An account by Field Officer, Paul Mogosi

Last week the local Ministry of Health’s Nutrition Team officiated a CHW training on IYCF. Training materials were developed in conjunction with Path, University Research Co., LLC, and UNICEF. 

Here is an account by one of our most astute Field Officers, Paul Mogosi.  This will be the last Healthcare training Paul will participate as he is moving to the Training Team to learn how to facilitate Nuru’s newest curricula. He will be greatly missed, but will undoubtedly continue to help improve his community’s health-based decision making when possible. 

During the training the CHW’s learned thier expectations like how to how to use new knowledge in IYCF while explaining to the community and how to change behaviors.

The CHWs will do a very good job during household visits by using general counseling guidelines learned in training, mostly for mothers who are breastfeeding. They were trained to use open questions, rather than closed, to find out the information they need. 

Examples of which are:

Closed: 

CHW: Good morning. I am Esther Kebaki. a IYCF counselor. Is your baby, Cha Cha, well? 

Mother: Yes, thank you. 

This will not let the CHW know about the child to inform the rest of the visit.

Open: 

CHW: Good morning, Bhoke. I am Esther Kebaki, a IYCF counselor. 

How is Cha Cha? Can you please tell me about his health? 

Mother: He is well, but is always hungry.

This will make the CHW know more about the baby. Then the CHW can ask questions like why do you think he is hungry? What do you usually feed him? Can I provide some advice?  

The CHWs will have a chance to show the mothers the advantages and benefits of exclusive breastfeeding for the first 6 months of life. This education and demonstration can help build immunity and reduce illnesses like pneumonia, diarrhea and malnutrition. 

They will teach why families should not give the infant water or herbs immediately after birth, and that newborn babies should be given breast milk within 30 minutes in order to provide special protection from illnesses. 

CHWs will also teach mothers about proper attachment and position of their baby during breastfeeding. Proper attachment will reduce the common breast conditions like cracked nipples and Candida (thrush), boils, and plugged ducts. 

Along with exclusive breastfeeding, they will introduce new immunizations called Pcv10, which is given after 6 weeks of birth and is given three times. Thus reducing the number of children who are dying from pneumonia. 

CHWs learned about the needs of children after 6 months including giving a balanced diet of 3 types of food: Protein (body building food,) vitamins (protective foods,) and carbohydrates (energy giving food.)  During home visits they will give examples of each group and explain how much and how often to feed young children from 6-24 months. This will include critical nutrition supplements for children in our community because we have problems like eyesight, night blindness, diarrhea, anemia and brain damage. The CHWs will give advice on the use of vitamin A, Zinc, Iron, folic acid, and iodine in order to reduce the risk of deadly disease and long-term health problems. Our health goal is to prevent and mitigate diseases therefore household counseling will greatly help the community. 

CHWs had a follow up review session this Wednesday, and they showed impressive knowledge retention. They were reminded about the various determinants for nutrition related behaviors and were equipped with a food pyramid and checklist of topics to cover.  They will also introduce Moringa Leaf Powder as a nutritional supplement, which we expect will have an extremely positive impact on malnutrition rates over the next year. 

Nutritional value of Moringa Leaf Powder:

• 7 times the Vitamin C of oranges
• 4 times the Vitamin A of carrots
• 4 times the Calcium of milk
• 3 times the Potassium of bananas
• 2 times the Protein of yogurt
• Leaves contain all of the essential amino acids (proteins)
• Leaves contains antioxidants

We are still eager to learn about home visit methodology. This week we are specifically interested in tools for nutrition specific visits. We would appreciate any information you may have! 

In saying so, all has not been lost while recently staying focused on the bigger picture. We have now designed solid systems that will enable the job to be done right once the nuts and bolts are in place. These include the commodity sales inventory tracking system and monitoring structure for Field Officers to mentor and evaluate CHWs.  Now it is time to develop the meat.

We’ve got our maps. We’ve divvied up our households. We know how to account for goods coming in and going out. Now we need a methodical approach for teaching the details and a toolkit to facilitate the application of these skills. The details of sales and home visits won’t just make or break our profit, it has the potential to save lives or forever deter our ‘customers’. 

Health topics can often be difficult to discuss so we need to create a safe space. The CHWa needs to have confidence in their ability to advise, and households need to have confidence in their CHW to give them good information. We have seen improvements in knowledge sharing and demeanor during home visits, but only after several trainings and very close monitoring.  We hope to develop a training curriculum to speed this process up. We have researched several CHW programs, but have failed to secure specific lesson plans or in depth advice and are now seeking yours!

For those of you involved in CHW programs:

• What does your home visit structure look like?
• How do you train for successful home visits? 
• What materials do you use during training?
• What materials do you equip your CHWs with? 
• How do you ensure key messaging is consistent? 

For those of you involved in health commodity sales programs in low-resource areas:

• How do you train on sales strategy?
• What materials do you use during training?
• What materials do you equip your salespeople with? 

We are grateful for any information you are able to share with us and hope to reciprocate in any way we can. Whether it be in the form of curriculum or making a connection with someone you feel would be helpful, please send a note our way.  By sharing your details you will help us take the devil out of ours.  

Sneak peek: Nuru Healthcare is in the design and development phase or the CHW model. Here is a brief overview of what is in the works: 

After recognizing that our community’s greatest health needs would best be met at the community level, rather than from an infrastructure or clinical approach, Nuru began researching best practices for community health programs. Information was compiled about existing organizations and recommendations made based on these findings, field knowledge and Nuru’s philosophy. 

In June 2010 Nuru Kenya launched its pilot CHW Unit, now operating with 43 trained CHWs. While functioning on the basis of the Kenyan Ministry of Health’s Community Strategy Nuru found that inadequate MOH mandated skill training, coupled with lack of governmental support, hindered CHW performance. It is now our goal to equip Nuru Units with ample training, field tools, and guidance in Kenya and future locations. 

Clearly defined and enforced CHW roles and responsibilities create a solid base for a successful program. For Nuru, these roles include prevention education, disease assessment, clinical referrals, community meetings, homevisits, program monitoring and evaluation, and commodity sales. Initial CHW selection will be community led with an opt-out policy to guarantee CHWs are respected by the community and have a vested interest in the position. An intensive and comprehensive training will follow the selection process. 

Adopting a participatory-based training approach and deciding on an appropriate behavior change theory for which to base our trainings will facilitate the development of skills necessary for effective CHW activities, and foster community-based problem identification and solving.  The initial training will provide a comprehensive overview of disease specific information relevant to our jurisdiction, and will be followed by supplemental and refresher trainings based on a topic-specific approach over the span of a year.  CHWs will also undergo leadership, home visit strategy, conflict resolution and M&E trainings as part of their base education. Nuru will develop manuals and reference materials for trainers and CHWs.  A cell phone based support structure will be researched as a supplementary resource for future use.   

Armed with official identification and uniforms to ensure recognition and acceptance, CHWs will be expected to visit fifty households per month where they will train community members on preventive health behaviors, symptoms of diseases, and advise on treatment options. Visits will be conduced under a case management protocol. To complement the educational component of home visits, CHWs will provide first aid and sell health and hygiene products that will assist in disease prevention and low level mitigation.  Other innovations may include a bike/boda ambulance service and a boda-based marketing system. 

With the goal of increasing access to products in an otherwise unreached area, Nuru Healthcare Commodity Sales will include items such as long-lasting insecticide treated nets (LLITNs), safe water systems (SWS) such as WaterGuard and Pur, soap, nutrition supplements, first aid products such as fungal creams and bandages, and eventually common drugs for treatment. 

It is known that a strong relationship with a local Health Center is important for a CHW program for the following reasons: Collaboration on drugs supplies and storage, cooperation for referrals and case management, and for knowledge sharing.  We intend to work closely with clinicians when possible and develop a memorandum of understanding to outline our relationship. 

The Nuru Research Team is currently working with members of the Healthcare Program to develop logic models to inform interventions and related monitoring and evaluation.  The outcome metrics determined by these logic models will result in a detailed plan for data collection methods and indicators related to all healthcare program metrics. 

