dato was proud to take a picture in front of the bright yellow SF water tank sporting his usual Sumbanese warrior attire. I have forgotten to mention that all the Sumbanese men carry "Sumbanese guns" (machetes) around their waist 24/7. I've become so accustomed to this that I forgot to mention it! The swords are used for all sorts of daily activities--slicing coconut, opening up betel nut, chopping trees, and slicing the neck of animals during sacrifices. During all funerals, the Sumbanese sacrifice their animals--water buffalos, pigs, goats--which are all very sacred to them. Imelda (SF staff) was telling me Rudy's (SF staff) grandfather passed away and the Sumbanese sacrificed 14 water buffalos at his funeral. The more animals signifies his importance in the district. Rudy's grandpa was a leader who fought for and won the land in the valley which is luscious and green. Today was an ominous day: we drove 3 hours to a village and saw about 3 funerals which buffalo lying dead on the ground. It was quite a scene. The families then take home buffalo to eat. Just so you are aware, the water buffalo are the most sacred and important animals on the island. They can cost up to 65 million Rupiah. They are often given as dowry to the wife's family when a man wants to marry a woman. However, I have met many Sumbanese who do not like this tradition because a) they are almost buying women b) the water buffalos are worth the most money. The animals are a Sumbanese's bank account. Dato and I then went to Wagoli village which is atop a mountain. Gorgeous view! The famous Sumba Foundation symbol rock is there. The men there also showed us the headstick pole. The Sumbanese men used to be head hunters and would post the skulls on the pole. Insane culture and tradition. At Wagoli, we went into a hut where a 55-year-old woman lay moaning by the fire. She looked like a pregnant 80-year-old. It was awful. Her feet and ankles were swollen, her stomach as big as a balloon, and her frail arms and legs lying there. This woman hasn't moved for two weeks because it would be impossible to get her to the hospital or SF clinic. I am going to bring Dr. David (SF doctor) to Wagoli, hopefully tomorrow. She was thankful for us.

Today was overwhelming. 6 of us journeyed over to the Kodi District which is about 3 hours away from Nihiwatu. On the way, I met Celestiana; a young girl who was saved by the SF last year. She was bone-thin, hours from death after contracting cerebral malaria. Celestiana couldn't have been cuter--she immediately jumped on me and I carried her around for 15 minutes. Although she can't talk much, Celestiana was happy and playful. Yalawatu village in Kodi was very hard to see. Sumba Foundation doesn't help Yalawatu because it is too far. The village has nothing--no water, harvest has failed for two years now, no income, the kids don't visit the doctor when sick (too far) and they only eat cassava. They eat once a day at lunchtime and not before or else they will go hungry the rest of the day. There are 20 people in one house. Compared to the villages I have already interviewed, Yalawatu is in the worst shape. It was so tough because we spent yesterday looking into the village, researching their lifestyle and surveying them. However, we did not bring anything to help them. Hopefully in the future, SF can put a system in place where one person from Yalawatu can come to West Sumba every month to pick up milk powder and other foods. We also met a young 20-year-old man who looked like he was 5. He got cerebral malaria when he was 5 and wasn't treated soon enough. His growth is completely stunted and mentally, he is not there. Rainy told me that Kodi only receives money every 6 months from the government whereas the villages in West Sumba receive money every 3 months. There is definitely a large separation between rich and poor. The system makes no sense. Apparently, the district leader of Kodi is not as forward or forceful when asking for welfare from the government. As a result, the Kodi villages suffer. There is a ton of land near the river where Kodi gets its water and I asked Rainy why the villages don't move there. I guess the land is owned by someone else.

It has definitely been hard to research in a perfectly scientific manner. It is difficult to know whether I survey all of the moms or some are gone during the day--farming, getting water, etc. It is also tough to make sure every mother understands the questions thoroughly. It seems like some copy what their friends say when they don't know how to answer.

We stopped for a picnic on Perro beach (perfectly untouched and beautiful) on the way home.

Yesterday during malnutrition clinic at Deke, the government was there also. As soon as the government found out SF started the malnutrition program, so did the government. We pass out 7 eggs per week and the government passes out 1 egg per month! I can't even believe that! That is so pointless and definitely will not reduce the malnutrition rates.

Thanks for reading,

Abbie

Olyotya!

2011-07-12T07:11:00.000-07:00

I’ve been slowly learning Lugandan, the local language they speak here. My jaw’s sore from trying so hard to form the words of a different language. However, “Olyotya!” is one that I have down. It means “How are you doing?” and is a greeting you say to someone when you approach them.

A little bit about what I’m doing with Twezimbe. We’ve isolated 6 schools, 2 of high socioeconomic status (SES) and 4 of low SES. The four low-SES schools are each from different sub-counties of Uganda. The idea is to get together a group of 20 girls ages 11 to 21, broken up into a younger group and an older group, to provide a safe place for them to talk about girl problems. Most girls even in our own country don’t like to open up about their awkward encounters with boys, problems with periods, and disproportioned body parts. Hopefully through these small groups we can facilitate a discussion about these problems, with an emphasis on physical fitness, obesity, and diet. St. Lawrence, one of the high SES schools, is completely on board. Their PE teacher has had trouble getting the girls to participate in gym class, so I proposed dedicating a session for yoga and pilates, something they’ve never heard of before.

We’ve also spoken to two schools of low SES, and I’ve had a few more problems with those. The headmistress of St. Mark didn’t understand what exactly was the benefit of our program, and the headmistress of Bulamu questioned whether our time spent would be effective. Both of those are valid points. Indeed, it’s hard to understand why physical fitness and non-communicable diseases even matter when you’re still struggling to scrape by with just enough food to eat. Yes, it’s an up-and-coming problem for the world’s low-income countries, but I only know that from days of reading articles and looking at statistics. The locals have more dire issues to worry about. But I suppose our presence there is to assess their knowledge and thoughts about these issues, not necessarily to solve a problem.

Today, we visited the Twezimbe office that is in charge of Mudwma sub-county where Bulamu school is located. They were having a sub-committee meeting, where the representatives from all the villages in that sub-county meet and discuss issues. It was inspiring to see the young people that lead Twezimbe speak so passionately (in Lugandan of course) and the village leaders listen so intently, under the shade of a tattered blue tarp supported by tree branches. Yet, an air of professionalism was expressed in the straight rows of chairs lined up one after the other, and the notepads and pens in the hands of many of the sub-committee members. Suddenly the speakers started pointing at me, and the next thing I know I was to “say a few words” to the group. I had nothing prepared and those that have had me in class know that I am not the best presenter. Of course to make matters worse, not a minute into my introduction everyone started laughing. They couldn’t understand the English I was speaking and needed a translator. Through exaggerated hand motions (my nervous habit during presentations), I spoke for about five minutes about our project and the importance of awareness of non-communicable diseases in the next few decades for Ugandans so that it does not end up with the monetary burden that the US has had with diabetes, heart disease, and the like. I saw a few heads nod. I’m not sure if the rest of the group bought my speech but I gained confidence as my speaking picked up momentum. I’m proud of how it went!

