Where's the seat?: The Healthy Model Village

THE HEALTHY MODEL VILLAGE

Only 1 week back from Madagascar, stuck in the library studying for my Step 3 board exam.  The smooth, fresh clean water hit the back of my throat quenching my thirst immediately.  It's my second bottle of water for the day and it's still morning.  I rush to the bathroom as my full bladder has finally become uncomfortable.  I enter the well modeled beautifully toiled restroom on the third floor of our hospital.  As I opened the private stall and glanced over at he abundance of toilet paper and the porcelain white toilet with a seat, yes a toilet seat.  I remember in Kenya I always wondered, where is the toilet seat?! The same question puzzled my mind in Madagascar when I wasn't exercising my quads squatting and praying I wouldn't leave the bathroom with the telling sign of wetness in the perfect embarrassing position, to let everyone know when you unsuccessfully used the bathroom.  I wondered all the time why there were no toilet seats in Madagascar.   Usually when i ask that question it's met with laughter with no real answer.  Maybe because that's such a "First world question".  The toilet seat is the least of the problem, especially in rural areas of Madagascar where its common practice to "OD", open defecation, a term I learnt from PCVs, I guess that was their way of making it discrete.  Sorry! Were you eating while reading this? I Promise it gets less graphic, I think!  Who cares where the toilet seat is, I should be puzzled about much more important things. Please forgive me, I digress!

I left the bathroom and sat back down at my desk in the library reminiscing on our travel and tour of the "Healthy Model Village" in Fontsimavo, a small remote community, a few hours from Tamatave, a main city, that was our home base in Madagascar.  The healthy model village, a project designed to help facilitate clean water, well-built latrines and primarily education to rural areas in an effort to reduce diarrheal diseases.

We traveled by SUVs and a "open back" truck filled with luggage to Fontsimavo.  Rolling deep of course, 4 real doctors, me (I'm a doctor in the making really!) 2 pediatric nurses, Ginny, CRMF Director and amazing organizer of our trip, Brother Edwin, Andy, Ginny's sister, 10 peace core volunteers and who am I forgetting? of course! Darwin, CRMF trustee and avid french speaker and multi-purpose team member.  "Darwin, we need electricity!" was a common statement he heard and a need he always fulfilled to help us get our ultrasound working so we could evaluate our OBGYN patients.

I can't talk about our trip to the healthy model village without talking about the travel.  We traverse long winding, bumpy roads, mostly made of potholes with very little road, and get this crossed a river using rafts to transport the SUVs to get to the healthy model village.

 The bridge, yes bridge we crossed, don't miss those planks, or else!

 We get to the River

 Brave "water walkers", shall remain un-named

Video: Car crossing the river on raft, so creative, and a multi man operation.

 Mission accomplished!

We cross and walk up a short hill, some were driven while others walked about 2 miles.  I was one of the walkers, I wanted to test out my new waterproof hiking shoes.   At the end of our journey we walked right into a welcome party organized by the team at Fontsimavo. We are given gifts and enjoy a beautiful dance performed in our honor. 

 Wearing our "Lambda Hoaney"(spelling?)

The beautiful wraps all with different special messages for us.
(Bro. Edwin, Ginny Dr. Wiltse, Ally, Kris, Andy, Dr. Huxley, Darwin, Ruina (sp), Me, Dr. Alexander, Dr. C aka Dr. Egner)

Sitting upfront to enjoy the demonstrations through skit, dances and song of all people have learned about hand washing, sanitation and the importance of well built latrines that don't leave human waste open to causing infectious disease. 

At the Fontsimavo Village

Latrine demonstration.

Ginny receiving Chickens as a thank you!

Dr. C and I in our wraps

Trying to blend in like a Malagasy 

Latrine built by digging a very deep underground area, covered by concrete, and water buckets available to flush the toilet. This type of toilet requires squatting, which is ideal positioning for increasing abdominal pressure and ... you get the point... :)

Brother Edwin congratulating the people of two villages who have together installed over 300 latrines in their villages.  Open defecation was previously a major issue in causing a plethora of diarrheal diseases. 

After a long day, Sister Christine prays as we sit down for dinner at the Nunnery where we will spend the next 2 days administering medical care. 

The next time you drink a refreshing bottle of water and then run to use the porcelain toilet, think of how blessed we are.  If you would like to learn more about Caring Response Madagascar Foundation, visit http://www.caringresponse.org/ or look them up on facebook.

Thank you for reading, Veluma (Goodbye in Malagasy)!

Next blog - our medical work in the clinics.

Peace & Love!