Program sustainability requires that financial and human resource needs be met.

CHW motivation is imperative for low attrition rates.  Though CHWs will be considered part-time employees, they will not receive a salary. Rather, they are eligible for commission on non-drug commodity sales and will receive non-monetary incentives including sample products and community respect. Commodity income will also assist in program overhead, and be supplemented by local grants. Nuru will conduct additional research on small business loans for salesmen and women, and micro-insurance options to augment financial needs. 

 We are looking forward to iterating on these recommendations and following up with our plan for approaching these next steps.  As always, your thoughts are welcome

This means that while our team is busy trying to prevent diseases they rarely have the opportunity to see the fruits of their work. Prevention, other than successfully designing a vaccine, is for the most part intangible.  Especially those on the front lines, it is impossible to exactly predict if would have contracted a disease or not. 

When you work so hard to do something you can’t see it is easy to become demoralized and feel that your work is not making a difference. That is why I was so pleased to learn of a recent measurable accomplishment made by one of our field officers, Stephen. 

Steven brought a case to our attention a few weeks ago. It presented signs similar to Guinea Worm, which we had been surveying for.  We visited the two-year-old- twin, Zalipa, to find out more about her condition. We could see the worm under the skin on her foot and learned that the site was extremely itchy causing her extreme discomfort at night. To ease the itch her mother would burn Zalipa’s foot with scalding cooking utensils, creating an altogether different health concern. After collecting all of the information, we believed the worm was instead hookworm, a parasite that enters the body through the food and infects the intestines.   Hookworm is especially dangerous for young children because it can cause or worsen anemia, stunt physical growth, and impair learning and cognitive growth. However.  The good news is that unlike Guinea Worm it can be treated with a drug dose such as Mabendazole.   

While we were visiting Zalipa’s family we also learned that they had been using a crushed up white rock, which they were told was natural chlorine, to treat their water. Not convinced of the efficacy of this strange powder, we took the rock back to our water-testing lab.  

Steven followed up with the family the next week to inform them about our beliefs regarding the worm and to encourage them to visit the local clinic before Malazi Bora ended. (A MOH sponsored campaign that includes deworming, vitamin A supplementation, ANC, growth monitoring, and health education services.) He also informed them that the white rock was not effective in treating their water and that they should use another method. The family agreed to go to the clinic, but scoffed at the news about the faulty water treatment. 

Once again, Steven returned to the house the following week to check on Zalipa.  This time he saw with his own eyes that his advice led to the successful treatment of the worm. He knew right then that he had prevented anemia, stunting, and cognitive impairment, and saved the little girl from excruciating pain of being burned and the likely infections that would have resulted. Her foot had healed from the scratches and burns that were previously there, and the worm was no longer visible under the skin. 

An added triumph:  This time Stephen came armed with the test-tube and information sheet as evidence of the faux chorine solution to prove the water treated with the rock still contained fecal matter. Upon seeing this, the family admitted that they often feel sick after drinking the water, and agreed to purchase WaterGuard on the spot.  

Talking about these victories with the team served as a reminder that with persistence, creativity and accurate information we truly can help our community improve its health. This type of success adds to the evidence for a casework approach and the need for a rigorous follow-up system—two recommendations we will be making in our upcoming Nuru Healthcare Model Plan Presentation. 

Even though we won’t always be able to see the exact results of our efforts, we can hope that over time we will notice a gradual improvement in the lives of our neighbors and that every now and again time will be laced with little bits of hard evidence for encouragement. 

Guest blogger: John Weisiko, Healthcare Field Manager, Head of Commodities Sales.

John and I attended the Nyanza Provincial Community Health Strategy Stakeholder’s Forum on October 25, 2010, which was hosted by JICA’s (Japan International Cooperation Agency) Project for Strengthening Management for Health in Nyanza Province.  This is John’s recap of the event. 

The Project for Strengthening Management for Health in Nyanza Province was launched to improve provincial and district health management systems to increase responsiveness of the health problems and enhance the quality of health services. To achieve this objective their is a need to strengthen the capacity and functions of the provincial and district management teams by using CHWs, as they are the people who can reach those who are below poverty line and have little information to influence their behaviour. Currently CHW coverage only reaches 14% of people in the province. CHWs are faced with many challenges like lack of chalkboards (a monitoring tool used to record health statistics collected by CHWs) and lack of motivation due to not being paid.  The speaker emphasized the importance of community participation because dialogue is a two-way stream of knowledge and helps people interact.  

Statistics shows that Nyanza Province has the highest rate of HIV/AIDS and TB in Kenya, and therefore there is need to come up with strategies to reduce the burden of this virus. This can be done through comprehensive messages of facts, and provision of other preventive measures.

We also learned that there is a case of Wild Polio Virus confirmed in Bugiri district on the border of Uganda and Kenya and alerted the surveillance team to our case of Guinea Worm. 

Some organizations presented on their CHW programs including: Mildmay, Millennium Villages, Essential Health Services, and UNICEF.  

Take aways from the forum:

• The government supports an honorarium (or small payment of CHWs to help reduce attrition rates)
• The provision of drug kits for minor illnesses (though it does not include malaria treatment yet)
• UNICEF is working with the Ministry of Health to redesign the initial 3 week CHW training program
• We will be attending the 1st National Strategy Convention on Nov. 22-24
• The most common challenges for Community Health Worker Units seen in Nyanza are poor relationships with local clinic staff and CHW motivation. 

The Lessons I Learned: 

• I learned the importance of reading and reviewing what one has prepared to be familiar and comfortable with the presentation. Being prepared with facts and knowledge will enable the presenter to guide the discussion and answer questions that arise.
• We (health workers) should be role models by practising what we are teaching the community. We should repeat the benefits of what we are teaching. We need to support our groups (of CHWs) until they practice proper health behaviors and we must be confident in the job we are doing.  
• It is good to adopt positive bahaviours and attitudes that can enhance the quality of someones life. These may involve getting tested in order to know our HIV status and accepting ourselves the way we are. 
• It’s very important that community members interact with other people in the community to get more information. This can be done through support groups or interacting with family, spouse and peers. This can inspire people to continue with work to earn a living or help others as volunteers or peer educators.
• On the topic of commodity sales, we were able to meet with others organizations to obtain some of the booklets and posters. These are very educational can influence our community’s behavior.   
• We were able to find a supplier for mosquito nets at a cheaper price, which will be affordable to our community members as most of the people have complaining of high prices of nets in our area. We are excited to work with SWAP.

These worms are spread when barefooted children tread on soil contaminated with feces containing such worms. The parasite passes through the sole of the foot, then makes it’s way to various places in the body to multiply. Worms can also be ingested after dirty hands have contaminated food, or are put in ones mouth.  

Most of these parasitic infections can be treated with simple medication. This is why it is common in developing countries to see semiannual school de-worming campaigns. Worms often cause children to miss school as infection manifests into symptoms similar to other diarrheal or respiratory tract diseases, and can lead to serious complications like malnutrition. 

Worm infections can be prevented if simple hygienic measures are taken, such as hand washing, cooking foods thoroughly, wearing shoes, using a latrine, and keeping compounds free of fecal matter.

Some worms live in the body until a drug dose destroys them, and some are passed out through bowel movements.  But there is one worm that leaves the body through the skin: the Guinea Worm.  

Guinea Worm Disease (GWD), also known as Dracunculiasis, is said to only exist in five countries. Sudan, Ghana, Mali, Nigeria, and Niger.  In 2000 the Carter Center Guinea Worm Disease Eradication Program, one of the leaders in the fight to eliminate GWD, acknowledged Kenya’s efforts toward eradication during special ceremony. In 2000, alongside, Benin, Burkina Faso, Chad, Côte d'Ivoire, Mauritania, Togo, and Uganda, it was noted that Kenya has stopped transmission all together. The last case of GWD was in Turkana in 1997, but it was said that transmission within the country’s own borders ceased in 1994. 