The site of the Twezimbe office was also the place where girls were put through a 9-month training program to learn the skills necessary to make clothes of quality high enough to be competitive in the market. At the end of the program, each receive a sewing machine to take home.

Till next time!

Arrival in Kampala

2011-07-11T12:10:00.000-07:00

Descending into Entebbe, Uganda, the landscape was worlds different from Dubai, where I had a layover last night. While Dubai sprung from a desert with sparse shrubs, Uganda is lush with vegetation. Green grass, thick trees, grazing cows, and red dirt set the background for the view form the car on the hour-long ride from Entebbe to Kampala.

This is my first time out of the country alone, and I feel like a little kid in a candy shop, so eager to take in everything and do as much with my time as I can. I am here to work with the Twezimbe Development Foundation started by former personal private secretary to the President of Uganda. From what I hear she’s a powerful political figure and popular among Ugandans. I am staying in her house in Kampala, the capital of Uganda, and I feel very fortunate to be able to.

Driving around Kampala, I noticed that the city was actually a lot like some parts of China. Commercialization hasn’t really taken over and business consists of mom and pop shops selling their wares along the sidewalk, every shop window is small and right next to the next one. Fruit stands are often homemade and the many of the homes look like they were built by the families themselves. I noticed that a lot of them were carrying large yellow jugs. Shida, my Twezimbe helper, told me that 60-70% of families that live in Kampala don’t have running water so that have to fetch water in these yellow jugs, called Jerry cans from the water spout. Children and adults alike were carrying these around everywhere we passed.

Today I will be going to Twezimbe for my first day of work. Twezimbe Development Foundation was started by Madame Amelia after she stepped down from her position as secretary to the Pres. Madame petitions for monetary support from the government for certain projects that Twezimbe carries out. Their projects complement all parts of life, with a focus on rural villages. For educational support, Twezimbe builds and restores schools, and provides lunches and books for the kids. For agriculture, they distribute seedlings and give farmers technical support. They also give a cow to each farmer, then when the cow has a calf the farmer is to give the calf to another member of the community, in a program called “Give a Cow.” For economic support, they have taught women how to make crafts so that they can sell them in the markets. A lot of the young folk from the villages leave to go to the city, leaving the villages full of the elderly, which is a big problem. Also in the villages is the problem of domestic violence. While the culture in the cities has revolutionized so that women are seen more as equals with men, the villages have not caught on and women are not aware of their rights. I will be working with 4 schools, 2 of high SES and 2 of low SES, and talking to girls about body weight, body image, physical fitness, and obesity. More on that later when I make a plan of action at work today.

Our Burkitt's Patient

2011-07-11T01:37:00.000-07:00

Although the vast majority of Burkitt’s lymphoma patients are found in the Malaria belt around equatorial Africa, it is still a relatively uncommon illness, especially when compared to HIV or Schistosomiasis. The number of patients in a small region such as Shirati varies greatly, and it just so happens that there was one Burkitt’s patient when we arrived. When we asked about his history, we found that he had not responded to treatment as had hoped (with typical cases, the tumor almost disappears after the first dose of chemo). He was diagnosed just a few weeks before we arrived, and he had already undergone four doses. The tumor shrank a little with the first dose, remained stagnant for the next two, but had started growing again last week. His demeanor reflected his history. When we went to visit him and interview the mother, the 8-year-old boy was drained. He seemed to be in pain with each movement and had to lie down with each exertion. There was little more the Shirati clinic could do for him since he was not responding to the chemo and was referred to the regional cancer center in Mwanza.

Getting the boy to Bugando is almost another story. It is amazing how differently some people can react when given similar circumstances. In our interviews, we’ve talked to parents who went to great lengths and sold half their fortunes to bring their child to treatment facilities across the country when treatment at Shirati wasn’t working. This boy’s father, however, had spent his money paying the dowry for another wife. When confronted with the need to send his son to Mwanza four hours away, he lied about how he could catch a ride with a friend. It seemed clear that his only intentions for the boy were to take him home and wait for the cancer to take its course. Unable to accept such inhumanity, Dr. Kawira insisted he contribute any amount. My friends and I were happy to donate the entire cost, but we wanted the father to take some responsibility. Grudgingly, the father offered a small sum.

With this ugly episode behind, Dr. Kawira arranged for the boy and his mother to be taken to the hospital at Mwanza and start treatment. He arrived last Wednesday and was given IVs to rehydrate and prepare him for the taxing chemo. Unfortunately, we got word on Saturday that he passed away that morning right before his treatment was scheduled to start. Dr. Kawira assured us that we did everything we could to help, but the question still looms: would he have survived if he had gotten to Mwanza sooner?

Friday July 8th

2011-07-09T01:14:00.000-07:00

Today, we went to the Larawatu malnutrition clinic which has been running for three months now. We weighed the babies and passed out eggs and milk for the week. The kids then eat porridge while we are there so we make sure they are eating at least once a day. I asked Rainy how does SF monitor whether the families are feeding the kids with the food we provide. Usually, they can tell by the kids' weights weekly--if they are gaining, they are most likely eating. However, some families have been selling the eggs and milk and buying rice instead because it is cheaper. It is pretty upsetting that parents do not understand that their children need this protein for the week. Maybe the SF Malnutrition program should add an education component to it. Also, I find it interesting that during the surveys, many mothers say their children are not malnourished when in fact they usually are.

I ended the day with a run on the beach. The sunsets here are incredible!

Thanks for reading,

Abbie

Thursday, July 7th

2011-07-07T03:55:00.001-07:00

Hey All,

I continued surveying yesterday and today. I have collected data on about 50 mothers & children so far. Interesting that some mothers don't even know their ages! Many of the kids' birthdays are written on their bamboo house. Yesterday, Rainy and I walked to Taailelu's water source which is 3 kilometers away and not an easy hike. The water comes from the ground. It is dirty and muddy. Most times the village boils the water to clean it. Sometimes, though, kids drink water straight from the source. No wonder why most children I have interviewed have had diarrhea multiple times. Taailelu has a big farming plot to harvest vegetables. However, the Taailelu villagers sell all of their vegetables for income instead of eating them. They use the money to buy rice because it is cheap (most farmers make $70/year).

I spent this afternoon inserting the data into an excel sheet. I compared the anthropometric data to a WHO growth chart. Most of the children are under the 5th percentile for all measurements--weight/height for age and weight for height. Pretty heavy to comprehend. Actually looking at the numbers makes the prevalent malnutrition seem more real. When I am in the villages observing, most children are smiling/happy and do not have the typical physical symptoms of malnutrition that I expected to see (rib cage sticking out, big stomach and small limbs).

Malnutrition clinic tomorrow.

Thanks for reading,

Abbie

Tuesday, July 5th

2011-07-05T03:31:00.000-07:00

Another awesome day. I met Rainy at 9:30 to head out to Deke village which is about a 45 minute BUMPY drive. The malnutrition program at Deke started three months ago. We were greeted with "salamat pagi" (good morning) from all the kids. We spent the first half of our day recording weights and passing out eggs, vitamins and milk for the week. All the mothers are holding their malnourished child or children and wait to be called. Rainy and I sit on a woven bamboo mat in one of the huts. It is pretty chaotic: there was a horse under the hut eating right behind us, pigs and dogs getting into fights, kids crying from being weighed and mosquitoes all around us.

