This is a co-authored post by Lisa Shawcroft and Sruthi Chandrasekaran, 2014-2015 co-fellows at Marie Stopes International in Washington, D.C.
Global Health Corps is a fellowship program that aims to create the next generation of global health leaders. The program model pairs two fellows—one national and one international—within a placement organization and gives them tools and supports them to develop into confident professionals. While certain things during our fellowship were beyond our control, we knew there was one thing we could always count on: each other.
Over the past year, we took a selfie together every day we were together—usually in the office, but as our project gained momentum, we got more creative, snapping photos during retreats, on co-fellow date nights and even during Skype chats.
We love our selfie collection because it illustrates the evolution of our relationship from strangers to steadfast supporters of one another, and capture so many memories from this past year, even if they just barely capture both our faces in the same frame.
They say a picture is worth a thousand words, but we didn’t feel like it was right to wrap up this year without getting in one thousand words or less about our selfie project.
If you had to choose one selfie that sums up the fellowship year, which would it be, and why?
Lisa: May 29: Sruthi was in Ethiopia and I was a roundtable discussion on contraception access for youth. This is indicative of our diverse roles (and experiences). It also illustrates the bond we formed over the course of the year—even when we were on opposite sides of the world, we tried to take a selfie because it connected us. I can’t imagine not having her around in a few weeks—and not having a co-fellow in my next job! #CoFellowLove
Sruthi: My pick is the selfie of us which was processed to look like us when we are old. Though it may not be reflected outwardly, we’ve become more mature professionally and personally. And we hope to grow old together, so that picture is pretty perfect!
Looking back to the selfie from our first day at MSI, what do you see? What do you wish you had known then?
Lisa: Mostly my face looks sooo tired from lack of sleep for the two weeks leading up to our first day! It’s funny to look at this picture—Sruthi and I were laughing about it yesterday—because both of us look so uncomfortable taking a selfie in Starbucks and uncomfortable with each other.
I wish I had known on my first day that it was all going to be OK. That there would be hard days, and harder days, but there would also be days that made the hard times worth it. #itsGoing2BOK
Sruthi: I wish I knew where to look when taking a selfie – I’m squinting! Jokes apart, I wish I had known that this year was going to be a challenging one. It’s been challenging to work on myself professionally and personally and to have Lisa as an ally in that process has been a tremendous source of support.
You recreated your first day selfie on your first anniversary at MSI-US. Comparing those two photos, how do you feel you’ve grown: personally, professionally and emotionally?
Sruthi: Professionally, I have gained great clarity on the workings of policy advocacy in the US and developed a keen interest in sexual and reproductive health. This year has helped sharpen my focus and widen my horizons by pushing me to think about reproductive health and rights in India.
Personally, I’ve grown to learn how to deal with transition. I’ve also come to understand how simple things like taking a selfie everyday can bring transformational changes to a relationship in the longer run.
Emotionally, I’ve become a stronger person and learnt how to better handle stressful situations. I’ve also learnt how important it is to have a community you can relate to and share your thoughts with.
Lisa: We haven’t really changed much physically. We got haircuts. Gained a few pounds here and there, lost them again. Nothing too dramatic. At the end of the year, we’re still us: Lisa and Sruthi (@lisa.and.sruthi.ghc). And I’m glad for that, because I think where we started was pretty great.
I think the same can be said for me personally. I’ve grown a lot over this year, and that’s as a result of a lot of introspective work. I’ve learned to focus on me rather than strive for others’ acceptance. That’s served me well in my professional life, too. For once, not having a clear idea of what I want to do next seems fun and exciting rather than completely terrifying. (Still a little scary, though!) #Lisa2.0
If you could sum up this fellowship year in a hashtag, what would it be?
Lisa: It’s cliché, but: #changemaker. For the times when it felt sooo ridiculously far from who I was and what I was doing, the times I used it ironically and for the magical few times when it felt exactly right.
In ten years, what will your selfie look like? Will you still part of the movement for #healthequity?
Lisa: In ten years, my selfie will be me, calm, confident and happy with where I am in my life. I’m less concerned with the rest of the details. I believe that being part of the #healthequity movement is more about your core values and beliefs and less about your profession or degree. #Lisa2025
Sruthi: Lisa and I at a conference pertaining to reproductive health, with Lisa bossing me over. We are both doing what makes us both happy – believing health is a human right.
I hope to find my way through my interests in policy, economics, developing countries and reproductive health in working towards health equity.