Last week Moses, one of Nuru’s Education Program Managers, brought a case to Healthcare team’s attention. There was a boy who lived nearby his home, claiming to have a worm living and moving under his skin.  Our team met the boy, also named Moses, at his home to discuss his problem. Sure enough, there was a worm under his skin that had tried to emerge through the top of his foot twice. Both times, despite the painful lesion, he pinched the white head of the worm, causing it to retreat and find another escape. We advised the 13-year-old and his family to call us the next time the worm surfaces and gave him instructions on how to remove the parasite and keep it for testing.  He has agreed to avoid contact with all bodies of water to reduce the risk of further contamination. 

On October 27th members of the provincial and national Ministry of Public Health and Sanitation’s Division of Disease Control and Surveillance came to confirm our findings.  The next steps will be to work in conjunction with the WHO to test the water in surrounding areas, launch a prevention campaign, and investigate for other cases. 

More information on Guinea worm: 

Transmission: 

Guinea worm is spread by drinking water that contains a flea that is infected with the even tinier larvae of the Guinea worm. 

“Inside the human body, the larvae mature, growing as long as 3 feet. After a year, the worm emerges through a painful blister in the skin, causing long-term suffering and sometimes crippling after-effects. Infection can be avoided, even in areas where the disease is very common. Use only water that has been filtered or obtained from a safe source. Keep people with an open Guinea worm wound from entering ponds or wells used for drinking water.” 

Treatment:

This type of infection differs from the others in several ways, but most significantly in that it can only be diagnosed by seeing the worm extracted from the skin, and there is no drug treatment to kill it.  

When the worm presents itself at the sore, one must gently pull it out while winding it around a stick, despite the immense pain. This process comes with great difficulty, and often takes days, weeks or even months of repetitively pulling pieces out.   

While living in South Africa we got a good laugh at the blunt proclamation of illicit activity. Since then it has taken has strangely morphed into a light-hearted, but functional analogy for anything of consequence being borrowed or utilized from an inspiring source. 

I couldn’t help but be reminded of this memorable aphorism when I was first introduced to Nuru, an organization that prides itself on being a general contractor of experts, rather than a non-profit that reinvents the wheel.  Nuru knows there are several effective methods of fighting extreme poverty specific to our 5 areas of development already in existence and seeks to partner with them—an activity one could hardly consider criminal. As mentioned in my last entry, we have contracted Safe Water System training and commodities out to notorious experts at PSI Kenya. In fact, this week we successfully distributed WaterGuard to our CHWs to sell to their community and are eager to see how fast our first supply will fly out of our storage area.

We are also taking specific steps toward strategic communication and simplification of our messages. Therefore have made a programmatic shift to dedicating a specific amount of time to one disease or health topic per month. November will be geared toward prevention of diarrheal diseases with the main tool being WaterGuard.   

Next in line for December will be Nutrition. In liu of October’s Maternal and Child Health Day we have supported the completion of the Ministry of Health’s ‘Integrated Management of Acute Malnutrition’ training for the clinic and hospital staff in our catchment area and those to which we are expanding. The objectives of this training were to teach staff how to: 

• Identify patients affected by moderate and severe acute malnutrition
• Manage moderate acute malnutrition by applying standard protocols
• Know the requirements and procedures in setting up a program to manage moderate acute malnutrition 

Once the Commodity management system is put in place, the trained clinics and hospitals will be recipients of USAID funded Ready-to-Use Therapeutic Food (RUTF) or Fortified Blended Flours (FBF). We will then have a subsequent training for our CHWs, who will in turn be the eyes and ears of the clinic. They will be equipped to identify and refer patients to receive food therapy free of cost. 

In Kenya the management of moderate acute malnutrition strategies are linked to the National Health Programs, specifically incorporated in the Mother and Child Health Programs (MCH). This structure, along with the curriculum used for our training, was created in part by the USAID Nutrition and HIV Program (NHP). The NHP funds the Food by Prescription (FBP) Services.  The goal of which is to build capacity of health providers through training, job aids, strengthened monitoring and supportive supervision, and enhanced community linkages. 

On average, the project supplies about 120 metric tons of fortified blended foods per month to health facilities. Currently more than 380 health care providers have been trained in FBP services are prescribing and dispensing therapeutic food. Now we can add ours to the list!  

CHWs aim to encourage healthy behaviors by showing value and ease of adaption. Their ‘toolkit’ ranges from disease specific knowledge to problem solving tactics to physical means of preventing illness and improving health.  Now that the team is building their skills to listen intently, advise appropriately, and share knowledge in memorable, efficient and effective ways, we have officially added an ingredient to the third, tangible component- commodities! 

Introducing…..WaterGuard & Pur

Last week we finalized our partnership with Population Services International (PSI/Kenya). PSI/Kenya works to improve health conditions for Kenyans in seven out of the eight provinces and has built a network of more than 5,000 commercial partners that help enable low-income and vulnerable Kenyans to lead healthier lives.  PSI offers WaterGuard and Pur, two safe and effective, low-cost alternatives to boiling and filtering contaminated water, reducing the risk of diarrheal diseases-- a leading cause of under 5 mortality.  PSI/Kenya estimates that between January and October 2008 its products and services helped avert 19,707 diarrhea episodes. As distributors, promoters and educators, Nuru's Healthcare and Water and Sanitation Teams will work with PSI to increase access to safe drinking water in Kuria West.

WaterGuard is a dilute sodium hypochlorite (chlorine) solution used to disinfect water at the household level. One capful of solution treats about 20 liters of water, about the size of most containers used to obtain and store water. The solution is easy to use and extremely inexpensive —a bottle typically costs less than thirty cents to protect a family of six for one month. 

PSI’s reputation for excellent training was once again corroborated when they joined our Healthcare and Wat/San Field Teams and CHWs to run through the how to’s and myth busters that will enable our educators to properly distribute the safe water systems.

See how PUR purifies water in this video. 

Coming soon… Moringa Leaf Powder:

CHWs will also soon be selling the powder form of what has been dubbed, “the miracle tree,” which contains a serious amount of vitamins and antioxidants, plus all of the essential amino acids. 

Studies conclude Moringa can:

• Boost the immune defense system
• Increases CD4 count in those with HIV AIDS
• Lower blood pressure
• Help children maintain or increase weight 
• Help pregnant women recover from anemia and had healthy babies
• Promote muscle relaxation to increase sleep time
• Added to carrot juice it will work as a diuretic to increase urine flow
• Increase milk production in breast-feeding women
• Balance blood sugar levels

As we’ve gained recognition on the district and provincial levels we are starting to receive invitations to ministry meetings and other NGOs are reaching out to us to combine efforts. Recently we attended an ActionAid sponsored Female Genital Mutilation strategy meeting and our CHWs partook in an Essential Health Service funded Maternal Health Baraza. Last week Nelly and I traveled to Kehancha, for the district’s ‘Annual Stakeholders Meeting for Maternal and Neonatal Health.‘  

It was an opportunity to learn about the efforts of other NGOs in the area and to gain access to the most up-to-date Kurian health statistics—which are very hard to come by.

Despite the 8:00am scheduled start time, around 11:45 the district statistician took to the stage for a ‘year in review’ presentation.    

To ease into the AOP (Annual Operation Plan) Performance Report for July 2009-2010, Samwell reviewed the Millennium Development Goals. He then focused on local stats specific to #4 (Reduce Child Mortality) and #5, beginning with the district demographics- there are 14,6,669 individuals in the district, 5% of which are under one-year old and 19% under five. 25% are of childbearing age. 

The next set of information pertained to access to family planning. Anecdotally knowing the low rate of use in Nyametoboro and surrounding areas, the impressively high-recorded percentage of women using contraceptives struck me as fishy. He then noted that 51% of all under 5’s received Vitamin A supplementation thanks to five outreaches sponsored by a International NGO. Also higher than I expected, but certainly not unreasonable. Who am I to judge? I am not a statistician, and didn’t have all of the background information that informed this dataset. 