After the typical malnutrition program and food distribution, we started the surveying. It was definitely harder than I thought. First of all, none of the women are literate, so they cannot write on the translated questionnaires. I imagined handing out surveys and pens to the mothers. But, now I know most women have only gone through elementary school (if they are lucky). Secondly, the survey went through three translations--Rainy asked the questions in Indonesian, one of the women from the village translated the questions to the Sumbanese dialect specific to the village, and Rainy translated back to me in English. I recorded all the information. There was definitely a lot of help from the sidelines--many women participating in the translation or explanation of the question. And a few laughs! One lady didn't consider herself to be married because it wasn't in a church. The surveying took quite a bit longer than I had anticipated. We will finish Deke village next week. After surveying, I measured the children's head circumference and height. Using these measurements and weight, I can look at the WHO Standard Growth Curve (and BMI) to see which children are malnourished.

We left Deke in the afternoon after a successful day. I spent the late afternoon surfing with the other kids my age who are also staying at Nihiwatu. It was epic!

Tomorrow we are going to an old village who has not received any Sumba Foundation help. It will be interesting to compare this village and Deke.

Thanks for reading,

Abbie

Monday July 4th

2011-07-04T06:56:00.001-07:00

Happy 4th of July!

I had an amazing day in Sumba. I woke up at 5:15 AM to go stand-up paddle boarding down the river. The paddle ended at the beach. Along the way, we saw many traditional Sumbanese villages. Women were washing clothes, 8-year-old boys were washing their horses and men were harvesting rice patties near the water. We saw lizards the size of my arm. We paddled through rapids and fell off a few times. We watched the sun rise and swam under palm trees that had broken off the bank. A very peaceful trip all around!

I was dropped off at the Sumba Foundation office on the way home to meet up with Rainy. Rainy and I developed more survey questions focusing on the mothers--education level, marrying age, etc. Then we left on a 26 kilometer rocky road trip to the local town, Wakabubak. I was really impressed with the amenities in the town. It was filled with stores imported from China. There were soccer fields, two hospitals, many churches, a police station, courthouse, bank and classic Indonesian food restaurants.

We stopped by the government hospital for which Margarita works. I was so happy to finally see her again after 5 years. We gave each other a huge hug and talked through Rainy who translated for us. She was dressed in a classical white nurse uniform triaging patients. Margarita said she couldn't be happier. She loves nursing, she helps pay for her parents and she still lives in her village. Margarita left the SF clinics for the bigger government hospital because she is a "VIP nurse." Not sure what that is, but it sounds good to me. Margarita now has a secure job and is still working for her people. She works at the SF clinics in the morning if she has night shifts at the hospital. I'm going to visit Margarita at her house sometime this week to say hi to her parents.

We then explored the two hospitals. Both had the typical departments--ER, labor & delivery, pediatrics, ICU, etc. The hospitals housed at least 6 patients per room. There is no circulation whatsoever and dogs meandering around. Not much sanitation or hygiene to say the least. We roamed the different departments. I observed some very sick patients--a 1 lb baby (2 months premature), a 7-year-old with malaria and malnutrition and a 1 month old baby suffering from epilepsy. It was pretty heartbreaking to see. Also, I watched many patients wheeled OUTSIDE from one building to the OR. The nurses would just take off their shoes when stepping in the OR. I can unfortunately imagine many terrible infections after entering that room. At least the labor & delivery unit in the hospital is better than in the villages where they have witch doctors deliver the babies. If the woman hemorrhages, the witch doctor can't do anything. Kind of unbelievable.

After touring the hospitals, we walked around town to buy the eggs for the malnutrition program. We had a classic Indonesian lunch. I really had a taste of the town life of the Sumbanese.

Finished the day off with another stand-up paddle board session in the ocean with a few people here at my hotel. Watching the sun set while on the ocean was gorgeous.

Thanks for reading,
Abbie

2011-07-04T06:56:00.000-07:00

The Beginnings

2011-07-03T04:07:00.000-07:00

Hi All!

I arrived safely in Sumba last week. Since then, I have been very busy coordinating translators and transportation for my project. Last week, I met Rainy Octora who is the malnutrition coordinator for the Sumba Foundation. I followed Rainy out to the Larawatu Village last week to observe the beginnings of the malnutrition program there. Larawatu started receiving Sumba Foundation aid since May. I was amazed to learn that households consist of 7-10 children in the villages; which means a greater distribution of food, resources, and water among the children.

At Larawatu, Rainy and I weighed the children and recorded the information. It was relieving to see that most children had put on approximately 2-3 lbs since May. We then passed out 7 eggs and milk for the week. Rainy has also started teaching the mothers at Larawatu how to plant and cook. They are now taking turns cooking the green bean (full of protein) and coconut milk porridge. Water is still a big issue for Larawatu village because of its isolation. The mothers in the village wake up at 3 AM to pick up water from a source about 2 kilometers away.

Sumba is unreal. Outside of my project, I absolutely love exploring the culture and heritage of the people. I have learned a few Indonesian words: apanama (name), umur (age), and DA!!! (which the kids scream at you to say hi and bye). Despite some sickly-looking children, they are very enthusiastic and energetic.

I can't wait to continue my project tomorrow.

Cheers!

Abbie

Serendipity’s Flowers

2011-07-02T12:29:00.000-07:00

This is a story of how serendipitous fate can be sometimes. Last week as we were on our way to clinic, our car slowed down just enough for Dr. Woodrum, a visiting doctor from the US, to notice some flowers growing on the side of the road. They were pretty little purple and white flowers, and Dr. Woodrum immediately decided they would add a pleasant touch to the Burkitt's lymphoma center down the street from our hostel. So the next day as we headed out to clinic, we also brought some gardening tools to uproot the flowers.

When Dr. Kawira, the resident doctor of Shirati, saw the flowers, she remarked how much they looked like Periwinkles. Sure enough, these flowers turned out to be Periwinkles, which is scientifically called Vinca major. Vinca major is the same flower from which the drug Vincristine is derived. Vincristine is a broad chemotherapy drug and is used in the treatment of Burkitt's lymphoma. I couldn't help but marvel at how appropriate it was that Dr. Woodrum, without knowing it, planted Vinca flowers for the Burkitt's lymphoma center.

Searching for our patients

2011-07-02T12:26:00.000-07:00

Interviewing patients these past two weeks have been very interesting. Dr. Kawira gave us about 20 case files of her previous patients for Reshem and I to search out to interview, but I had no idea what an adventure this task is. With a guide and translator, we set out on rented motorbikes to search for these patients. The first day was relatively straightforward. We found the first 3 patients with ease. We rode to a neighboring village and within minutes we found ourselves at their homes. Each passing day of interviews, however, has been increasingly difficult because we had to travel farther and farther from the main road and deeper and deeper into the hills. Just a few days ago, we were riding through corn fields to reach the patient's hut. Today, we went off-roading for at least half an hour to get to the patient. At several points, the road was so impassable that we had to get off our bikes and push them through the rocky crevices. It was so difficult and took us so long to get to some of these patients that I marvel at how they ever able to travel to the hospital and clinics to get treatment. Even though it's been quite a trek getting to these patients every day, it's been well worth the effort just hearing their amazing stories.

