Saturday, October 20, 2012

Murabeho


Despite the fact that I have not written anything new for my blog, I have been thinking a lot about it and how to proceed in light of some large adjustments and changes. I’ve come to two conclusions: 

1. I no longer live the life of a Peace Corps Volunteer working on community development in a small village in Africa, and all the cross-cultural and comical experiences that entails. Those have been the content of my blog for the past two or so years. I now work in a professional office in the capital city, Kigali, and struggle to find stories of a similar content to share. I must accept that people are not interested in reading stories about typical office bureaucracy and life. In addition, I find little time to commit to writing in light of my new job responsibilities. For this reason, I have decided to complete the chapter of my blog devoted to Peace Corps and begin a new one.  I am not sure if I am going to be able to maintain this blog or the new direction it will take. In any case, I would like to refer you to the Stomp Out Malaria in Africa website, where there is a blog dedicated to all the malaria activities taking place in Rwanda. There, you will be able to read stories about what I have been doing as a Peace Corps Volunteer to help “stomp out” malaria in Africa.

2. I have decided to work with the content of this blog and turn it into something permanent; in other words, a book. The little time I have for personal writing I will dedicate to this pursuit. I would like to do this while I am still in the environment that fostered my experiences in order to produce a piece of work that is accurate and captures the true sense of the place that I am writing about. I feel that I would only be able to do this while I am still in Rwanda, my memories and words not skewed by returning to life in America. Please do not lose interest, but be patient while you wait for the final result.

I will keep you updated as I go. Until then, murabeho (goodbye, farewell).

Tuesday, September 4, 2012

Incredible Reunions


Yesterday, I was invited to a friend’s house for a dinner party. I had never met his "mama" and she was celebrating a reunion with a group of old friends. She had hired the Rwandan version of a caterer to come to her house, slaughter a goat, cut the meat into skewers, and barbecue them with potatoes and plantains for dinner. We stood next to the outdoor kitchen under the stars with our crisp lemon drinks, and watched the chef sweat over the meat roasting on the grates of the wood stove.

My friend’s mama does not speak English, and I spoke to her in a mélange of Kinyarwanda and French. She was shocked to witness a muzungu who spoke Kinyarwanda and she cried out at each utterance. Her warm heart and motherly presence permeated the evening. We clicked immediately and giggled constantly.

Of course the other guests were late, but we were not surprised. We discussed the difference in our cultures. Americans are rarely late, and if they are, it is usually only a few minutes. Rwandans are characteristically late- by hours, even days- and it is completely acceptable. When the guests finally arrived, we greeted them and they apologized to us. The Rwandans employed the proverb, “Do not try to be something that you are not, because you may find that who you are trying to be will disappoint you.”

The guests were old friends from their period of life as refugees in Burundi. They had fled the conflict, danger, and horror of their country, and found themselves together as they built lives in a new and unfamiliar place, providing support after the pain and destruction of their experience. The bond that connected them was strong, beyond words or outside understanding. It was an incredible reunion to witness.

I reflected on the situation. With so many people fleeing quickly in the face of such grave danger, even death, I thought about the families and groups of friends that were torn apart to settle in different parts of the world, if they even survived. I wondered, “The world is huge- how were these families and friends brought back together? How did they find out who had survived? Were reunions just by chance? You are walking down the street one day, recognize a friend from your village and exclaim “Hey! You’re alive. Want to catch up?”

I remembered my counterpart in the village telling me about his job after the war when he worked to repatriate refugees to Rwanda and reunite children with their families, extended families, or surviving friends of family. He told me that children who crossed the border back into Rwanda alone were placed in orphanages. Staff took pictures of every child and displayed them around the country with the orphanage’s contact information in the event that one was recognized. In this way, they slowly reunited children with their families, or if none could be found, decided place them under foster care. I can’t imagine what a monumental task or process it must have been. That was immediately after the war, only for children and families, and doesn’t describe the larger task of reuniting families that spent longer periods of time as refugees in neighboring countries, traveled further abroad to Europe or North America, or friends.