But with the next slide all credibility was lost.  Samwell was pleased to announce that the MOH successfully vaccinated 118% of their target under 1s.  How wonderful! But what was the targeted percentage?  I asked. His response: 100%. Wow! I was puzzled when the statistician did not use this opportunity to explain this odd piece of information, and immediately moved on to the next topic without further explanation. Dissatisfied with this, I raised my hand and suggested that perhaps the reason for this was that every under-1 had been vaccinated and some even twice. After calming down from a brief laughing fit he said, in a tone that insinuated my stupidity, he said, “of course not! Children from Tanzania and other districts are sometimes immunized in Kuria.” This is well and good, immunize as many kids as possible, but please record where they are coming from.  Besides, in my opinion, there is absolutely no way that over 90% of Kuria’s under 1 population have been immunized. 

Perhaps worse was the data on maternal deaths. According to the AOP there were two maternal deaths in 2008, three in 2009, and eight in 2010. For a country with a maternal morality rate of 5.6%, with the Nyanza province as it seems odd that the rate in Kuria West is so low. Turns out, they only accounted for deaths at the District Hospital, none of the other clinics or location hospitals, and it happened that the district hospital’s generator was broken during 2008 and 2009 so they were referring maternal complication cases to other facilities that had electricity. 

You may wonder why this is happening. Along with inadequate recording procedures and materials, laziness, and misdiagnosis, it has become clear that there is a conflict of interests in the incentive system for rural facilities. The health workers want to report good statistics to be recognized as a worthy facility, but these fake numbers impede granting for support they actually need. 

Though terribly frustrated that the MOH was knowingly presenting wrong data to local stakeholders, I am concerned about the implications of this publication which will reach international donors and the ministry at the national level, which is responsible for allocating funds. This data indicates that Nyanza is not in need of improved services impacts available assistance. Perhaps this is what accounts for Kuria being the forgotten district and this is what we are trying to change. 

On my first day of work at Micato Safaris, my first job out of undergrad, my boss called me into his office to discuss my role and give me some tips before embarking on what would be a valuable three-year journey of personal and professional development. He said to me, “the best manager is a lazy one.” Seeing as I was a young, obedient literalist at the time, I was confused for obvious reasons. Despite my limited knowledge, I was quite sure that there was no room for laziness in the workplace. 

As he went on to explain his facetious claim, the moment of sheer panic that I had made a poor decision to work for this company passed. The point he was trying to introduce was that the key to successful management is to hire well-equipped, hardworking, adaptable staff. Then, train them well, and put your trust in them as you delegate responsibilities, as this allows the manager should focus on strategic design that impacts the company as a whole and other such managerial undertakings-- none of which involve anything close to idleness.

Nuru’s fifth Foundation Team is already in its second trimester on the ground, but the Healthcare program is still developing. It is not to say that we totally lack structure, but rather as we work hard to hone in on an exact CHW model, it becomes increasingly evident that we need a clear division of efforts.  

In my experience, this is where many NGOs go wrong.  Money is allocated to a project. A Westerner comes in to implement. Money dries up. The Westerner leaves. And the cycle repeats without long-term impact because the local leadership has not been properly developed or given the appropriate tools so to carry on the efforts. And, while foreign aid is truly trending toward genuine sustainability models, this practice is easier communicated than successfully implemented.  

Always up for a challenge, this is exactly the foundation Nuru is built upon.  We seek to employ the poorest of the poor, and help the staff leverage their valuable local knowledge while promoting technical and management skills. As for Healthcare, we have finished physically mapping households and health facilities, now it is time to map our management plan to ensure we reach those houses. 

Before deciding that investing in Community Health Workers was the most effective path to improving health in our community, Nuru tested several other options, including mobile clinics, hosting ‘Children’s Health Days,’ and upgrading permanent clinics.  During these activities our staff members were assigned one task at a time.  As the previous Healthcare Program Manager and Field Manager learned more about each person’s capabilities, their duties became more regular, but when changes were made in the program few roles remained relevant.  People thrive when they have significant responsibilities and feel that their efforts are legitimate steps towards achieving goals. Having a set of job description also eliminates a lot of confusion and pressure at all levels.   For me this means micromanagement and initiative exclusively on my behalf will cease, my ‘laziness’ will increase- aka trust and delegation, and ownership by the true owners of Nuru will amplify.

The tiered skeleton will remain- Community Development Committee Member (CDC)/Field Manager will work closely with the Healthcare Program Manager to oversee the Field Managers, who ‘rank’ above the field officers, who ‘rank’ above CHWs, however we will also implement roles with on-going management responsibilities that are pertinent to our long term goals. Plus we have added an addition level that needs managing: the CHWs! New roles are beginning to include additional responsibilities such as materials, communication and commodities management

While in Kenya I have thought at length about my time at Micato and other organizations that allowed me to grow personally and professionally. I can attribute that growth directly to being given space to operate, which often times included failing, and also the reward of confidence after success. The team here has the same right to learn as I had, and I hope to allow them that. Already I have seen an increased excitement and work ethic, driven by a sense of personal investment and confidence. The Healthcare staff is extremely capable; they just need the opportunity to thrive. They need to feel that they are Nuru, not just that they work for Nuru. 

For those who choose the public health career path, an eye is always peeled for risk situations and poor practices. People who consciously decide to dedicate their life to need-finding and improving health often already exude several of the characteristics that lend to those tasks. Some may include, a good work ethic, the appropriate balance of cynicism and hope, or empathy—traits that are arguably a combination of nature and nurture. In this field you don’t leave your work in the office. In fact your job is likely in the field- an expansive, borderless one at that.  So I couldn’t help but laugh at how typical it was when I caught myself making ever-so-Kenyan Tic’s and X’s about health do’s and don’t while on vacation in Tanzania.   

After inadvertently learning a bit about health on Zanzibar, I returned to Kuria West with a fresh mind to continue working on the problems in our community (some similar and some markedly different.) Before departing the week prior, it became evident that we are still struggling with how properly address local issues through community-based education. While our team, Field Officers and CHWs alike, have more than adequate knowledge to teach life-saving disease prevention strategies and advise on common illnesses during home visits, the messages are not yet being delivered in an effective way. 

While a few of the health team members have some relevant experience, the majority happened upon the job. They were either elected by a group to be a health representative, or they recently found an opportunity for employment, which also serves a huge community need. This is not to say that their intentions are any less admirable than a person who has had the opportunity to pursue their career of choice, or that hey lack interest in preventing diseases and improving lives- quite the contrary!  It is simply that ‘bedside mannerisms’ and serving as health teachers is, for the most part, a new concept and they go about their job in the way in which they are accustomed—much like I continued my customary thought process even while on vacation.  Looking for cues and constant ‘health awareness’ is not yet part of a regular repertoire for our team. And for most, an empathic approach and showing emotion is culturally frowned upon. 

The sad truth is Kurians are accustomed to illness and death on an alarmingly regular basis.  After watching some of the officer’s demeanor in the field and in recent “mock homevisits”, I couldn’t help but think that a certain hardening that ultimately lends to the appearance or actual lack of empathy due to the realities of their lives has the potential to place a weighty burden on the ability to address individual needs of community members. 

Is empathy, or the body language that goes with it, the missing ingredient in our proposed CHW recipe? U.S.-based research points to the value of this communication component and the fact that it is teachable and learnable. In fact, most medical schools in America now include courses dedicated to bedside manner. But can this data be applied to a culture that instills stoicism from an early age, and whose daily experiences and though-processes differ from the studied sample? Is empathy even a necessary trait to perform well as a community health worker in a place where emotions are suppressed? Or does a pragmatic understanding of the reality give the context that is needed? And if so, how is that harnessed?  

Surely it must be a combination, though it begs the question: for those who are hardened from the burden of disease in their own lives, and those who a simply of a tougher, C'est la vie mentality, can empathy actually be learned and effectively integrated? And, if so, how is it taught so that it is not a canned response and is culturally relevant? 

Healthcare Program Manager, Lindsay Cope, gives an update on the GPS and Google mapping project that will greatly help the local CHW's (Community Health Workers).