Embarking on a Safari

2011-06-29T16:26:00.000-07:00

Tomorrow, I will be leaving from London Heathrow to fly down to Johannesburg, South Africa. It will mark the first time I've set foot on the African continent, and I am ever so excited!

This past month has been a flurry of making contacts, reading, reserving cars/hotels, and mentally preparing for a fantastic trip. My goal is to assess the nature of the current public-private partnerships in South Africa in the area of health services delivery. In India, a robust engagement of the private sector by the government has resulted in a thriving private sector that has not only retained, but attracted health personnel. I would love South Africa to carefully, but consistently develop similar partnerships. I could see this goal being a long-term personal goal for me.

South Africa is a country riddled with HIV/AIDs, TB, and inequalities in access to health care. It has a lower life expectancy than India. It's HIV and TB incidence rates are on the orders of 25 and 4 times the global averages, respectively, leading to an adult mortality rate that's roughly 3 times the global average. I find this absolutely shocking for perhaps the most Westernized country on the continent. There are a lot of problems with the health system in SA, and my intention is to analyze the health care delivery (personnel is perhaps the most important input of a health care system) and specifically look at the private sectors interaction with the public sector. On this brief one-month project, I intend to survey the current state of the department of the treasury-sanctioned PPPs (Public-Private Partnerships-not typically involved in service delivery) and more informal PPIs (Public Private Interactions).

What do I know? That there exist about 5 PPPs related to health care, and a limited, unspecified amount of PPIs in the country. My whirlwind tour will include stops at government departments, hospitals, universities, research institutes, and clinics. I hope to come away with a handful of information about current PPIs and to be able to describe the PPIs in existence.

Here's to my African Safari.

Cheers from London.

Travelling to Loliondo!

2011-06-28T07:59:00.000-07:00

Hello again,

Tomorrow morning, I'll be heading out to visit Loliondo, the site of Babu's faith healing that attracts millions of followers. Located in a very rural area, it is interesting to see how infrastructure has begun to spring up in respond to the overwhelming demand for transport and accommodation - Babu's healing itself costs only 500 Tanzanian shillings (about 30 cents) but many have recognized the profit to be made surrounding him and the hordes of followers desperate for the chance to meet the faith healer. From the city of Arusha, the drive is about three hours - accompanying me is my good friend Alex Herman, a Tanzanian university student who is my teaching partner and translator during out village teachings. Having known many who have traveled to Loliondo for healing, Alex is also interested in understanding the phenomenon and graciously agreed to help me translate during my visit. Both of us have noticed Loliondo becoming a recurring theme brought up by the villagers we are working with, and we have struggled to find the appropriate way to respond to their inquiries. Many of our villagers expressed uncertainty about Loliondo, and we have done our best to emphasize the importance of continuing traditional ARV therapy regardless of their faith or disbelief.
While in Loliondo, I plan to observe the rituals and behaviors associated with the healing process, both for the healer and the follower. I plan to do a comparative analysis of these rituals with the Brazilian faith healer John of God, who I studied about and visited last year in a USC Problems without Passports class. Furthermore, I hope to conduct short interviews with other travelers to the site to better understand their health situations, beliefs about faith healing, and ultimately their motivations for traveling to Loliondo.

I am so excited to visit this site tomorrow, and I will let you know how the experience goes!

Badaai,
- Anu

Starting patient interviews

2011-06-25T13:38:00.000-07:00

After getting acquainted with the clinic and hospital setting around Shirati, I started my first interview today. The plan for the day was just to visit the Sota clinic again because the two translators were both busy helping other students here. (The translators are apparently in very high demand because there are only two of them, while there are eight other students with various projects requiring their services. The students are very possessive about their translators, so since I am new, I have to work around other students in booking the translators) Fortunately, the mother of a Burkitt’s lymphoma patient brought her child in for a checkup, so Dr. Kawira arranged for one of her nurses to act as my translator. It was very interesting because the interview helped me understand a little more about the social and economic challenges for the mother and child during her treatment, and it showed me how I needed to edit some of my questions for future interviews.

I’m looking forward to doing more interviews, but as I’m arranging my translator and guide for tomorrow, I’m starting to realize that completing these patient interviews are going to be much more difficult than I had imagined. Originally, I thought that the majority of the interviews would be of patients that are currently receiving treatment and living at the Burkitt’s center down the street. It turns out, however, that currently there is only one patient there. For the rest of the interviews, Dr. Kawira has given us their old case files, and we are to rent motorbikes and search for them at the homes. The difficult part is that there is no system of addresses in the villages, so we are told that we have to find the village chairman, who will direct us to the subvillage chairman, to the head of homesteads, and finally to the parents themselves. It will be an adventure searching for them tomorrow and we’ll see how it goes, but I’m still looking forward to it nonetheless.

Getting to know the clinics around Shirati

2011-06-25T13:36:00.000-07:00

I spent these first three days in Shirati shadowing Dr. Esther Kawira at two of the local clinics, Sota and Roche clinic. Dr. Kawira is one of the two resident doctors in the district of Shirati and is the founder of these two clinics. I decided it would be a good idea to first understand what the basic healthcare structure is here for all patients before diving into challenges specific to Burkitt’s lymphoma patients. The first two days of at the clinic was a good orientation to the basic types of cases in the area. We saw quiet a few malaria cases, a typical case of schistosomiasis (a disease caused by a parasite), and some cases of urinary tract and vaginal infections.

Today though, it seems like all the cases were complex. There was one child with congenital heart and eye defects, a woman with a severe cancer causing her entire eye to protrude, and a woman coming in for shingles only learn that she had HIV. While it was a good learning experience, I couldn’t help but feel a deep sadness to how limited the clinic could help them. I don’t know how much better their outcomes could have been if they had presented in a developed country, but seeing how little we could do for them here now made all of us feel so powerless. It even made me rethink whether I should have picked a different project that impacted a larger population than Burkitt’s. However, Dr. Woodrum, one of the visiting doctors, gave me a good piece of advice. She said, “you can’t fix everyone, but you just try to do the most you can for them, and that’s enough”.

Let there be power…

2011-06-25T13:25:00.000-07:00

Electricity, like many other resources in Tanzania, is apparently in scarce supply. The hostel I’m staying in and the rest of Shirati have been experiencing blackouts the entire week. When they started at the beginning of the week, we were told by the locals that blackouts usually occur regularly once or twice a week, but not for longer than a day at a time. The reason why blackouts are so recurrent are not because of weather or structural damage, but it is because the government purposely alternates turning off power to certain districts in an effort to conserve energy. The regular blackouts have become a fact of life. This blackout, however, went on for 5 straight days and affected the entire country. The power just returned this evening, and it’s uncertain how long it will stay. One this is for sure though, the government has not released the reason for the extended blackout and local businesses are suffering.