Sash :)

p.s. My waterproof shoes weren't high enough...hehehe

Hehehe.... Don't worry he made it!

Faithful Beginnings

The Start of CRMF

I preface this by saying this account is far from being complete or entirely accurate.  Truly it cannot serve to report the amazing beginning or even as a complete information source of all the work that Caring Response Madagascar Foundation does, but I hope you will learn a little more about the amazing work that has been done in Madagascar over the last 15 years by this phenomenal organization.  I am grateful for the opportunity provided to me by Dr. Carol Egner and the CRMF team in allowing me to accompany them this year.  Not only have I learned so much about the work they have done and continue to do but also, it has been a life altering experience.  

The story begins that sometime in the year 2000, David Eugene Wiltse, son of Doctor David Wiltse and Mrs. Virginia “Ginny” Wiltse met Edwin, a religious brother of the order of saint Gabriel from India while he was studying in France.  From their meeting, ignited a lifetime of friendship and the subsequent timely birth of the Caring Response Madagascar Foundation, CRMF.   At the time of their meeting, Ginny says her son David was searching for a path that would allow him to truly help others.  Ginny describes her son's meeting Edwin as a revelation of her son "finding purpose" in accordance with his faith.  To her son's enthusiasm in fulfilling his dream to help those greatest in need in Madagascar she responded with receptiveness and agreement in helping her son fulfill his dream to help those less fortunate and so began CRMF.  In our casual conversation at the airport awaiting our flight from Cincinnati to Paris she says “the duty of those who have plenty is to help those who have very little”.  I smile in awe of her amazing strength and radiating smile.  She has had her own personal trials but you would never know as she remains so very organized and key in formulating and organizing the endeavors of the foundation for the last 15 years.  Of course, Ginny could not do such great work without including her husband Dr. Wiltse, a critical care pulmonologist well known for his work in Cincinnati and most humble in his demeanor. 

                             Ginny and Dr. Wiltse

Dr. Wiltse (sitting on the ground evaluating a patient)

      Ginny, Dr. Wiltse and Ginny's sister,  Andrea

Brother Edwin recalls that in the same here he started his call to service in Madagascar, three tropical cyclones had left great damage to the country of Madagascar in the year 2000; and in the same year the Cholera epidemic was ravishing the country.  Soldiers were administering medicine by force at borders in an effort to eliminate the disease burden.  There were multiple deaths from cholera with over burdened hospitals filled with dying Malagasy people. 

For those of you wondering what a cyclone looks like, don’t be ashamed I had to look it up too J

On initial arrival to Madagascar, Brother Edwin’s role was to preach the gospel.  Ginny exclaims passionately that Edwin realized he had many steps to take to help the people of Madagascar before he could start talking about the gospel.  “He had to live the gospel, not talk about it”.  That was the saving that people needed Brother Edwin says, as we strolled the grounds where his office/toilet factory/computer training center/sanitation education center is located. 

                                  Brother Edwin

At the Literacy class where people from the community cone to learn to read and write Malagasy.

There were and are many things that lead to the cholera epidemic, most of which are culturally rooted.  For starters the “bathroom” appears to be any open land surface, even I have seen people “OD” as the peace core volunteers put it “Openly Defecate” everywhere.  I know what you’re thinking, “kinda gross”, but that’s just what people have been taught to do.  Unfortunately with rain like that of a cyclone you can only imagine how infested essential water sources were with human waste.  Additionally, Malagassy people consider the land to be sacred, it’s where they burry the dead, uproot their bones about a year later and dance through the streets celebrating the life of their ancestors, so for many people it is unacceptable to dig the ground deep enough for latrines.  Working against "Fadi" “taboo”, was a major issue, people were against constructing toilets where they lived because they fear bad things happening by disturbing the sacred ground.  So educating the people in the face of Fadi has been quite the challenge. 

Malagassy dancing in the streets with the bones of a relative. Photo taken while on our way to the clinic.

In order to prevent cholera people needed clean water, greatly improved sanitation and even more important, education!  Literacy, the simple basic ability to read and understand written information became a primary goal of CRMF as that would allow them to educate people about sanitation and clean water more effectively. With help from Unicef a lot has been done already to help many families with improved sanitation.

Dr. Huxley and Brother Edwin, the concrete models behind them, used to make latrines that require a much deeper hole underground to prevent unsanitary conditions. Later it was discovered that Bro. Edwin was the first to employ women in construction when he employed them in masonry in building toilettes.

Touring the compound where Brother Edwin has been working with his team on constructing different toilets, performing experiments to recycle human waste for fertilization and educating people on sanitation.