I hope you don’t mind the slight interruption of the 2-week mapping video series, but I couldn’t pass up the opportunity to share a bit of recent news that impacts Nuru’s presence in Kenya. 

While we have been working diligently to make a reliable map of the area that includes all households, clinics, drug dispensaries, VCT, and water sources, Nuru and its surrounding area is becoming better known for two other reasons as well—one positive, the other both dangerous and distressing. 

Let me start with the bad news: Last week the Ministry of Health confirmed a cholera outbreak in the Mabera Location. (One of the two new areas Nuru has begun its scaling in.) Despite the MOH’s diligent response, the death toll has surpassed 20. 

Cholera has the deserved reputation of being an extremely violent illness, however, it is preventable and treatable.  The symptoms mimic an intensified version of those common of typical water and food-borne bacterial diseases resulting from fecal contamination. The incubation period is shorter and body fluid loss from diarrhea and vomiting is far greater, sometimes exceeding 10 liters of diarrheal fluid per day if untreated. (The average adult male body has 40 liters of water). 

Treatment is ‘simple’ if one has access to Oral Rehydration Salts (ORS) and antibiotics (cotrimoxazole, erythromycin, doxycycline, chloramphenicol, or furazolidone.) We have been assured by the MOH that all clinics in the surrounding areas have been stocked with the appropriate treatments, yet the ongoing concern remains: what happens to those who don’t make it in time, those who are unaware of the virulence of the disease, and those who cannot afford to make the trip to the clinic? 

This is where Nuru can assist. The Healthcare team is working with the Water and Sanitation team to inform the local Health and Wat/San Representatives about the current situation, transmission, prevention, symptoms identification, and treatment options.  The Healthcare team also held an emergency meeting for our CHWs to provide a framework for prevention, monitoring, and treatment education at the household level in areas neighboring the outbreak sight.

For more information on Cholera please view the WHO factsheet. And to find out more about prevention and Nuru’s Water and Sanitation response have a look at Matt Lee’s account of the recent activities. 

In better news, last Monday Nelly Andega (Healthcare Field Manager and Community Development Committee member), Philip Mohochi (Nuru’s Community Development Committee Chairman) and I partook in a long anticipated meeting with the Nyanza Provincial Coordinator for Community Strategy and the Provincial Medical Officer (PMO) in Kisumu. The purpose of this meeting was to introduce Nuru and solicit support and advice for our CHW unit. They were pleased to learn more about our work, especially since we are operating in a province that has extremely low household healthcare coverage (~14%).  The creation of CHW units is the official recommended scheme outlined in the Kenya Essential Package for Health (KEPH and The Second National Health Sector Strategic Plan specifics CHW approaches for rolling out healthcare at the community level. 

The provincial officers are committed to supporting our expansion, sharing data with us, and fully recognizing our activities as they coincide with the national health goals, including the reduction of maternal and under five morbidity and mortality rates, increased immunization and vitamin supplementation coverage, and greater usage of Long-Lasting Insecticide-Treated Nets.  They also informed us we will be receiving an invitation to the Provincial Community Strategy Meeting in late September, where other attendees will likely include UNICEF, APHIA II, World Vision,  Essential Health Services, UCSF’s FACES Program. 

Now that we are on the map- or at least the radar of the Kenyan Government and those involved in disease control, our physical mapping plans will prove even more relevant for support, program implementation, monitoring and evaluation and knowledge sharing. Keep an eye out! The maps are soon to come

Healthcare Program Manager Lindsay Cope talks with Julius Nyamohanga, Nuru's Volunteer Partner Program Field Manager. Using a GPS and mobile phone, Nuru is making the world's first accurate mapping of households in the Kuria area to assist the Community Health Workers.

Not only do the Benidictos of the developing world inspire me to do my job daily, but motivating also is having the opportunity to take a ride in our community members’ shoes.

For those of us who have grown up with the understanding that the flu comes around once a year and modern medicine is just a phone call away, it becomes easy to second-guess our staff members for calling out sick for the 3rd time in a month or missing a meeting to attend another funeral.  So many in the developed world pass judgment when they see photos of African mothers slumped outside their compounds not tending to sobbing children or farmers breaking from work on the shamba that should inch them out of poverty.  

It is a whole different ball game when you take a few steps in their shoes. Disease and the unfortunate aftermath are daily realities here—and this past week I had another unwelcomed opportunity experience just that. 

With an incredibly rapid onset I fell ill with a bacterial intestinal infection, most likely caused by consuming contaminated food or water. I was immediately rendered bedridden, pining for the comforts of home.  Though I would never wish this upon my worst enemy, let alone myself, it did offer some wonderful perspective on what exactly we are dealing with here in the Healthcare Program. 

I was experiencing the exact symptoms my team has spent so much time training the health reps and CHWs on- 

• Nausea 
• Vomiting 
• Diarrhea
• Fever
• Chills
• Body aches 
• Unusual sleepiness 
• Sunken/tearless eyes 
• Dry mouth/cracked lips 
• Dry skin 
• Sudden weight loss 
• Dark urine/no urine
• Faintness/confusion 

I could not hold myself upright, not to mention get myself to the kitchen to drink water- the sound of which practically sent my stomach lurching. I couldn’t think straight (Ironically, I was slated to edit the Diarrheal Disease curriculum script the day I fell sick!)  And while I was so exhausted it hurt to speak it instantly became more than evident that people can’t just ignore these overwhelming symptoms, will themselves out of their lethargy and head to work.  

Lucky for me I had my Cipro prescription and ORS mixture just a few steps away from the mosquito-net-encased, cozy bed that I could not imagine peeling myself out.  I laid there imagining the average Kurian’s lengthy trek in the blazing sun, on a dusty, bumpy, wreaking road to reach a clinic that likely doesn’t have the drugs they need even if the staff is actually present to help to help them.  Then I had the chance to live it myself. Though feeling slightly better, I made the mistake of getting on a boda boda too early. This truly assured me of my convictions!  It was an awful and painful idea that sent me straight back to my bed.    

There is no wonder why clinic attendance is low despite a vast need. This is why it is so important to provide prevention education and early mitigation at the household level.  We already have the education piece in the works, but in the next few months we plan for our CHWs to bring ORS and Zinc (to prevent severe dehydration), supplemental food (to reverse malnutrition due to diarrhea and other causes) and even antibiotics to help treat children under 5 years old who have been suffering for too long. 

Did you know?

• Diarrheal disease kills 1.5 million children every year.
• Diarrheal disease is a leading cause of child mortality and morbidity in the world.
• Diarrhea is a leading cause of malnutrition in children under five years old.

(Facts from WHO)

Now imagine the long-term implications of a society of children frequently missing school or adults that cannot work due to preventable and treatable diseases. 

Now that I am on the mend, largely due to the help of our FT5 version of CHWs (Thank you Team for taking such great care of me!)  I can fully say that I am grateful to learn exactly what it means to have the type of disease we are working so hard to prevent and treat here.   

One of the main factors that sets Nuru apart from other organizations fighting extreme poverty is that that all operations are founded upon a ‘Service Leadership Model’ that calls for a humble, growth-focused, feedback driven, selfless approach to designing and implementing programs.  

For Nuru, possessing qualities of a Service Leader is crucial when engaging and mobilizing the community therefore it is essential for such attitudes to be apparent thought the ranks. And while Jake, our Founder and CEO, has a management style that epitomizes these characteristics, it is almost more critical that our farmers develop this manner as they become the face of Nuru and teach the community.    

For Healthcare the first introduction to Service Leadership unveils with the Health Reps who, as mentioned last week, will be vetted to become CHWs based on those abilities. As they invest their own time and energy, and ours, they are empowered by a wealth of knowledge and are charged with sharing it amongst their farming groups. They have been elected by their groups to a leadership role and really have the opportunity to impact the health of their community.  But, should this new knowledge and responsibility be used inappropriately there is potential for dangerous miscommunication, a faulty sense of hierarchy, or a detrimental breech of health related confidentiality. 