Five Minute Blog Post!

2011-06-22T05:46:00.000-07:00

Running out of time at an internet cafe in Arusha, Tanzania, where we have a break in our program. Our group has successfully started a soccer tournament in our village of Sangaiwe with hundreds of vollagers making the trip to watch the games. We hold HIV education teachings at each of the games and so far it's been an incredible success. So excited to visit Loliondo in the next week, will keep you updated on the progress with my research!

Thank you for reading my blog posts, please let me know if you have any questions or would like a postcard while I'm here!

- Anu

Welcome to Roatan!

2011-06-20T04:43:00.001-07:00

The view from my front porch!

I just made it to Roatan so here's my first post!

Some background: Roatan is an island off the north east coast of Honduras with a population of ~60,000 people. It is surrounded by the second largest coral reef in the world, making it a prime tourist destination. Though the resorts and beaches are beautiful, the deteriorating health status and poverty of its natives tell a very different story.

Over 65% of residents are living in poverty, with approximately 1 in 4 making less than $1 a day. On top of that, about 40% are unemployed.

The Honduran government has done little to help. There is one public hospital on the island that asks for a 8 L (~50 cents) fee to see the doctor, plus the cost of any medications and special supplies they may need. Though it seems like a small amount in America, that could be half a day's work or more for many Roatan residents.

Besides the public hospital, there are a few privately run clinics around the island, many of which are staffed and run entirely by volunteers. Because it is such a beautiful island, many doctors come to do a short rotation where they can work in the mornings and enjoy the beaches/snorkeling/scuba diving in the afternoons.

**
My project will be a basic needs assessment of stove quality in one small community called La Colonia, located in Sandy Bay where I'm living. Stoves can pose a significant health risk especially to women and children, putting them at elevated risk of acute respiratory illnesses, school absences, and chronic aches and pains. The WHO estimates that 1.6 million deaths each year are attributable to indoor air pollution, many of which are the result of using biomass burning stoves in developing countries.

That said, there is hope- several stove types have been shown to be effective and efficient at improving quality of life on multiple levels. First, the use of a chimney diverts smoke and harmful particulate matter outside. Second, newer models generally require much less wood, with some using only 25% of that of a traditional model.

I'm hoping to get out to La Colonia tomorrow as I'm going to spend most of today getting settled and finalizing details for the project. Hopefully by next week the study will be well under way!

Renita

Hello from Shirati, Tanzania!

2011-06-20T03:27:00.000-07:00

Hi! I'm Grace, and I will be spending this summer looking at the available treatment options and any potential barriers to receiving treatment for Burkitt's Lymphoma patients in Shirati, Tanzania. I've been looking forward to this project since January, and I'm very excited to finally make it here.

After almost two days of traveling, Akil, Reishem, and I finally made it to our site in Shirati. The journey was a bit exhausting. We flew for nearly 20 hours to get to Nairobi and landed at 2 in the morning. Since we landed so late, we decided to spend two nights in Nairobi, but that turned out to be a good call because the drive to Shirati was 9 long hours. With our full day in Nairobi, we visited the animal orphanage, which is basically a zoo where they raise injured animals. It was a great experience because not only did we get to see the usual animals, we also got to hold a lion and cheetah cub! It was a great introduction to Africa.

The drive to Shirati was long but scenic. It’s amazing how you could see antelope and giraffes just looking out your window along the drive. Even though the past two days have been fun, I’m glad we’re finally in Shirati now. Shirati is much bigger and more developed than I imagined it to be. Our accommodations are also much nicer than I anticipated. There’s internet here. The only thing I wish we had, though, was hot showers, but I guess I have a whole month to get used to that. We got the basic tour of the town today while we’re waiting to for our final paperwork, but I’m looking forward to going to the clinic and starting my project tomorrow!

Survey and Data Collection

2011-06-19T20:08:00.000-07:00

Soon, I'll be on my flight to Indonesia. I cannot wait. Over the past few days I have been preparing myself physically--buying 100% DEET lotion, receiving 5 shots and picking up my malaria prescription. I have also been preparing for my research project--translating and printing of surveys for mothers, developing excel sheets to organize my data, collecting previous anthropometric data for children nutrition and creating community-specific qualitative questions. I will be using four major anthropometric calculations to assess malnutrition: height-for-age (stunting), weight-for-age (underweight), weight-for-height (wasted) and BMI (overall assessment). Looking forward to filling the excel sheet in!

Faith Medicine in Tanzania

2011-06-12T00:55:00.001-07:00

Hi again,

I've been having an amazing time in Tanzania. I've met my homestay family and settled into my new home - the village of Sangaiwe in the Mwada district of Northern Tanzania. Over the next six weeks, I will be working with two other American volunteers and two Tanzanian partners to conduct a village-wide AHIV/AIDS awareness campaign. This involves teaching at the schools, meeting local organizations and community leaders, and spreading information about HIV transmission and prevention techniques. All of this work will culminate in a village-wide testing day, where we will try to have the whole village come out to get tested and take the steps to stay healthy and empower their community. After we leave, our work will be continued by peer educators that we will train as well as community health workers who will provide support and aid for those living with HIV in Sangaiwe. In the last week, we taught the primary school children about the basics of health and HIV transmission. We had such a great time working with the kids - they really are incredible. They've been so receptive and interested in learning, and it's a privilege to be able to work with them.
On another note, I have been continuing my research with the Mwada district. We have conducted household surveys to understand the information and misinformation this population has about HIV and its transmission, as well as important questions about the role of religion and stigma in the community. We are compiling the results now, but I'm excited to see the trends that emerge in our communities. I have decided to focus my reserach on a prominent emerging faith healer in Tanzania whose presence has proved an immense challenge for several NGOs in the area. Babu, which means grandfather in Swahili, claims to cure HIV by prescribing a certain special drink - the kikombe. Hundreds of HIV positive Tanzanians have abandoned traditional ARV treatment in favor of this healer, and it has caused a significant amount of worry among health workers in the area. I will conducting interviews with villagers to better understand this phenomenon and the reasons for Babu's rise in popularity, as well as travelling to Loliondo, the place of Babu's healing, to interview his supporters in an attempt to find a means of addressing the issue within my own village and the larger Mwada district.

I sincerely thank the Africa Fund at USC for helping me to fund this research project!

Until next time,
Anu

Faith Medicine in Tanzania

2011-06-12T00:35:00.000-07:00

Pictures from the First Trip

2011-06-10T17:24:00.001-07:00

Margarita and me after I underwrote her nursing education.

Families from Margarita's village.

An elder Sumbanese from the Rua village.

This man's first pair of sunglasses.

I am sterilizing medical instruments.

A lady with teeth ravaged by betel nut chewing. The volunteer dentist and I pulled most of her teeth.

This is the beautiful west coast of Sumba.