As we sat in a circle in the living room, my friend recalled his experience growing up in Burundi. Families are very close in Rwandan culture. My friend is lucky that his family managed to stay together and also in contact with his extended family, even though his uncle’s family ended up in the Congo, a far and impossible journey at the time. He remembered that his mother would travel and bring back stories to share about his cousins. His aunt would visit and take stories to his cousins about him and his brothers. He felt like he knew his cousins well, but they didn’t meet until much later. When they finally did, after years of hearing stories about each other, it was epic.

It was incredible to attend and witness such a special reunion between people who are bound so strongly. We sat eating, drinking, and conversing late into the night. I didn't understand and couldn’t relate to their shared experience, but I felt welcomed as a part of the family.  I was reminded that it is the people who witness discrimination and hate that are usually the best examples of acceptance and love. As I said goodbye and thank you, I told my friend’s mama in my broken, incoherent language that I was happy that she got to see her friends again. The smile that spread across her face, reflecting the joy radiating from her heart, remains in my memory as one of the most truthful images of love one can witness.

Sunday, August 26, 2012

Photo and Essay Contest


Stomping Out Malaria in Africa is having an Photo and Essay Contest. For more information, visit the website: http://stompoutmalaria.org/essaycontest/

I submitted a photo along with an essay, displayed below. Please visit Stomping Out Malaria in Africa's Facebook page and "like" my photo. The photo with the most "likes" wins. http://www.facebook.com/photo.php?fbid=456633297710537&set=a.449323021774898.102391.208478415859361&type=3&theater.

No Place for Pride
Dedicated to Jean Marie Vianney Twizerimana, a Malaria Hero in Rwanda...

Perched on top of one of the green rolling hills that characterize the landscape of Gisagara District in the Southern Province of Rwanda, overlooking the grassy plains and swamps that run into the Akanyaru River on the border with Burundi, Groupe Scolaire Nyagahuru is in session for the day. Approximately 1,200 primary students in tan uniforms walk long distances down red dirt roads from their homes in neighboring villages to attend the government school. Throughout the day, the chants and calls of students echo across the valley.

The area is impoverished because of its isolation from cities and roads. The low elevation and presence of water ensures malaria is endemic. In fact, Gisagara is one of the districts with the highest burden of malaria in Rwanda. Many residents suffer from malaria often, including students. When students are sick with malaria, they miss prolonged periods of school, causing them to fall behind in their lessons and threatening their ability to perform well on the National Exam. The grade a student receives on the National Exam determines whether he or she will continue to secondary level and the quality of school. Only 10% of students pass the National Exam in Rwanda.

Rwanda has a difficult past scared by decades of conflict culminating in the Genocide of 1994, during which approximately 1 million Tutsi and moderate Hutu were killed by Hutu extremists. In 18 years since the war, Rwanda has made enormous progress, emerging as a beacon of development in Africa. There is an energy that permeates the country and fuels the fires of development. Perhaps it is borne from the ashes of destruction after the war; from the momentum of success; from the mantra that is on everyone’s lips. “Never again,” they repeat. You can see it in the orderliness of lawns in front of mud huts in the village; hear it in the persevering way Rwandans pursue a task; and feel it in your heart when you realize that something unique and special is happening around you.

During breaks from school, Peace Corps Volunteers in Rwanda organize regional youth camps. Camp GLOW is a global Peace Corps initiative with the aim of encouraging leadership, empowerment, and development of young women around the world. Peace Corps Volunteers have more recently introduced Camp BE focusing on specific issues that prevent young men from leading, developing, and allying with women to create a better future.
As Rwanda’s Malaria Volunteers, we attended Camp BE in the Southern Province. Working with a Rwandan Facilitator, Jean Marie Vianney Twizerimana, we taught four sessions on malaria to 56 young men. Our goal was for each student to be able to explain how malaria is transmitted, how to prevent transmission, the signs and symptoms of malaria, where to go for treatment, and common malaria intervention strategies by the end of the lesson.

The evening before sessions, we met Jean to review the lesson. As we huddled around a table in the teacher’s lounge discussing the lesson’s content, I noted his exceptional enthusiasm and passion for teaching, a rare quality among teachers in Rwanda. He reflected, “You know, I suffered from malaria once.” I asked him to tell me more. We sat late into the evening as I was captivated and moved by the personal experience he told. When he concluded, I suggested that we revise our lesson plan to incorporate his story.