(Left to Right: Darwin, Dr. Wiltse, Ginny and Dr. Huxley)

Now in sanitation park people come to choose the type of toilet they like and help in building them in their community.  Choosing based on affordability while also showing accountability.Using urine separated from human feces to fertilize plants a big difference has been seen in the growth of the plant. The plant in the center is fertilized with urine. 

On the same compound is a computer literacy center used to aid students in learning how to use computers on four sessions throughout the day.  Students learn how to use word, excel, etc to improve job opportunities. Nearly 6,000 people have graduated from the computer literacy program and more than 15,000 from the reading literacy program, a program funded entirely by CRMF.

IF YOU WOULD LIKE TO LEARN MORE ABOUT THIS ORGANIZATION CHECK OUT THEIR WEBSITE AT: 
www.caringresponse.org or look them up on Facebook! 

More to come regarding the "Healthy model village" created in a very remote area of Madagascar, welcoming dances and life in the "Bush".

Madagascar team at lunch after the clinic.

Peace Core Volunteers, Darwin, Ally, Kristen (RN at Children's Hospital and Dr. Huxley)

Thanks for reading!

Veluma, Sash :)

Day 1: How to bag mask a dying baby while riding in a Tuc Tuc

Nothing in life can prepare you for the day you ride in a tuc tuc bag masking a baby in every effort to save his life.  Absolutely nothing in life can prepare you for the minutes the 3 wheeled mildly powered vehicle bumps in and out of potholes, around cars, bicycles and other motor operated tuc tucs, pedestrians and crowded market shoppers, no doors, sliding from side to side, while holding the new born baby tightly in an effort to keep him warm mostly, and also to prevent his small body from flying out of your arms onto the dug out road with every hard drop into a pothole.  Nothing could have prepared me for the language barrier that I had with his grandmother sitting on my right side, emotionless from her lack of understanding of what is happening, almost nonchalant because of not knowing how "white" this little African baby emerged from his mother’s infected womb.  She doesn’t know how he was not breathing when he was born, she doesn’t know his heart rate was 30 when he was born, she doesn’t know the pus filled meconium stained fluid that came before and after his large body expelled from his mothers small pelvis after great assistance.  Maybe to her it was normal, normal that her daughter or granddaughter, I don’t even know whose grandmother she is, the baby’s or the mother?  But maybe it was normal to her that this mother was in labor since Thursday, today is Tuesday! , in labor for 6 days, then travelled 6 hrs by tuc tuc to the clinic. 

She arrived in the clinic just as I was in the next room with my American attending, talking to midwives about newborn resuscitation, ironically enough.  She commented on expected skin tone, muscle tone, vigor and breathing.  I sat across from the mom who delivered 10 hrs ago, holding her quiet beautiful infant and smiling at the midwives as we demonstrated.  Then in walked the "head midwife" at the clinic to tell us that a patient had arrived "complete and ready to deliver" she says casually and walks back to the delivery area.  Everyone rushed out the room to learn from Dr. C about delivering a baby.  I stayed behind using the huggies wipes I had bought for my own personal use in times of unpredicatable toilette situations, to wipe the dried poop off the little baby boy's bottom and thigh, it's the least I could do as he was so quiet during our demonstration to the midwives during our newborn assessment.  I cleaned the dried green poop from his small bottom and changed him into his reused resale but “new clothing”.  I wrapped him tightly handed him to his mother, with the package of buggies wipes, to which she smiled, and bid her farewell by saying “Merci Madame” and headed to the next room.  I walked in to see about 16 midwifery students surrounding the bed of a laboring mom.  She was 21 years old but looked no older than 17 years old, laying in the bed with her legs shyly opened for delivery.  The word pushed being spoken in three different languages, all out-drowning the other, Dr. C saying "push, push", then translated to french "Pousser" then the Malagasy people yelled " Manilika".  I placed gloves on my hands to try to help Dr. C and hopefully reduced the chaos. But I only added to it, joining with all words simultaneously I  yelled, “Push!”, Pousser! Manilika!  I wasn't sure at the time why we were saying all three words or even which language the patient understood but as I got closer I was stopped in my tracks by the strong stench of infection I smelled coming from the bed where she laid.  The smell of rotting skin or pus collection filled the room.  I made my way over to the young delivering mom's bed,  I wanted to say her name but I don’t even know her name, I am ashamed I don’t know her name, I don’t even know what she wanted to name her baby, my mind wrestles but there is no time for formalities, it was clear that her baby needed to be delivered and soon!