Pre-Trip Preview

2011-06-10T16:31:00.000-07:00

Halo! An easy translation for “hello” in Indonesian. My name is Abbie Armstrong. I graduated from USC in May 2011 and I’m beginning my Master’s in Global Medicine in the Fall at USC. I will spend this upcoming July on a remote island, Sumba, off the coast of Bali to perform a malnutrition research study. I have been fortunate to have traveled to Sumba before when I was 18 years old. I volunteered at the medical clinics, painted murals with kids, and helped to develop a sustainable biodiesel power source. The Sumbanese people were most appreciative of the medical interventions that had the most direct impact on their well-being.

Sumba is an island of raw beauty. It almost seems as if the population lives in the past—the people cherish old traditions, perform ceremonies and Pasolas, and maintain relationships with ancestral spirits. Ever since I stepped foot off that island, I have always dreamt of going back. I am so thankful for the opportunity USC has given me to perform my malnutrition study on the island. Despite its beauty, Sumba is also home to a severely malnourished population. Drawn by its exotic location and pristine surf, tourists and surfers now support a private resort called Nihiwatu on the island. This has generated an influx of global dollars and attention to the struggles of the Sumbanese. This confluence of activity makes Sumba an ideal microcosm to examine the effects of international socially minded eco-tourism directed towards improving the health status of the Sumbanese people.

I plan to evaluate the effect of Western influence, improved farming and access to water on the prevalence of malnutrition rates in Sumba. My project involves investigating the three-year impact of the Sumba Foundation’s intervention in nutrition on the island of Sumba, Indonesia. Previous research concludes that 33.8% of Sumbanese children are underweight due to malnourishment. This cross-sectional study will use quantitative and qualitative methods to evaluate how farming techniques have improved the health status of the Sumbanese people. The relationship between malnutrition rates and sustainable farming techniques as introduced by the Sumba Foundation will be examined. This baseline malnutrition study will help to establish to what degree the intervention has or has not succeeded in reducing malnutrition on the island.

A huge thank you in advance to the USC Institute for Global Health, the Sumba Foundation, the Sumbanese people, the Quiksilver Foundation and the staff at Nihiwatu—Claude Graves, Dr. Claus Bogh, and Rainy Octora.

Arrival to Tanzania

2011-05-23T07:22:00.000-07:00

Hi everyone!

I'm Anu Ramachandran, an undergraduate at USC studying philosophy and neuroscience, and this summer I'm participating in Support for International Change, an immersion volunteer program focused on increasing education and awareness about HIV/AIDS in rural communities in northern Tanzania. As a volunteer, I will be living in a village in the Mwada district of Tanzania and working with Tanzanian university students to conduct a village-wide education program that will culminate in a widespread HIV testing campaign for the nearly 20,000 Tanzanians who live in this district, many of whom never had access to testing facilities. In addition to my volunteer work, I'm going to be conducting a research project focused on understanding the role that religious belief and tradition plays in shaping HIV stigma among these communities - most Tanzanians in this region are Christian, but there are also strong traditional East African spiritual beliefs that play an important role in village life. I will be investigating the links between these beliefs and HIV stigma and specifically the role that faith healing plays in the Tanzanian struggle with HIV. I just arrived and and am in Babati, Tanzania, a beautiful market town, where we are conducting our volunteer orientation - intensive Swahili classes and constructing a curriculum for our awareness program. I'm incredibly excited for my time in Tanzania, can't wait to share my experiences with you!

Kwaheri,
Anu

2/16/11 Tata

2011-04-01T12:13:00.000-07:00

The second mission was different then the first, but went well. I hear in total between the two missions, 509 surgeries were completed. I think Minh and I interviewed close to 200 of them. The power would go out mid-surgery and even one operating table was shut down due to this gastroenteritis thing that was going around. Recovery room set up a “power nap” station for those who needed to rest. Minh and I were back there one morning. Otherwise, things went smoothly. Minh and I had a good system going to integrate ourselves within the mission structure. We also took over Stephanie’s speech project she worked on developing with the speech therapists. We arrive early in the morning and interview those we didn’t get a chance to the day before a few hours before their surgeries. In the afternoon we interview those arriving for surgery the following day. Our goal for each operating day was 25. Also, patients were coming for one week follow-up. We surveyed them about surgical satisfaction and their overall experience at Op Smile for internal evaluation. On top of all of that, we interview those patients over 7 with cleft palate before surgery about how speech has effected their lives and take speech recordings. The team wants to investigate whether cleft palate surgery actually improves speech if the patient is over 7 because there’s debate if it does or not and whether surgery is worth it. The other option would be an obturator, which is a molded piece to cover the palate. So they will do follow-up speech recordings at 6 months and speech therapists will see.

The research meeting went really well with Alex, Carolina and Justin. Stephanie, Minh and I found a lot of great articles and have some good ideas. I was reading that basically not much work has been done in establishing "normal" growth curves and measurement of malnourishment. WHO completed one, but Indians aren’t “normal” compared to that curve and I think it's because their phenotype is just on average smaller either due to diet, environment, genetics or a combination. So first, some type of growth curve will need to be established in Assam using anthropometric measures (body measurement ratios). Ultimately Alex and his team want to be able to define which patients are too malnourished and at too high of risk for surgical complications so that Op Smile can treat them until they’re ready. Currently, Gary (team doctor), Alison (mission coordinator) and Reza are working on malnourished patient cases. They subjectively target patients who come in for screening that are too small and record their information for follow-up. Meanwhile, they’re given nourishment packages. The problem with cleft lip/palate babies is they can’t create a suction to the breast so aren’t breastfeeding the first 6 months of life which is vital for substantial nourishment especially in some of the impoverished situations these families come from.

During post-op, Minh and I will collect the data from the first few pages of every single patient’s charge whom we interviewed with our survey, which ended up being about 208. This is a great sample for a study! We may have to throw a few out and will use some for validity testing. I also re-interviewed some patients for reliability testing with the test/retest method. This will help our study’s credibility. I hope we can produce strong results, even if they're only qualitative.

2/10/11 Tika Se

2011-04-01T12:11:00.000-07:00

We’ve done so many awesome things this week. Saturday we observed a few surgeries (both cleft lip and cleft palate) and I actually scrubbed in for one of them! I mostly just suctioned for Carlos, the surgeon from Lima. It was sooo awesome! The operation was mostly in Spanish too, so that was interesting. I ended up translating for some of the medical staff, like the anesthesiologist from Egypt. It was such a memorable experience. I couldn’t believe the way surgeons just cut right through the mouth so aggressively and then carefully stitch it back up. I’m so interested in trauma medicine and surgery. Maybe I can become a physician assistant in surgery because I can’t see myself for the next 8+ years committing to medical school.

Sunday was the last day of the first mission, so it was a half-day. Minh and I have taken on a side project doing post-op evaluations or satisfaction surveys before patients are discharged. This was appointed to us by Cindy who is in charge of quality assurance. Most of them are happy with their surgical results, but some said the wait time was too long. I’m not surprised; some of them had to wait 24+ hours. This project is more for internal use to improve the mission experience for patients.