Jean is a teacher of English, history, and civic education at Group Scolaire Nyagahuru who suffered a critical case of cerebral malaria. He admitted that he used to be too proud, believing that his “immune system was so strong that it could hardly be invaded by any kind of disease, especially, including malaria.” He knew about malaria and how to prevent, but said, “to use a mosquito net was like a taboo for me. So the mosquitoes buzzed in my ears, and when I got up, I found they had bitten me.”

One day, he became very sick. Clutching his head, he described, “I did not go for medical care immediately because, for example, in the day I was okay, but at night I had a high fever and a great headache which barred me from sleeping. Today and the following day it was alternatively the same phenomenon. Later on, I felt that my disease was becoming more serious to the point that it could either kill me or hurt my brain. It was impossible for me to remain standing up. I chose to lie down in the mud on the side of the road to phone [my friend]. I forgot that I was a teacher.”

His friend called a motorbike to take him to the nearest hospital. On the way, he had to tell the driver to stop many times so he could rest on the ground. At the hospital, the doctors checked him for fever and took his blood for microscopy. They informed him that he suffered from cerebral malaria and gave him medication with instructions for use. “Thankfully, after six days, I was okay.”

“After my treatment, I could not bear standing aloof. I adopted preventive measures, just to have my destiny in my own hands. So, I decided to lie under a mosquito net every night. Even during the day, for fear of malaria, I use it when resting.” To conclude, he conjured the fundamental rule of health, “Prevention is better than treatment.”
His experience with malaria caused him to become an advocate of net use and treatment. “I learned a lot from my [it]. Let me invite anybody who jokes with life like I did to end it right now and abide by preventive measures. When invaded, everybody should go to the Community Health Worker for treatment.” Jean was a role model for the young boys at camp, speaking to their own perceptions of pride to reinforce the importance of using a mosquito net. Before dismissing the class, we asked who planned to sleep under a mosquito net every night. Every student raised his hand.

Tuesday, August 21, 2012

Photos from Camp BE in Kinazi



Please find below photos from our day visit to Camp BE (Boys Excelling) in Kinazi, Ruhango, Southern Province. Although I only had the opportunity to participate in one day of camp this year, the experience was just as rewarding as previous years. It was very special- one boy even remembered me and my name, Arielle (very difficult for Rwandans to say, which is why I decided to go by my local name, Muhorakeye, for the duration of my service) from the National Camp BE in 2010! Working with a Rwandan facilitator, we taught four sessions on malaria to 56 boys aged 14 to 18 years. We also had the chance to get out of the classroom and engaged youth in an arts and crafts activity. By the end of the day, we were smiling and covered in white goo. If we can’t appeal to their reason for using a mosquito net, perhaps a malaria monster can! Enjoy!

Virginia Burger, my co-Malaria Volunteer in Rwanda, teaching  a class of campers about malaria



Our Rwandan facilitator, JMV, engaging the students in the lesson on malaria

JMV shares his experience suffering from malaria to a group of students

Arts and crafts is always a favorite activity at camps.
Some youth took their own initiative and made a World Cup trophy from paper mache.

Another youth made a detailed truck. He even took the time to cut  windows in the cabin.

PCVs team with youth to create structures from paper mache.

Some campers gain confidence through their art.


In the end, we were covered with paper mache goo, but it was worth it!
Continue to read the article I wrote about Camp BE and published on the Stomping Out Malaria in Africa's website: http://stompoutmalaria.org/camp-be-kinazi-2/

During the school break in Rwanda, youth freed from their daily lessons cram buses and flood back into villages to visit home. But there is no rest for the weary. During break, Peace Corps Volunteers in education and health sectors in Rwanda team to organize regional youth camps. Camp GLOW (Girls Leading Our World) is a global Peace Corps initiative with the aim of encouraging leadership, empowerment, and development of young women around the world. Peace Corps Volunteers in Rwanda have more recently introduced Camp BE (Boys Excelling), focusing on specific issues that prevent young men from leading, developing, and allying with women to create a better future.

We returned from Boot Camp in Senegal after the planning for this round of camps was nearly complete and there was little room for last-minute incorporation of malaria. Just in case, we prepared a malaria lesson plan and activities that we distributed to Regional Camp Coordinators. We made arrangements to observe camps to learn more about them and how they operate, as well as improve opportunities for malaria outreach through them.