I once read somewhere that obstetric fistula was eliminated in the United States of America in the early 20th century. Now this is the 21st century and obstetric fistula continues to be a problem in many African countries including Malawi.
Firstly let me tell you all what obstetric fistula is. This condition is regarded as a birth defect or one of the complications of child birth. Obstetric fistula is a hole that is formed on the tissues of birth canal. This hole might be formed between the vagina and bladder (vesicovaginal) or between a vagina and rectum (rectovaginal) leaving a woman with uncontrollable leakage of urine and/or feces through the vagina. This usually happens as a result of obstructed labor where the baby is too big compared to the woman pelvic or when there is prolonged labor where by a woman labors for too long than expected.
Fistula is not a pleasant condition and many women suffer from devastated effects. Fistula women experience physical discomfort, bad smell from the continuous leakage of urine or feces, shame, embarrassment and humiliation in the society. These women feel rejected, stressed and have relationship problems with their partners. They are treated as social outcasts because of their condition.
Many women live with fistula for a while before they get treatment. Some up to two years or more, and some never even get treatment at all. Lack of information is one of the reasons these women delay in seeking treatment. Most people do not know that fistula is a medical condition and it can be treated. They think it a curse for being unfaithful to their partners hence they do not disclose this condition to anyone or go to the hospital in fear of being judged by the community. Access to health facilities and trained surgeons who are capable of repairing fistula is another big problem. More than 90% of facilities in Malawi are not well equipped or competent enough to conduct fistula surgery. I know of only two medical centers in Malawi (Queen Elizabeth central Hospital and Freedom from Fistula Foundation) that are able to do fistula repairs and once or twice a year there is a camp that happens for a week or so where doctors from outside come and do repairs.
I am writing this because I feel fistula is one of the neglected medical conditions in Malawi. I have worked as a clinician for five years and I think as a country we have a long way to go to eradicate obstetrics fistula. I learned about fistula and its treatment in college, but throughout my whole career I have only met two clinicians who are able to do repairs. Despite the knowledge that I, and other clinicians in this country, have there is no room to perfect our skills due to lack or resources in our health facilities to enable and expose clinicians to feel comfortable doing fistula surgeries. As much as effort is put to eradicate obstetric fistula, I still think as a nation we can do better. For example there is more work to be done to improve access to emergency obstetric care services at all levels. There is need for educating the masses about what causes fistula and where they can get treatment and, that just like any medical condition, fistula is nothing to be ashamed of. There is also need for political will, from both the national and international levels, to ensure adequate resources are available to train clinicians and nurses so they are competent enough to do repairs as well as availability of treatment and equipment in most health facilities across the country. There is no loss in investing in human capital. Let us restore these women’s dignity.
More than Midwives and Medicines: Educating Communities in Malawi with the Safe Motherhood Initiative
Malawi, a landlocked country in southern Africa, has one of the highest rates of maternal mortality in the world. However, the country has seen a notable decline of deaths resulting from complications during childbirth. Leadership at the district levels and political will of government leaders was key, along with educating communities on family planning, maternal health, and the importance of delivering in a health facility. Malawi’s Safe Motherhood Initiative (SMI) plays an important role in these areas. SMI is a country-wide program that was conceived in the office of the President and aims to improve maternal health by training up to 2,000 community midwives, constructing maternity waiting homes, and mobilizing traditional leaders, also known as chiefs, as agents of change in their districts.
SMI’s Community Mobilization Coordinator, Timothy Bonyonga, was working as an OBGYN Clinical Officer when he felt inspired to do more outside the ward. “I was attending to a lot of complications and I was seeing a lot of women dying due to preventable causes. I decided to really take action on behavior change.” SMI’s discussions focus on preventing what he describes as “too early, too many, too frequent and too late pregnancies”. This means discussing healthy timing and spacing of pregnancies, pregnancy-induced hypertension brought on by bearing too many children, and HIV testing before and during pregnancy with an emphasis on couples testing and counseling. The SMI team target not only expecting mothers, but chiefs, husbands, and school children.
In Malawi maternal health was traditionally framed as a women’s issue, but among stakeholders there is general consensus that male involvement is worthwhile for promoting safe motherhood. In the beginning Timothy received pushback from some communities when trying to involve males, and he accredits the influence and leadership of chiefs for the change of attitude. It doesn’t hurt that chiefs have instituted bylaws which penalize nonparticipation in community sensitization meetings. The hope is that, after these discussions, men will begin escorting their wives to the antenatal clinic for HIV testing and HIV counseling, if necessary. Timothy adds, “It’s very important because men in our society are regarded as heads of families and considering that religious following among our women is very high, it was really difficult for women to adopt family planning methods without male involvement. In communities where men have really been involved, things are really working.”