It was her 6^th day of labor, with a narrow pelvis, the obviously large baby became wedged tightly in her pelvis, we should have known because as we continued to tell her to push, there was no movement of the baby's head. I placed my fingers at her perineum and yelled “Pousser”, twenty French instructed “Pousser” later, a midwive says, “she doesn’t understand French”.  I become quickly frustrated by how long it took us to realize that and ask, “How do you say push in malagasy?”, that was first translated to french to the midwife by Darwin our french translator and team member, to which the midwife responded “Manilika”.  As the entire room instructed the patient to push, she appeared to be doing so with all her might, but the large infant would still not move. 

Dr. C applied a vacuum we had brought in her back pack for teaching purposes with some maneuver of the labia in the tight area that this baby was expected to come through.  But still even with our American equipment there was no movement.  We don’t have the ability here in Madagascar to continuously monitor the baby’s heart rate like we do in the U.S. but I am certain at this time if we did it would be having a sustained decrease in the heart rate and be in the least favorable category.  She called for a pair of scissors, which like every other request resulted in a frantic run outside the delivery area to return what seemed like 10 minutes later.  An episiotomy was made to create more room for this clearly large baby, and with the vacuum, pressure on the patient’s fundus (belly) the infant was expelled in a pool of the baby’s poop and pus. 

I stood still thinking why is this baby gray, literally gray! This baby should be another color besides gray, I am sure of it.  I run around the bed to the baby’s head and start rubbing the baby vigorously, “Stimulate, stimulate, stimulate”, okay what else did you learn from that “Neonatal resuscitation course you took more than a year ago, come on think!”.  The nurses or pediatric team was always at the delivery waiting to take the baby back at the hospital where I work in the U.S., I realized then I had not been practicing the skills I once knew so well.  “You know this, wake up! Heart rate, breathing!”.  Dr. C is steps ahead of me, and checks the baby’s heart rate and counts it as “30 bpm”, I start bag masking as she gives compressions.  A midwife walks over with what looks like a silver blow horn puts it over the baby’s mouth leaving the nostrils uncovered.  She  blows into it with all her might and out of the baby’s nose comes meconium and mucous.  There is chatter and laughter in the background, the others aren’t as frantic in what is likely a familiar situation, neonatal and maternal sickness and death is seen far too often for the Malagasy people to be alarmed.  Dr. C stops her from re-using the blow horn (later I realized it was an old fashion obstetrical stethoscope now being used in a new way) in fear of her forcing all the mucous and stool into the babies lungs.  The midwife then throws alcohol on the baby’s chest, just missing his mouth and starts vigorously rubbing the baby and pinching him.  Dr. C and I look at each other and then resume bag masking after now realizing the baby's HR is normal.  Somewhere in between our researched and implemented neonatal resuscitation and the local medical practices of the midwives the infants color was slowly retuning with tiny sporadic shortened cries.  We wrapped the baby in a small flimsy thin blankets and I hopped in the tuc tuc waiting outside.  I hop in and Darwin stuffs a wad of ariary 10,000 dollar bills into my pocket. 

On the way to the hospital, I continued bag masking the baby while occasionally turning him and patting his back firmly to help dislodge any mucous and to essentially perform chest physiotherapy as I would occasionally see the nurses do when I looked over while caring for a mom in the delivery room back in the U.S.  As the tuc tuc fell into pot holes the baby muttered little cries.  In that moment, my eyes began to well up, I held my tears back and said “keep fighting, you’re a fighter, I know it little guy”.  I looked into his now opened eyes with a male midwife bent over me now bag masking the baby occasionally to keep him breathing while I kept him warm.  We made it to the hospital, seconds later the pediatric consultant arrived.  We exchanged information regarding the patient in the little English she knew and the little French I knew.  She then says “bien, it’s okay now, you can go”.  I went to the pharmacy and paid for the medicines with the money Darwin had stuffed into my pocket.   I thanked the midwife, gave the grandmother more money for medicines and walked away knowing she didn’t understand what happened and being totally incapable of comforting her in any other way.  I rubbed her shoulder, smiled and walked away.  I hopped back into the tuc tuc waiting outside and retuned to the clinic.  On the way back I rustled with the motion of the vehicle, stunned and overwhelmed with self-evaluation, nothing could have prepared me for this, I couldn't help but wonder, "Am I really ready for this?!"

 Riding in a bicycle Tuc Tuc on the way to the hospital.

Mother we delivered is doing well. We go to the hospital to give her the IV antibiotics we bought ourselves, since she is just staying in the Pediatric unit. 

 Our little fighter is hanging in there.

 Dr. C, overseeing everything.

Traffic in Tomascina.