Our plan was to attend Camp BE at the Groupe Scholaire du Bon Pasteur in Kizazi, Ruhango in the southern province of Rwanda. Kinazi is known for its extreme heat and dryness. As a result, malaria is endemic to the area.  One day, I received a phone call from the Camp Coordinator asking us not only to observe, but participate, in the camp. “What would you like to do a lesson on?” he asked. I smiled. “How about malaria?” I suggested. We were in!

We traveled over dusty red dirt roads and green rolling hills to the camp site perched on a mountain overlooking a valley shrouded in clouds. Working with a Rwandan facilitator, we taught four sessions on malaria to 56 boys aged 14-18 in one day. Our goal was for each student to be able to explain how malaria is transmitted, how to prevent transmission, the signs and symptoms of malaria, where to go for treatment, and common malaria interventions and strategies by the end of the lesson.

Our lesson strategy was interactive. Activities in the lesson demanded student’s involvement and they were willing participants, exceeding requirement to ask insightful questions. We clapped for a skit that illustrated a mosquito biting a student suffering from malaria, then a healthy one, and explained how the healthy one would become sick. We laughed when students demonstrated fever, head and body aches, nausea, vomiting, and diarrhea; the signs and symptoms of malaria. We refuted some common malaria myths that exist in Rwanda, in particular that patients should be given ACT even if testing for malaria is negative, nets are dangerous to touch because of the insecticide, and cutting bushes and alcohol consumption prevent malaria. Students were very interested in learning about the history of malaria and why it predominantly affects poor countries in Africa, including Rwanda.

The most enlightening part of the lesson was when our Rwandan facilitator shared his experience with malaria. JMV is a teacher from a local secondary school who suffered a bad case of malaria. He admitted that he used to be too proud, believing that his immune system was strong and malaria could not affect him. One night about five months ago, a mosquito bit him as he slept without a net. He became very sick and endured severe headaches. Finally, he visited the hospital where the doctors told him that he suffered from malaria. “Now, I sleep under a mosquito net every night,” he concluded. He was a role model for the young boys, relating to their own perceptions of pride and strength to reinforce the importance of using a mosquito net. Before dismissing the class, we asked who planned to sleep under a mosquito net every night, and every student raised his hand.

At Camp BE in Kinazi, we witnessed how camps could be successful channels for malaria outreach to youth. Youth are a niche of Peace Corps Volunteers, as they are a cohort with which we tend to have great rapport. Our goal is to expand and incorporate malaria lessons and activities, and possibly bed net distributions, into future camps, hopefully all. Even though this round of camps is complete, we have more work to do preparing for the next, taking place during the long school break from November to December.

It wasn’t all malaria talk at Camp BE. We did get out of the classroom to interact with students in other activities, such as arts and crafts. The boys created soccer trophies and cars from paper mache; unfortunately no mosquitoes. In the fun, some of the paper mache even got on us! If we can’t appeal to their reason for using a mosquito net, perhaps a malaria monster can!


Friday, August 17, 2012

Unexpected Rewards


I never imagined my blog would get me anywhere. It's a blog- traveling gets your somewhere. At the time I started blogging, I thought of it only as an extracurricular activity that occupied vacant time with something productive. The journey that my blog and I have been on in the last two years has proved more than productive; my blog has become a meaningful journal of my time here, a way to communicate with family and friends back home and around the world, a source of pride and accomplishment, a stabling mental exercise, and a release for bottled up emotions. And finally, it has got me somewhere.

One of my greatest personal accomplishments during the last two years has been the maintenance of my blog. Sure, some posts are long, tedious, and unnecessary, but many remind me of what I went through on a daily basis in my village in Rwanda, the joys and struggles that I have too soon forgotten. I know the stories of my service will continue to touch my heart for the remainder of my life. Where my memory fails, my blog succeeds in recording them. I am fortunate to have such a record.

I include the link to my blog in my external communications and resume because the stories contained therein are an important part of who I am today and describe the hard work I’ve done in more detail.  I believe that my blog is an important reason why I was recruited to the position of Malaria Volunteer in Rwanda.