This is especially important here where the strong sense of community can lend to gossip, and because local leadership positions tends to come with the connotation of clout, bribe-seeking abilities, and a laissez-faire approach-- perhaps the polar opposite of ‘Service Leadership.’ With the sheer numbers increasing during expansion we do run the risk of finding that some Health Reps who are most familiar with former version of leadership may be unwilling to adapt the ‘Service’ mentality. 

The good news is that today I am sharing a story of a Health Rep who embodies Service Leadership in the most impressive way.  His name is Bendicto Mogendi and I had the pleasure of meeting him at a Health Rep training two weeks ago. 

Nelly pointed out that he was ran a Voluntary Testing and Counseling (VCT) clinic for HIV/AIDS.  I was immediately impressed with his patience and engagement in the basic training we were conducting since he is clearly well versed in local health issues. After the meeting adjourned I introduced myself and asked to hear more about his work.  Rather than having a lengthy conversation in our current location, under the tree in a schoolyard, he invited me to visit his office the following week. 

On Monday I found myself on the District Chief’s grounds in a small, two-room cement building filled by one desk, several record books, finger prick tests and counseling resources. I later learned that Benedicto, so passionate about his previous work as a CHW trained on HIV in the early 90s, had submitted his own grant proposal to ActionAid to build the small VCT site.  

We were both equally radiating excitement about the other’s work! During the conversation I could see how strong his commitment was to educating his community on HIV/AIDS, reducing the stigma that surrounds it, and encouraging people to learn their status.  Though already convinced, he corroborated my theory that he was exceedingly experienced when he proudly whipped out over a dozen graduation certificates from extensive education and training. He then took me through the budget and activity breakdown of a grant he recently received from AMREF, and with the utmost trust he allowed me to view his VCT records which broke down sero-positive outcomes by age group and gender. He also informed me about locally relevant information that influences risk behavior here here.  

When we began to chat about possible collaboration he expressed extreme willingness to help train our CHWs on at home testing and counseling. I asked about costs and was informed that they would only be for training materials. This is when it became apparent that he actually did his job unpaid!  Here is a man who has dedicated over 20 years of his life to judgment-free combat of a deadly and locally stigmatized disease and he doesn’t see a personal dime from the Ministry of Health, International NGOs or anywhere else- In fact, he makes his money growing Nuru Maize.  I was blown away! And he is one of our very own Health Reps!  

It is meeting the Benedictos of the world that serve as my inspiration when frustrations run high and remind me that it is truly possible to improve health when the odds are against us.  I am meeting with Benedicto again next week and will keep you posted on how the relationship progresses.

Seeing as televisions are more rare than paved roads here and billboards (in this area at least) are not kept up, various, clever approaches to marketing are needed.  Cell phone carriers tend to overhaul small town buildings in Lime Green (SafariCom), Pink (Zain) and Kenyan flag signature red and green (Yu) making for vibrant swaths and immediate recognition when passing by at lightning speed. But even more penetrating and cost-effective is the seemingly bland age-old word-of-mouth tactic. The combination of the two is essential!

Like brands, clan names are well known through the area and certainly come with historical reputations- tough business people, exceptional farmers, well educated, cheeky, etc. Yesterday when I told Alice our Lab Tech at the Nyametoburo Health Clinic my given Kurian name, Nyakorema, she then asked me where I lived. I answered, “karibu (near) Isibania.” She laughed and said, “No! You live right down there,” pointing across the dirt road. Confused, I reconfirmed the location of the Nuru house. Then serious, she was appalled that I was unaware of my namesake’s property—this was obviously widespread information.   

In a place where everyone knows everyone and their business, and are informed about brands, there is no surprise that as the number of non-farming jobs increase, people are eager to make clear their new titles ensuring they too becomes common knowledge.   

Hopefully you recall the How To Lose Trust and Anger People blog where we discussed what would serve as barriers to the CHW program. As mentioned, we also conducted a ‘How to Win Trust and Serve the Community’ brainstorms with both the Foundation Team and the Field Team. Both concluded the definite need for CHW identification as a way to establish their well-earned role as community resources and promoters of health.   

Separate to our brainstorms, the CHWs also directly requested the same. So, after all signs pointed to badges, yesterday we took head shots for official documentation. Despite rain during our outdoor meeting and an offer to reschedule picture day, they were so eager to have proof of CHW-dom they unanimously voted to remain in the elements while close to 40 snaps were taken. 

I am proud to present the template for step one of Nuru’s CHW branding strategy:

-  Perceived self-efficacy
-  Social norms
-  The perceived ability to maintain the new behavior
-  Perceived benefits (not necessarily health related)
-  A call to action
-  The perceived severity of the consequences should the change not be made. (Proven to be least        important factor!) 

In our community those perceived (and real) barriers vary from cash poverty, which can prevent the initial investment in preventative measures like buying a net, distances to clean water sources, and knowing someone who has contracted malaria despite taking precautions.

How this relates to our CHWs:
Though we must ensure the appropriate and correct information circulates from our Field Staff to Health Reps/CHWs to the households, that is not all that needs to happen. We are currently exploring creative ways of using effective behavior change communication to have non-invasive repetition of messaging, increase the sentiment of health ownership, influence social norms to include positive health behaviors, and integrate strategies to guarantee the desired behaviors are easier and less expensive than the current behavior.

Your ideas are most welcome!

-Households believe that the CHWs are using them to make money

-Survey fatigue due to the extensive questioning the Ministry of Health requires CHWs to conduct

-Households are unaware that CHWs will be providing services and therefore, don’t believe the CHWs have anything (knowledge or otherwise) to provide them with.

In an effort to address these issues in a creative and effective manner we called the last joint FT4 and FT5 conclave to anti-brainstorm.

Though I had heard the term ‘anti-brainstorm’ before David proposed the strategy, I had some serious doubts. We would be asking our teams what our CHWs could do that would ensure their failure. I felt I was generally familiar with what infuriates people and causes them to lose faith in a service, and thought our time would be better spent exploring out-of-the box ideas about how to ensure their success, earn the trust of the community, and insert our health messages wherever possible. Not so!

We did open the meeting with a quick-fire collection of trust-gaining ideas, but the most valuable part of the exercise was breaking down what attitudes, actions and lack there of contribute to loss of credibility of and confidence in our CHWs.

So, what is the best way for our CHWs to lose trust and anger people specific to life in Kuria? Here is a representative sample of our conclusions:

-       Not fully greeting the head of household
-       Not introducing oneself and the purpose of the visit
-       Asking too many questions
-       Wasting people’s time
-       Pulling farmers off their shambas (farms)
-       Using technical language
-       Not being knowledgeable about topics discussed
-       Being a bad health role model
-       Being rude and passing judgment on their homes and lifestyles
-       Visiting too often
-       Making disrespectful comments or facial expressions
-       Make the family feel health problems are their fault or that they are stupid
-       Gossiping about what is discussed in the visit
-       Making promises and not delivering

After reviewing the chaotic whiteboard I realized the value of exploring the inverse. No matter how creative or useful the services provided are, if we don’t understand exactly what upsets the community and change our approach we will never be successful.

So what now? As per the recommendation of our field managers the first of our supplemental CHW training will be on home visits style.  While it will outline the process of what to do (introducing oneself, making a connection with the person with whom they are speaking, how to ask questions and give advice in a respectful manner, and how to following up as needed), a large part will be based on what doesn’t work using specific examples. We will have our own anti-brainstorm in this training which I suspect will incite a few ah-hah moments about their own behaviors, and we include the popular activity of role plays to demonstrate productive and counterproductive visits.

After this training we hope the CHWs can paint a clearer picture of their role and goals for the community while developing a good foundation of trust and respect as they continue to go door-to-door enhancing access to health care.  I will let you know what happens!

During a planning session with Paul, the astute and optimistic Field Officer who would conduct the nutrition segment, David brought a wonderful analogy to both of our attention. Using building materials such as bricks, a candle and corrugated metal, Paul would draw on parallels between fueling the body for vital functions and protection against disease and the act of building a house that would protect its inhabitants. Paul would equate the building blocks of a home, which serves to protect a family to adequate nutrition used to fuel the body and safeguard it against diseases. 