Another vital target group for SMI is adolescents (age 10-19) because they are the next generation. According to the U.S. Agency for International Development, this age group counts for 20% of maternal deaths in the country. An underlying cause of maternal death is early childbearing which in Malawi begins at the average age of 19. Interrelated to this is child marriage which is high; half of Malawian girls are married by the age of 18. Earlier this year the passage of the Marriage Bill gave hope to child’s rights advocates by raising the legal age of marriage to 18. And SMI discourages early childbearing by advising women to hold off on pregnancy until after age 21. Timothy thinks the legal age of marriage should be raised to 21 or 22, to not only align with this but with school completion and financial independence. “[Family planning] will work much, much better if the girl child is empowered through formal education. Once a woman is educated, things work much better, whether she’s married or not.”
Among the barriers that come with gender are religion and deeply rooted cultural beliefs. To combat this, the Safe Motherhood Initiative conducts “Influential Leaders Trainings” whose participants are a combination of religious leaders, teachers, and other prominent members of a community. The purpose of the trainings is to try and understand what approaches are appropriate and effective to engage with community members. An important outcome of working with religious leaders is to counter religious arguments and texts that contradict SMI’s family planning messages. Timothy describes another challenge which he calls “intellectual poverty” as something demonstrated by those who are the educated elite. “They block some of the messages that I give because of their cultural beliefs. They are educated but aren’t knowledgeable on some of the issues we discuss with people.”
In addition to seeing a reduction of maternal deaths, the Safe Motherhood Initiative has seen an increase in hospital deliveries, young mothers returning to school, and a demand for cervical cancer screenings. Malawi is showing that using a range of interventions can contribute to SMI’s vision of a healthy mother, healthy baby and healthy Malawi.
12 June 2015. It was 9:00am and I sat there exhausted in the lobby of Beit Cure International (BCI) Hospital – supposedly one of the best hospitals in Malawi. I arrived late the previous night after traveling five hours on a pot-holed and accident-ridden highway from Lilongwe, the capital city to Blantyre. This trip was an urgent request by my physician to get a second opinion for my leg injury. Unfortunately, this visit was one of many over the last five months that allowed me a raw, but privileged access to the Malawian healthcare system.
First, let’s go back to my minibus accident on 9 February 2015
It was 5pm and I was quick to clock out from work. I flagged down the minibus beside the road. The minibus is a hybrid between a family and utility van, and minibus drivers are notoriously reckless. Just a few weeks ago, a minibus carrying 14 passengers flipped three times and killed two passengers in southern Malawi.
This recklessness – no doubt – contributes to the fact that motor vehicle crashes are ranked one of the leading causes of death in Sub-Saharan Africa.
The minibus was jammed pack with four sitting per row, which legally and safely sits three. As we proceeded, I noticed a green sedan encroaching into our lane. Both drivers interlocked glances, but my minibus driver sped up. The next thing I heard was the screeching tires and all 19 of us thrown forward. The bench that I sat on was dislodged from the baseboard and I was shoved up against the metal engine. Suddenly, a sharp pain permeated up my leg. I looked down and my pants were ripped behind a freshly new wound.
My introduction to the Malawian healthcare system
Helen, who is the Malawian Country Manager at Global Health Corps, arrived and took me to a local private clinic. The injury was benign. The doctor gave me a tetanus shot, prescribed a week’s dose of antibiotics and painkillers and bandaged me up. The doctor insisted no stitches.
I’ve heard of horrific minibus accident stories, so I was grateful that I hadn’t become just that, a tragic story.
9 March 2015. Over the next two weeks, my leg became swollen. Green pus inundated the wound and the skin around turned bluish-purple. I was worried, so I consulted my “American doctor friend.” He demanded that I go to the hospital and so I went to the African Bible College (ABC) clinic. A doctor from New Zealand confirmed that it was an infection. She prescribed a week dose of cleaning and dressing, but no antibiotics. She said to apply honey twice a day to the open wound. I looked up at her, puzzled, and she said, “It is proven to work…and it has worked wonders for the locals.”
I didn’t question her because I believe that indigenous and traditional medicines can offer an alternative to Western medicine. So I agreed and applied the local, natural Mzuzu honey for two weeks.
However, four months later I was back in the clinic again.