That’s where it has got me today. One of my responsibilities as Malaria Volunteer is to maintain Stomping Out Malaria in Africa’s social media campaign for Rwanda. Now, I have more than one blog, as I am tasked with many social media activities. Synergies exist by overlapping them. It is my aim that people who read my blog will also visit the following links.

Check out Stomping Out Malaria in Africa’s website:
http://stompoutmalaria.org/

Visit Stomping Out Malaria’s Facebook page and “Like” it:
http://www.facebook.com/#!/StompOutMalaria

Get caught up on malaria activities in Rwanda by reading our blog:
http://stompoutmalaria.org/country-by-country/rwanda/

I just posted on the Rwanda Stomp blog about our visit to Camp BE (Boys Excelling) in Kinazi, Southern Province. This is the third year that I’ve participated in the regional youth camps organized by Peace Corps Volunteers from the education and health sectors in Rwanda. Camps GLOW (Girls Leading Our World) and BE (Boys Excelling) are global Peace Corps initiatives that share the aim of encouraging leadership, empowerment, and development of young women and men around the world. This year was just as rewarding as past ones. In addition to teaching malaria, I had the opportunity to get covered in white goop again when I assisted the boys in the creation of World Cup trophies, cars, and people from paper mache!

Read the post of our visit to Camp BE:
http://stompoutmalaria.org/camp-be-kinazi-2/

Monday, August 13, 2012

Reflections on a New Life


 Here are a couple of reflections on my third year as a Malaria Volunteer in Kigali:

·         I have morphed from a sexual education nurse who is comfortable talking about taboo issues, to the overly enthusiastic malaria nerd. I think and talk about malaria all day long. I read about malaria every day. When volunteers in Rwanda think of malaria, they see me. I was told that I need to “be malaria” and I am…that’s me. I have observed people censoring the word “malaria” in conversations with me to avoid my enthusiasm and explanation. They tease me for informing them that the Anopheles mosquito rests at a 45 degree angle on their leg. “Nerd alert!” they have started to say.

·         I am no longer a community development worker with a certain level of accepted informality, but a real professional. In my community, I altered my attire to reflect that of the villagers I was working with, or rather, for. I couldn’t expect to relate to people if I dressed better, highlighting the differences between us. I had to look similar to gain respect. My dressing down was hard for my colleagues to understand. They were always dressing up. “You have something different to prove,” I told them.

Now, I must dress like the professional I am. In order to do so, I desperately needed a new wardrobe. I left most of my clothes in the village, gave them to neighbors and friends, when I moved to the city.  I had worn the same clothes for the entirety of my service and, as you can imagine, they were permanently stained from the dirt in Africa and filled with holes from the caterpillars that shared by house (and it appears, my clothes). I may have looked nice and appropriate in the village, but the city is a whole new world. Appearance is of utmost importance in Rwandan culture and everyone always looks clean and neat (smart, as they say). I am no longer meeting with villagers on a daily basis, but professionals and sometimes officials. I must look my new part. Needless to say, I’ve been buying and sewing a new wardrobe.

·         Living in Kigali is somewhere between life in the village and America. As I said before, it is exactly where I want to be right now. I was ready to leave the village, - I would never give it up, but I would never do it again-, but I wasn’t ready to return to America. Sometimes, I feel like I am cheating on my Peace Corps experience with running water, electricity, and access to eclectic food. I was able to live in the village for two years; some people continue their entire lives and I have much more respect for them.
  •  I've been living in Kigali for a couple of months now and I find it hard to remember what life was like in the village. In my conversations with other Returned Peace Corps Volunteers, I've found that we share this inability. It seems that once we leave our villages, it is difficult for us to recall the details of what it was like. The memory of Peace Corps marks and influences us in so many ways, yet all that remains is a series of static images to represent our service and which fade quickly almost immediately after we leave. Even though I am only in Kigali, a mere two hours away from my village, my experience there feels like a dream.
·         There is something settling about working in malaria, and malaria only.  When I was a volunteer in my village, I realized that there was so much to do and was overwhelmed. There stood HIV/AIDS, malnutrition, tuberculosis, diarrhea, pneumonia, and malaria. They were right outside my door, literally reaching through the gate to grab me. “Help me! Help me!’ they said. How could I witness their suffering every day and select the ones to help without feeling guilty for ignoring the others? Guilt was a feeling that squeezed my heart and conscience every day of my service. Only by accepting my own limitations and responsibility was I able to extract its threadlike fingers from weaving around my throat and strangling me altogether. I was never entirely successful.