Sure enough, Paul’s training was a hit and proved valuable as many CHWs had come across moderate and severe wasting during recent home visits. 

Two weeks after viewing this exceptional example of creative training I actually found myself on a construction sight. Sabora, a Nuru Education Field Managers, was building a house for his wife-to-be. He had invited our Education Program Manager, Lindsey Kneuven, and I had the opportunity to tag along.  While I was taking one of my many breaks from using my faulty hammering skills I laughed as I recalled Paul’s lesson. Then it dawned on me that this analogy was relevant to me on a larger scale than my own nutrition. I realized I was picking up where the previous Foundation Teams had left of on development of the CHW structure. 

Dumbfounded, I watched four incredibly strong men, a child and Kneuven build a structure from the ground up with only a rebar hammer, a few pangas, a jembay, and wood.  There maybe no surprise that construction, or ‘jenga’ in Kiswahili, is quite contrary in Kenya from what most of us are familiar with at home. There are fewer and different resources, and the process is organic, manual and community oriented.  Likewise, when thinking of the process of building a project- and in our case, the CHW program, we must remember to build a good foundation, be cognoscente of how we are reinforcing the community’s efforts, and focus on what will protect us as we see through our goals. 

Luckily for me, David and our Kenyan counterparts have laid the groundwork beautifully. While they have dug several holes where no foundation post would be buried, they’ve reoriented the floor plans and created a sound framework using relationships, community involvement, and initial trainings.  Now it is my job to help fortify the structure with a distinct interior plan while Nelly, the Healthcare Community Development Committee guru ignites the fire that will make certain our CHW unit can improve health at a household level. The details of the decoration remain to be seen, but we are confident that a financial sustainability CHW-based prevention education and disease mitigation system is on the horizon. 

Though sad to lose David to Stanford Medical School, I am looking forward to working closely with Janine, the integral constructor from FT 1 & 3, as she researches several of the existing CHW models Stateside. Some of organizations on our radar include Living Goods, BRAC, WorldVision, Partners in Health, and the Clinton Foundation.  Our goal is to put best, relevant practices into play while learning from less effective paths. 

We have no doubt our model will go through the elements and face some wolves, but we are confident that with a strong framework and the motivation to keep improving we will weather the storm.  I am eager to update you on how our strategy unfolds during the next 8 months. In the meantime, thank you for your continual support and please, please share what knowledge you may have of similar practices, commodity sales in developing countries, and life in Kenya! 

June 30th was International Aid Workers Appreciation Day, and as this is my last official blog post, I thought I would reflect a bit on my job category. 

I hear a lot about how hard and miserable this job is supposed to be. I’m supposed to be feeling tired and burnt out, as if I were some nub of a candle struggling to keep the flame alive. Most aid workers don’t last long, and every year in the field is another cannon shot to the walls of idealism. With one week left after a year in Kenya, I should be food lusting for cheeseburgers, annoyed to the edge of sanity by the mosquitoes biting my ankles right now, and looking ever forward to the plane that will take take me home. I shouldn’t even be writing a blog right now out of depression. I should be sulking. 

The only problem is that I’m not. I actually kinda like it here. Am I happy to see my family again? Of course! But I already have a weekly video call with them. It’s not the same, but the burden of separation is much lighter. Will I enjoy the delicious and fattening food of America? No question about it! But I really have adapted to the food, the bright sun and the friendly people of Kenya.

Because of my unique circumstances, I broke the Nuru mold and stayed a year when I should have stayed 7 months. We have had lots of breaks with flights back home, and always take Sundays off. This all was designed to prevent burnout, which is supposed to be really high. But I don’t feel it coming on. Not even a little bit.

Why? I’m not sure but I have some guesses. 1. I see results. The programs I’ve helped to build are real, working and continuing. I think this is probably not true of most Development work 2. I have freedom and resources to work. From what I’ve heard of Peace Corps, there isn’t much monetary support for their work. 3. I have good peers. Great friends both to laugh with and think with is a huge boon. I’ve heard horror stories about when this is absent. 4. I have good leadership. I suppose this is true of any job, but when your boss is a great guy, it makes the job much easier. 5. The community is supportive. The people really, really welcome us and encourage us in our work. Though it shouldn’t reduce the value of the work, unappreciative people would have made the job a lot harder. If I had more than a blog entry to write about this, I’m sure I could come up with a million reasons. 

In conclusion, I love my job. I’m sorry to leave it. I’ve got to go back to medical school, but would love to do this sort of thing in the future when I get out. But I am just fearing that Nuru has spoiled me. I will definitely look for an organization like Nuru when I am done.  

It’s that time of year again. The maize is growing, the rain has stopped, harvest is near, and we are transitioning. The funny time when 6 (or in my case 12) months of knowledge and learning and experience are supposed to be transferred from one person to another.

The first time I gave the program over in February, I had a difficult time. This time, the feeling is different. Perhaps spreading a turnover across three weeks instead of three days is a better plan. Or maybe we’re at a point where we’re clearer on the trajectory. 

We just crossed the mid-point of the transition today, and I feel quite good about Lindsay’s progress. She has a fairly good handle of our past programs. She’s reviewed all my old blogs, my copious pictures, and about a million miscellaneous documents. We’ve visited the key locations, and she’s met and immediately memorized the names of the entire healthcare team. Next week, she will be in charge, and I will be following. I can’t wait not to be in charge.

Today, we sketched out our rollout plan for the next year. What we learned is that she’s going to be busy. Very busy. She will continue in my tradition of putting the pedal to the metal. But she will have a path to follow rather than the programmatic off-roading that I did. She will be defining and expanding our community health worker program. 

We have decided to learn from other organizations’ successes with community health workers (CHWs, community members chosen to do healthcare work and trained at a basic level). Over the next six months, Lindsay will refine and focus that model, getting it to a functional and fine point by December. Unlike most NGO’s, we don’t just have to have a good CHW model, we have to have a good CHW model that pays for itself. This will be extra challenging. But we have some good ideas, I think the winner of which will be a door-to-door CVS. The workers have to go door to door anyways, and if they sell the stuff the people are already buying, they could get a commission and added incentive to do their job. We have only tested this idea; it will be up to Lindsay to take it out of the program laboratory into the real world. 

It is always a challenge to give up something one’s poured so much into. I have spent the last year birthing this program, and now I must adopt it out to someone else who I only met last Monday. Last time in February, it was hard. Maybe I’ve just gotten used to it, or never really thought of it as my own ever since then. But this week and last have actually been rather enjoyable and not too stressful. 

I think Lindsay will take good care of my baby. I’m looking forward to seeing how it grows up. 

Guinea! Burkina Fasao! No, it couldn’t be Burkina. Somalia? Malawi! Shouted the contestants.

Last Saturday, after coming back from a World Cup game, we sat on the front porch and played a game. There was some disagreement about what the largest city in the world was. Thomas on his iPod Touch looked up the answers using our WiFi. But he wouldn’t tell us. He made us guess and rank them. We argued with each other and shouted cities. 

Like an episode of Family Feud, Thomas would give us the top ten lists. We’d wait with anticipation for the answers to follow, “[World Bank] survey says…” Our respective knowledge or lack thereof on world city sizes was revealed. It turned out that Tokyo was the right answer for #1. Sorry Mexico City, you got passed up (twice). For another 10 minutes, we tried to guess #2 and failed. After a long long time, Thomas, our Korean Education Program Manager said, “I’m very disappointed in you for not knowing this,” to which I replied, “So am I. We should know this!” And he said, “No. I’m very disappointed.” I paused for a few beats. “Seoul!” I exclaimed! Stupid! How could we have forgotten Seoul?

After we finished off with the cities, we went on to top 10 GDPs, and then to bottom 10 GDP per capita’s. Then, just to spice it up, we did beer consumption per capita (Go Czech Republic!). We had a lot of fun. We laughed about dumb guesses, and at our own collective ignorance of the world. We drank Tuskers, the classic Kenyan beer, and enjoyed the just-barely coolness of the night.