Tuesday the second team arrived for the second mission. So yesterday (Wednesday) was screening. Minh and I were going to pull information from the first mission’s charts, but EMR was having logistical issues, so we ended up playing with the kids and making a flow chart for Justin who had a meeting with Prof. Samet to update him on the different research projects going on. Alex (plastic surgeon living in Guwahati) and Carolina (another plastic surgeon from Colombia) have many ideas for research. Last night we had a meeting at his apartment and there are literally 10-11 different project ideas they have! The most relevant one to public health was nutrition burden amongst cleft lip/palate patient, the associated risk with surgery and also whether or not speech improved after palate repair if they’re older than 7. So today we are doing a literature review of the different articles published on nutrition related to cleft lip/palate in India and also how the WHO measures their growth curve. Defining malnourishment is a whole other task, because it can’t be universal. Some phenotypes are smaller than others. For example, Europeans on average are taller than other population groups. Of course, this is a huge generalization, but a growth curve could be developed per region. Alex and Carolina want to develop one for Assam for insight on whether or not surgery would be appropriate of if the patient is too malnourished in which case Operation Smile can help the patient get healthy in order to get their surgery. Stephanie said that Op Smile actually just hired a MPH graduate who’s in charge of Maternal and Child Health at headquarters. Also, Stephanie is working on a grant to study the use of herbicides in the tea plantations and the prevalence of cleft lip/palate amongst the farmers. It’s so apparent that the worst cleft lips (bilateral with exposed gums) are in the farmers. There was this one man who every time I looked over he had the hugest smile, but really bad cleft lip. I saw him before and after surgery and took pictures telling him I was so happy for him and he just put his hands together bowed implying Namaste.

I hope I can continue to be involved in all the research and project ideas here in Guwahati. I don’t know how and to what extent, but I really enjoy this field work and especially how Operation Smile isn’t just concerned about cleft lip/palate, but also other factors effecting these patient’s lives like nutrition and herbicide exposure. This are the kind of upstream factors us public health students have been trained in evaluating and is what really inspires me to be in this field. Human health is not just disease, but also quality of life. That is something I’ve learned by being here. Public health is also concerned with how people live. Everyone deserves a life with full opportunities not hindered by bad health or environment. Cleft lip/palate severely effects prospects in marriage and education therefore effecting mental health. A couple patients’ parents actually told us that their children never left the house out of shame for their appearance and/or speech impediment. This has been difficult for me to process as I’ve always concerned myself with emergency medicine. However, some of these people have lived 40+ years with limited opportunities and social stigma because of the way they look and sound.

2/4/11 Mur Name Kakoli

2011-04-01T12:09:00.000-07:00

Stephanie, another MPH strudent, arrived Monday and Tuesday was a free day so the team went to visit the Hindi temple Kamakhya Mandir. The story is that Sati’s body parts fell throughout India and her womb or genitalia fell on Guwahati where the temple is. So there’s actually this huge festival in June/July called Ambubachi Mela where they celebrate the goddess’ menstrual cycle and dye the river red. The temple is made to look like a womb too, dark red cavern like rooms. We had to take off our shoes to enter and there are roaming goats everywhere. We walked in a room and got tikas on our foreheads (red chalk dots) from the priests. Then we sat on some steps overlooking the sacrificial pavilion and saw 4 baby goats get beheaded. It blew my mind. Families would come up to the priest and I guess pay them to sacrifice on their behalf and then they’d put some of the goat blood on their tika. Wow! Sometimes they even sacrifice buffalos. I saw them capturing pigeons too and putting them in boxes. After, we went on a little cruise on the Brahmaputra River and ate lunch. The locals have told me the smallest river island in the world is right off the shore of Guwahati called Peacock Island which we went by and where sits the Umananda Mandir temple. Hopefully we’ll get a chance to actually walk on the island. I took some nice pictures of people along the shore washing their saris.

Today is the third day of surgery. There are 1 ½ more days. The surgeries are from 8am to 8pm. On Wednesday, they did 36 surgeries at 10 tables. I can’t imagine how tired the medical staff is! Minh and I on the other hand usually survey for about 4 hours in the afternoons. Our population is limited to only those who have qualified for surgery so since they came the afternoon before the surgery day, we have set up a station to call those patients up after they arrive and check-in for surgery. Later in the evening they are admitted into the hospital to their respective beds. So then we move our station inside and call them out one by one from their bed. Minh and I have seriously revised our questionnaire probably 10 times. The first day we finished 12 questionnaires and yesterday we finished 16. We don’t have one student translator assigned to us, so we rotate through the ones that are free. The days have been hectic because not only is surgery going on, but screening is too! Medical staff also needs to be available to screen! Most of the busloads are from the tea plantations, which are the poorest populations of the state of Assam. Some don’t speak Hindi, Assamese or English and there are limited translators that speak Bengali and none that speak the tribal languages! Some translators are out because of university exams so basically resources and time is short right now. Alison (who helps manage the mission) says things should get less hectic and we’ll be able to complete more questionnaires. The first day we had them sign an informed consent, but then realized since most of them are illiterate, verbal consent would be better. So now the translator just explains who we are, what we’re doing and that the questions may be uncomfortable and that participation is completely voluntarily. This is a requirement of the Institutional Review Board (IRB). Our study’s application to them has actually been returned with 23 changes. So Minh and I spent the morning at the hotel revising the application. It’s ready to re-submit, I hope the IRB accepts it!

So the student volunteer translators are great. Most of them are 18-22 so I call them my vaity (little brother) and they call me baa (older sister). We also call each other bondhus (friends). They usually come hang out at our station and will cycle in and out with helping us translate, since there’s such a small supply of them. They’ve been teaching us Assamese and even gave us Assamese names. Mur naam Kakoli (my name is Kelly) is what I tell everyone. Also, my name is similar to Kali who is the goddess of eternal energy and destruction. However, Kakoli is prettier one who preaches to the birds. I like birds. They also really seem to want to learn Spanish, so I’ve been teaching them Spanish also. To each patient we interview I say “Subheshya thakil operationer bhaba kali” which means “Good luck with your operation tomorrow” and of course “dhonyabaad” and “Namaste” as you put your hands together like you’re praying and bow. A couple times I’ve felt emotional seeing the patient’s reactions to our questions. The one that is the hardest is “What do you think causes cleft lip/palate in general?” A lot of them think it’s their fault or they did something wrong so they feel really guilty and struggle admitting to the answer. Some of the answers have been superstitious like the woman walked outside at night when pregnant or ate something during the solar eclipse or cut the betel leaf, which is used in Ayurvedic medicine by chewing. Another interesting answer is that when we ask “What places do you avoid because of cleft lip/palate” they respond “wedding parties. We asked the translators what’s the significance of wedding parties and they said they are the biggest parties of your life basically. You invite everyone you know (friends and family) to your house for 2 days and it’s a common place to meet your own suitor. So, therefore marriage-ability seems to be a big concern to the parents. It’s beautiful to see how much these parents love their children though, no matter what. Only one person responded they hide their child, but most say they are happy and just want them to be happy. The bias here could be they know they are getting surgery the following day, so don’t feel as helpless. Our study is one of the first of its kind though, so we’ll be able to improve it in the future.