For my extension, someone selected malaria and told me to concentrate on it, not the others. It was not my decision and I don’t feel the guilt that once marked it. In contrast, it is a huge relief.  I feel the burden of the others disappearing from my conscience.  Malaria, that’s all I need to focus on. In addition, I felt during my service that my knowledge and skills in all technical areas were lacking. I knew a little about each and could perform adequately in all, but not well. Now, I have the opportunity to become an expert and engender a greater impact in one area.

·         Now that I am part of one camp, I note the competition between malaria and HIV/AIDS. HIV/AIDS activities usually receive more attention (and funding) to the dismay and resentment of the malaria campers. “Malaria affects more people,” they argue, “and it is easily preventable and treatable. The interventions are known and relatively cheap.” “Why?” they ask.  I am integrating into the malaria camp and have unintentionally adopted these arguments as my own.

·         It is empowering to note the number of Returned Peace Corps Volunteers working in international development agencies or organizations in Kigali. In fact, nearly every American that I’ve met working here is a Returned Peace Corps Volunteer. It seems Peace Corps service is a necessary step for this field of work, a sort of obligatory internship, only instead of fetching coffee and making copies, Peace Corps Volunteers get to participate, even hold leadership roles. That’s one of the aspects that make Peace Corps service beneficial to our professional goals. And it’s just so cool. I can’t help but compare- with my experience at a job in America, I would never have the attention or responsibility I have here. In Rwanda, I am learning by doing, doing being the important distinction.

I am sure that I will note many more changes during the course of my third year, but they are waiting to reveal themselves in their own time.


Update #4 (Last): Starting a New Job


After deciding to extend my service for another year in Rwanda, I: 1) climbed Muhabura Volcano, 2) returned to America, 3) trained in Senegal, and 4) arrived in Rwanda eager to begin work (see previous posts). Throughout my “updates”, I have often alluded to my new position, always with the caveat that I will expound in a future blog. Today, I am going to share the details of what I will be doing for another year. Perhaps you already know the gist from the clues present in my posts- I will be extending my service to work in malaria in Rwanda.

On World Malaria Day in 2011, Peace Corps joined the fight to end malaria on a level unprecedented in the organization’s history through the creation of the Stomping Out Malaria in Africa initiative. SOMA is an Africa-wide Peace Corps initiative aimed at significantly supporting the international effort to eliminate malaria from Africa. Now, 3,000 volunteers (6,000 stomps strong!) in 20 Peace Corps programs across Africa are exchanging ideas and working together in the name of malaria elimination. The goals of this unique Peace Corps initiative are to:
·         Reduce malaria where we work: We will accomplish universal bed net coverage and malaria education programs on prevention and treatment in all Peace Corps Volunteer communities in Africa by 2013.
·         Contribute to the  reduction of malaria in target countries: Through host country initiatives and work with partner organizations, we will achieve the Millennium Challenge goals of reducing deaths caused by malaria globally (by 50% or more), and substantially reducing deaths caused by malaria in all 22 African countries where we work by 2020.
·         Help build an online community of malaria prevention volunteers: We will promote documentation and sharing of malaria prevention practices between posts across the continent and internationally between the initiative’s partners.

To achieve these goals, Peace Corps is recruiting Peace Corps Response and third year volunteers in every African country to be Malaria Volunteers (that’s me!) focused tightly on malaria prevention and working with designated staff Malaria Focal Points liaising with partner organizations and supporting work in the field. The key partner is the President’s Malaria Initiative (PMI) (that’s who I work for!). Started in 2006, PMI is a joint initiative of the CDC and USAID and is responsible for all malaria prevention work by US Government Agencies.

The convolution doesn’t end with PCVs placed with PMI. PMI also has its own operation and partnerships. PMI manages the US Government’s malaria funding and works through local implementing partners who conduct malaria projects and activities. I am placed with PMI, but on a day-to-day basis, I work out of the offices of the Rwanda Family Health Project, PMI’s implementing partner in Rwanda. I have a real computer, on a real desk, in a real office, and I feel like a real professional with a real position and real responsibilities. My experience in the village was very surreal; this is reality, or as close as exists in Africa.