I realized a few things that night. First, that Nuru people are cool. I mean really cool. Even a hundred miles from a ‘city,’ we can make our own fun. Maybe we’re learning from the children here whose incredible creativity shows through in brilliant trash toys they play with (I’ve seen one kid who created a gear from a margarine lid to transduce rotational velocity in a perpendicular plane to power a series of spinners, made from flayed margarine tubs).

The fact that we could all be entertained by World Bank statistics is interesting it demonstrates a profound nerdiness in the development field. We all really care about this work and the numbers that surround it. This is not just a part-time deal for us. This is just a silly example of what my peers and partners live out each day. We all care about the poor and are excited to work with them on their behalf. We are all excited.

As I wrap up my time with Nuru, I’m really going to miss nights like Saturday and the work that surrounds them. Nonprofit work, particularly in Africa, is getting a bad reputation for stale and pessimistic workers. The vitality and energy I see daily which was caricaturized on Saturday gives me great hope for the world that there are such people in it. I hope that in my future endeavors, there will be other people like those in Nuru. 

Last week on a lunch break, I was nerd-ing out as I am wont to do. It just so happened that this time, my forays into the depths of the interweb (browsing the internet) and, against all odds, found something of worth. I found “Evaluation of current strategies and future priorities for improving health in developing countries”!!! What’s wrong? You don’t look very excited. Perhaps it’s because academic journals mandate that the titles of their articles be as lifeless as the content they head. Not really, but it seems like they do. But in this lifeless shell of a title lives information which could save many lives.  

The article is a summary of many years of research and modeling about Cost Effectiveness Analysis (CEA). CEA is a developing field which tries to answer the bargain question: where do I get the most bang for my buck? Some products have a big bang, but also cost a lotta bucks; some are really cheap in both senses. ; what you don’t want to buy is the expensive crappy thing. If it exists, you want the cheap thing that’s high quality. You want the used Toyota Camry, relatively cheap but very high quality despite the low price tag. But what if you didn’t know that Toyota’s were the best cars ever? You would buy the Consumer Report on cars. It’d tell you which cars were a good deal and which weren’t. CEA is like Consumer Report for health.

In some ways, it’s simpler. Instead of there being many aspects of a good car (acceleration, handling, luxury), in healthcare we are concerned only with one: years of quality life. You’re supposed to live 82 years, and when you die before that, you lose years to whatever killed you. If you die at 2 of diarrhea, we count 80 years lost to diarrhea. If you die at 72 of a heart attack, we count 10 years lost to heart disease. Though there is some debate over how to define ‘quality,’ the consensus is that disabled life isn’t as good as normal life and so a year of life without legs is discounted (so it is numerically not as good a year with your legs). 

We, in healthcare, are trying to save as many years of life as we can. And we have only so much money to do it with (this is particularly true of Nuru). Using fancy experiments (Randomized Control Trials, or RCTs for short), we can calculate how many years of life an intervention can save, say using bed nets to prevent Malaria. Then we divide the bang (years of life saved) by the buck (dollars spent on the intervention) to get a Cost Effectiveness Ratio measured in dollars per disability adjusted life years (DALYs). Then we can compare apples to apples. If we had $10,000, should we buy bed nets, or should be spray for mosquitoes? Bed nets cost $56 per life year saved ($56/DALY) and spraying costs $118 per life year saved ($118/DALY). Roughly speaking, with our $10,000, we could save 178 years of life (about 2 or 3 kids) with the nets or 85 years (about 1) with the spraying. CEA lets us know that spraying is the Ford Focus of Global Health: looks decent, but certainly not worth the money when there are Camrys available.

Now I’m going to surprise you. You know all the stuff you hear about on the Global Health news? HIV drugs and salts for diarrhea treatment and even bed nets? None of them are on the top 10 list. Here are the 5 most cost-effective treatments in global health: 1. Community treatment of baby pneumonia (did you even know that that was a problem?) $1/DALY;  2. Mass media campaign for safe sex $3/DALY 3. STD treatment and peer counseling of sex workers (prostitutes) $4/DALY 4. Basic TB treatment $6/DALY 5. Newborn package (breastfeeding promotion, support for underweight babies) $8/DALY.

Like any science, this says nothing of the ethics or practicality of any of this. CEA can only tell you about efficiency, not about strategy. Nuru, only in several villages, has no ability to run a national mass media campaign. The other big open question is on ethics; CEA can’t say a thing about right and wrong or moral priority. Is a prostitute’s life as worthy of saving as a baby’s, even if it is cheaper? Is it as strategically important for development? Would a public intervention with prostitutes affect our image and possible impact? Is it ethical to promote condom use? These questions raise extremely strong opinions, some so strong that they are angry with me for even conceding that these are questions. But they are. And we, as development workers, must answer them and hopefully answer them right.

This research is a shock to me. It informs me that my guessing machine is wrong; that some of the stuff I wanted to do isn’t high on the list, and some of the stuff I didn’t know about is. I now have new ideas for programs that I had not considered. The top of the list, treatment of baby pneumonia, is something we are very close to being able to do with our health workers and, thanks to this research, will now be a very high priority for our program. Nuru is using the best of the best for the poorest of the poor. In this case, it is research; we building upon the work of others. We are not just doing what feels good or what is fashionable, but to the best of our ability, we are doing what is right.

The roof was tin, but I could not see it because of the newspapers cut into snowflakes hanging from it. The walls were of mud, but veiled with advertisements and colorful newspaper front pages. The floors also were of mud, but clean, compacted swept mud; you could walk barefoot and not get dirty.

We talked with the matriarch of a family. I made out what I could, but barely understood; my Swahili is quite bad. I could understand her face, her tone of voice.

The healthcare team has been starting to focus on Community Health Workers. This means that low-trained community members regularly visit their neighbors and give advice and minimal medical treatments (bandaging wounds, simple drugs). We have been struggling to figure out how to win the trust of our members. It’s not much easier to go to win the trust of a complete stranger here than it is in the US.

In the past, we were survey-based. To make it easier, I gave them a series of questions to provoke discussion. But, after months of problems and a few weeks of supervision, I discovered that rather than an inspiration, these questions were a crutch. No matter how much I cajoled, I could not get them to converse. Rather than having a friendly conversation, the workers were robotically asking the questions from the list. So this week I tried something new: no questions. Or rather, just one question. Who did you talk to? No more bright orange arm floaties; it was time to sink or swim.

And yesterday, they swam. The woman we talked to had problems. Members of her family had problems. She worried about them, and had no one to share her worries with. When we asked her about her problems, she told us. Though I only found out afterwards what the problems were, I could understand her distress in sharing, and relief when it was through.

We had no knowledge of the difficult medical questions for her family (in the future, we will have the ability to refer hard questions to local practitioners). But the biggest thing for this old woman was the conversation itself. It was like we had taken a heavy burden from off her back (or to fit local custom, from off her head). 

Why didn’t I think of this earlier? Isn’t it obvious? We want compassionate doctors who actually listen. We pay psychiatrists to listen. We love friends who listen. Why wouldn’t the poor, also? Are they creatures so different that things true of Americans aren’t true of them? I feel bad for not realizing this earlier. I also am disappointed in the field of Global Health ; with all my reading and research, I have not read about this effect of Community Health Workers. Maybe it has and it’s so obvious that nobody needs to talk about it.

In any case, we have a new strategy to win trust: listen to people. It seems too simple. But it’s certainly a lot better than our old one: gather data on people.

I suppose I should not have ignored my teachers. Dale Carnegie, the management guru from the ‘20s, told me this: “Become genuinely interested in other people…Be a good listener. Encourage others to talk about themselves.” My other teacher, Francis Bacon (who is even deader than Carnegie), said, “For there is no man that imparteth his joys to his friend, but he joyeth the more ; and no man that imparteth his griefs to his friend, but he grieveth the less.” I should have listened.