I can’t wait until we can scrub in to surgeries. We’re hoping one of these mornings. We’ve been surprisingly busy most of our mornings either fixing the IRB application and now we’ll begin data entry using Qualtrics, which is an online survey/database system at USC. I’m excited to see what we find. The team has been very supportive in helping set up our stations and fitting into the patient flow. They also are curious to the responses patients give us. It gives such great insight into the culture and their perspectives which will really help Operation Smile’s permanent center they are opening here in Guwahati to provide more culturally competent care to their patients.

2/1/11 Ki Khobor

2011-04-01T12:07:00.000-07:00

I keep reminding myself I’m in India, on the other side of the world. I’ve finally branched out from the Americas to the farthest away I’ve ever been from the United States. I definitely felt that distance when traveling here to Guwahati. A six hour flight from LA to New York then a 24 hour layover followed by a 14 hour flight to Dehli and a 2 hour flight the next day to Guwahati. Now that I’ve been stuck on an airport runway on a slab of ice for 6 hours in the middle of a blizzard and only slept a few hours on the airport floor, I can travel anywhere.

When arriving in Guwahati, we drove through the streets on the other side of the road winding through other cars, buses, motorcycles, people, bikes, rick shaws and cowdogs. We call them cowdogs because they are cows that wonder and live like stray dogs! I also noticed the different dress and face/head decorations. The two principal religions are Islam and Hinduism and for the most part these days live peacefully.

So I left LA Wednesday morning and arrived in Guwahati Saturday afternoon just in time for the last bit of screening for the day. We met most of the team and got an overview of the screening process. There are about 8 stations – registration, patient image (photo), plastic surgery, anesthesiology, pediatrics, dentistry, speech therapy and laboratory. The children and their families arrive via bus from the rural districts outside Guwahati, so they are mostly farmers. Then it takes about 1-2 hours to go through all the stations and they find out that day if they are scheduled for surgery or not. For our study, since we are only including those who will get surgery, we won’t be administering our questionnaire until the days of surgery when they come in the day before for hospital admittance. So the past few days we’ve been hanging out and observing. The team asks what Minh and I are doing here and since we have to avoid the word “research”, it’s hard to explain. Our official title is “MPH observer”. “Research” has a negative connotation and the local ministry of health didn’t initially approve our project, so we have to be subtle. Therefore, we call ourselves “comprehensive screeners”. We’ve spent time at the plastic surgeons table and the electronic medical records station. Since we were stranded 24 hours in the Newark airport, the 25 of us on that flight really bonded. So we got to know the plastic surgeons Alan, Nolie and Tatiana (from Colombia). They let us sit with them and explained the form they fill out and let us look at the patients cleft lips and palates. There are 5 priorities for surgery – 1 is cleft lip, 2 is palate under 7 years old to fix speech, 3 is palate over 7 years old, 4 is previous surgery repair and 5 is anything else. Most priorities 1-3 are operable. The top priority of these surgeries are smiles aka aesthetics especially here in India where physical appearance is a matter of survival (marriage-ability, educational/career opportunities, mental health, etc.). It is so interesting and inspiring me to get a clinical degree in surgery.

We were able to also meet with 2 local student volunteer translators – Pompi & Salma – who looked over our questionnaire providing feedback and appropriate answer choices tailored to local culture. We’ve looked over our questionnaire 50 times by now, and are finally going to print the copies today. The student translators range from 19-23 years old so far that we’ve met and are amazing! Not only are they dedicated to the Operation Smile mission, but also very open and nice to Minh and I. They explained their health care system and caste system to us which is different in each state. The caste system is not officially recognized by the government, but is still an important cultural indicator. There are 6 categories – General (Hindus, Muslims), Other Backward Caste, Sechdule Caste (based on last name), Sechdule Tribes (Hills), Sechdule Tribes (plain), Minority Other Backward Caste (used to be called Dalites or “untouchables). One can’t marry down, but can marry up. But they all seem to be friends apart from caste and go to similar universities. The local government has actually reserved seats for lower castes, some type of affirmative action. They also pay ASHAS (rural health advisors) to bring in women to the hospital to give birth. If the woman gives birth to a female, she get paid more money. I guess they are trying to make up for the historical treatment of lower castes and women. Reza (another translator we’ve met) said still to this day in some tribes, they may kill female babies preferring the males. The students have provided such helpful insight and information that you can’t find anywhere else online. I’m so glad that we’ve come early to hang out with them and get to know local culture and society. We still have so much to learn and absorb though!

Engineers Without Borders: Photos of Water Containment System Construction

2011-03-24T17:28:00.000-07:00

Here are some more pictures from our trip to Corral de Piedras, Honduras:

This is what our site looked like when we got to Corral de Piedras. As you can see we had a lot of digging to do.

Here is the foundation right before we started to pour concrete. You can see the re-bar in a grid pattern. The rocks are to ensure that the re-bar stays 3 inches above the ground.

Here are some of the community members after our wednesday meeting when we gave out the water filters (blue buckets). The community members were very happy after this meeting.

This picture below shows one of the tanks that we are going to put on the foundation when we complete the system.

Here is Arturo, one of the community members, putting the finishing touches on the foundation. The hooks that you see will be used to tie the tank down and secure it to the foundation. They are tied to the re-bar that we put down in a grid pattern

The last picture shows the Mayor, Rigoberto Villatoro, signing our Memorandum of Understanding, which was signed by the mayor, the community, EWB-USC and ADEC outlining the responsibilities of each group with respect to this project.

Water filter distribution and rainwater catchment construction in Honduras

2011-03-23T18:28:00.000-07:00

On Wednesday we had a meeting with the community and with ADEC to hand out water filters to members of the community that still had not been able to get them. The community could use these filters to make the water they already get from the springs drinkable. These filters are filters that the community purchased and they were subsidized by EWB-USC. We found that this was a better alternative than just giving the filters to the community members because we felt that if they paid for at least a part of them they would care more for them and actually use and care for them properly. ADEC went through how to use the filters and how to clean them and how to make them last. The biggest challenge with the filters is to make sure they are sustainable and that people will continue to use them in the long run.

Construction also continued during the day on Wednesday. This is when we actually started to pour the concrete into the foundation. Again we had some issues with delivery of materials, which delayed us a little. But with the hard work of all the community members involved we were still able to reach our goal of getting one half of the foundation done. What looked like one half however was a lot more because of the differences in depths throughout the foundations; we actually had completed ¾ of the foundation.

On Thursday we completed the foundation. Upon completion, we engraved “CDP y EWB-USC 2011” in one corner of the foundation. Then, the community members wanted to play soccer with us so several members of the EWB-USC team played soccer with community members for some hours awaiting the arrival of the Mayor who was coming to see the final product. Most community members were present at the ceremony with the Mayor. Both were very thankful for EWB-USC for all their hard work and for making this project that they had been asking for for many years a reality.

On the last day, Kristen, our next Co-Project Manager, together with Luciano went to do some materials assessment with regards to the next phase of our project, which is the installation of the gutter system and the pipe that will take water from the gutter to the tanks.