Rwanda Family Health Project (RFHP) is a new USAID project. As a result of the economic difficulties in America, the US Government cut budgets and demanded more accountability for funds granted. Recently, USAID has been consolidating its projects. USAID determined that fewer offices meant smaller overall operational costs. In response, five USAID health projects in Rwanda are phasing out and consolidating as one, RFHP. The merger has been ongoing, chaotic, and messy, but a calm order is eventually settling.

The proposal for RFHP was written by a team from Chemonics International in response to a call from USAID two years ago. I learned that USAID has two types of projects- traditional agreements when funding is granted to a partner for approved activities, and contracts when the partner receives money to produce agreed deliverables. The most important difference is, if the project fails for an understandable reason, there is a bit of leeway in the former type; in the latter, the project must produce the deliverables or it is in trouble- breach of contract. Usually contracts are used when the project is an important one, requiring a lot of money, or an activity that USAID wants to ensure is completed well. On the ground, there is a lot more pressure to produce the deliverables on a team in the office of a contracted project. In the planning phase of the project, the team has to be extra careful and sure that it will be able to produce the deliverables before agreeing to sign their life away on the dotted line.

Development is occurring rapidly in Rwanda. A lot has changed in two years. Many components of the original proposal were no longer accurate or necessary. As a team, we had to revisit and edit the proposal in order to develop a solid work plan. We had to make sure that the information was up-to-date, the context accurate, the activities necessary, and the deliverables achievable. We also had to ensure that it reflected the five USAID projects that are phasing out, remained within the original scope of work approved by USAID, and followed the policies and priorities of the Ministry of Health in Rwanda. There were a lot of factors to take into consideration. The feat required a lot of coordination, as well as a meeting that lasted three days when we sat in a conference room with representatives from the Ministry of Health, agencies, and organizations operating in Rwanda to learn, sort through information, and establish what needs to be done and their priorities.

The first task of a team on a new project is work planning. The goal is to answer the question, what the heck are we going to be doing for the next year, five years? We accomplished the first step during our three-day meeting, when we determined what we could and should be doing. Now, we had to decide what we would do. We broke down into technical groups. At first, we brainstormed until every conceivable idea was on the table, written somewhere on one of the innumerable flipchart papers or sticky notes that littered the surface. Then, we examined, filtered, sorted, combined, and discarded our ideas until we narrowed them down to a few of the best options. Finally, from this short list, we chose the activities we would do. It was a relief to see order coming at the end of a long period of chaos.

The process was not only long and tedious, but a beneficial and learning experience. It introduced and improved our understanding of RFHP. We had a solid base to build from.  We contributed to the planning process so we were empowered to carry out our responsibilities. We witnessed the whole process required for a project to develop its plan. We were able to apply the same concepts to strengthen our individual work planning. It also reinforced the lesson I have grappled with throughout my service; you can’t do it all, so better to focus on a few things and do them well. It’s been a hard reality for me to accept during my Peace Corps service.

Three years ago, I developed a plan for the youth center in Kiramuruzi. That was another learning experience. It was my first time participating in a planning process, and I was directing it. It involved me, a couple of coworkers,  and a few stakeholders in an empty building in a small village conducting surveys with unknowing youth and villagers who were trying to express what they envisioned for a community center while not really comprehending what it was. My first experience was ad hoc, disorganized, and informal. We didn’t know what we were doing, but we tried and did the best we could to make something with what we had.  I recall a slight glitch in the survey translation when we asked a group of male youth whether they preferred to play with dolls instead of theatre puppets. I bet you can guess what they said!  But, the overall result wasn’t bad- a functioning youth center. In retrospect, I compared and realized the first was what we call participatory planning in community development; the second was professional work planning.

RFHP is not only working in malaria as I am; malaria is just one component of health in Rwanda and what it does. There is also HIV/AIDS, tuberculosis, maternal and child health, and family planning, to name a few. We are the Malaria Team; one component, and a small one at that. In fact, we are not even a standalone component. Rwanda is implementing a framework of integrated community case management (ICCM). What is ICCM? It is health care taking place at the community level through Community Health Workers (CHWs) who practice integrated case management. The common health issues they treat are not approached individually, but as a whole. That’s the integrated part.

An element of ICCM is integrated management of childhood illnesses (IMCI). When a childhood case presents, the CHW follows an algorithm to diagnose and treat it. Here’s how it works when a sick child visits the CHW in his or her village.
1.       The CHW records the child’s identification and basic information.
2.       The CHW measures the child’s middle-upper arm circumference to determine his or her nutritional status.
3.       Before continuing, the CHW checks a list of danger signs that would result in a referral to the health center if present, such as severe malnutrition, vomiting, or respiratory difficulty, because CHWs do not have adequate training and experience to handle these cases.
4.       If none of the danger signs are present, the CHW continues by identifying whether the child has fever, diarrhea, cough, pneumonia, or minor malnutrition. These signs are characteristic symptoms used to diagnose different illnesses. If any of these conditions exist, the CHW follows the algorithm for treatment. For example, if the child has fever, the CHW does a rapid diagnostic test for malaria and treats with Coartem. If the child has diarrhea, the CHW treats with zinc and oral rehydration salts. If the child has both, both are treated. And so on.

The guiding principle of ICCM is that a sick child is not considered for malaria and then diarrhea alone. Rather, all his or her symptoms are taken into account and treatment occurs as an integrated package in order to be comprehensive and complete. Integrated case management has been very successful in Rwanda, applied in the context of limited resources to save many lives. The other day, I was listening to a professional forum discussing health care in America, and I couldn’t help but notice that the word, “integration”, was used frequently. It appears America has a lot to learn from countries, like Rwanda, that have already implemented integrated case management. And it doesn’t stop there- community health and performance-based financing were also mentioned. It’s ironic because it’s contrary to the traditional flow of knowledge and experience from America to developing countries.

Integration determines how we work. For the Malaria Team at RFHP, integration means we are not working on our own, but as a part of community health. We work as members of a diverse team of officers from many technical areas. Despite our different backgrounds, we all have the same goal- to improve ICCM/IMCI by CHWs- because it will benefit every technical area.

The Malaria Team is composed of two people. My colleague is working to improve ICCM/IMCI trainings by ensuring the incorporation of a quality component for diagnosing and treating malaria. She will also promote the proper use and care of long-lasting insecticide-treated bed nets and assist with National Mother and Child Health Week malaria outreach activities.

On the other hand, I will be supporting improvement in the quality and timeliness of malaria data reported by CHWs to SISCom, Rwanda’s community health information system. The health system in Rwanda is based on two innovative health financing programs, namely performance-based financing and community-based health insurance (mutuelle), which have greatly increased access to affordable and quality health care, but depend on robust data to function. Currently, community data is transmitted by paper to the catchment health center where it is entered into SISCom and transmitted to the central level for analysis, aggregation, and incorporation in the Health Management Information System (HMIS). As Rwanda works towards pre-elimination of malaria, quality data that is reported on a timely basis and used to inform programmatic decisions will be necessary. Utilizing the network of PCVs in Rwanda, I will conduct a malaria data quality audit by carrying out a retrospective review of SISCom data compared to CHW-collected data. I will work with the National Malaria Control Program to incorporate a data component into CHW trainings, as well as organize a ToT for PCVs who will train CHWs in data reporting. Further, I will analyze data reported to SISCom and relay feedback to health centers where PCVs are placed to encourage data use in decision-making. Under my scope of work for the PMI, I will also be surveying long-lasting insecticide-treated bed net use and tracking malaria commodities in communities through the PCV network.

I have spoken a lot in this blog about ICCM and IMCI. I hope that you have gained a better understanding of what those are. I realize that I brought up a lot of unfamiliar or additional terms in my position description above- Rwanda’s health care system, performance-based financing, community-based health insurance, community health information system, and pre-elimination of malaria- that require elaboration. An explanation of each would be helpful to understand exactly what it is I will be doing, but that would require additional pages of writing and I fear this blog is turning out to be a long one. For today, we’ll stop at ICCM and IMCI. In another blog, I’ll introduce you to the rest of the terms that are critical for my work. Look for that coming soon.