11 June 2015. The signs should have been obvious a few weeks prior, but I ignored them. I had a fever and the lymph node in my right groin area had hardened. When the wound oozed and turned red, I knew I was in trouble. I visited ABC clinic again and the same New Zealand doctor suspected a more serious infection. She prescribed an x-ray to make sure it hadn’t infiltrated the bone. She saw nothing, but she wasn’t satisfied. So she sent me to a specialist in Blantyre immediately. She told me, “There is something going on under there and if this were my leg, I would get a second look.”
12 June 2015. The following morning I saw the orthopedic doctor, an American, at BCI Hospital. I told him about the accident. He prodded and palpated, and decided on an MRI. I agreed without thinking about the cost, how the procedure would occur, or worse, what they would find. I assumed that it would be cheap. Also, I figured I would just strip down and get into my surgical gown and be out the door just like that – well, I was wrong. My 9am day ended at 5pm.
The MRI Centre at Queen Elizabeth Central Hospital, which is the government hospital and the only facility in the country with an MRI machine, was 30-minutes away. When I got there I bypassed the dozen pregnant women and went to the front of the line because I was a “paying customer.” This was my first reality-check to what privilege can buy in the developing world. However, moving to the front of the line did not equate to me finishing early. BCI had failed to tell me that it would cost $500, cash. Additionally, I had to bring a CD for the MRI images; and I had to travel another 45 minutes to get them read by the only Radiologist in the city. To say that I was flustered would be an understatement – I was agitated. I was that “spoiled American” who expected the convenience of Western medicine.
Once I got to the Radiologist’s clinic I was surprised that it was nothing more than cellulitis. I was relieved, but deep down inside I had hoped for something worse because that would’ve at least validated my shameful charade in the city.
What I learned from this experience
Never compromise when it comes to your safety and health.
It is important to not delay seeking medical attention – as it could be a matter of life or death. Trying to resolve an infection months later could save you time, frustration and money. Secondly, don’t self-medicate. Rather, seek the advice of trained professionals no matter how minor the injury or illness may be. Lastly, make sure to have traveler’s health insurance – otherwise you could end up paying exorbitant fees out-of-pocket.
As an American living in a developing country, I was thrust into a healthcare system that was foreign, unfamiliar and difficult to navigate – a system that I took for granted back home.
As Global Health Corps fellows, we believe health is a human right. Coming into GHC, I certainly believed this, but also felt as though calling something a “human right” has become a “sexy” buzzword trend. Sometimes the word seems so quotidian that almost everything is becoming valued as a human right. I share an office, for example, with an organization that believes housing for people living with HIV/AIDS is a human right. Having worked for four years in a Baltimore City HIV/AIDS clinic, I saw firsthand how adequate housing provided a sense of stability that could allow one to focus on his or her long term health when not faced with the pressing question of where to live for that day. Housing as a human right? You bet. More recently, while researching the topic of women in technology for a presentation I made recently, I discovered a 2011 report from the UN Special Rapporteur that asserted access to the Internet is a human right. In a world in which the internet is needed to gain and perform a high number of jobs, lack of internet access is a detrimental economic burden. Furthermore, we’ve seen how social media has allowed people to have a voice in democratic processes and move forward human rights agendas. Be it housing, Internet or healthcare, the demand for each of these to be treated as a human right would greatly contribute to equity and empowerment.
As I’m overcoming cynicism, there’s one other human right I’ve come to purport: sexual education as a human right. I’m currently spending my fellowship at The Grassroot Project in Washington, D.C. which is a nonprofit that trains DC college athletes to become HIV educators in DC middle schools using games and sports. One of my favorite responsibilities as a Program Manager is to conduct site visits at each of our programs. Occasionally, I also fill in for our student athletes in our programs when needed. During these visits, I was able to build a strong relationship with one of our partner schools and specifically one of the teachers whose class participated in The Grassroot Project. In her classroom, I was struck by a chalkboard filled with two columns: “What we know” and “What we want to know.” The class was beginning their sexual health unit and the teacher chose to start the unit with open conversation. On the know column, there were facts such as “women have ovaries” and “male voices lower during puberty.” On the want-to-know column, there were questions such as, “What is a wet dream?” and “Why don’t men menstruate?” I was impressed by these unabashed questions and more importantly, by the the safe and trustworthy atmosphere the teacher created. I had to learn many sexual health lessons by asking friends, as we received very basic information in my middle school health classes. My experience is receiving limited sexual education in school is far too common, but I was fortunate enough to have many outlets to turn to for information: the Internet, my parents, friends, higher education at the university level. But what about the girls and boys who do not have safe places to discuss sexual and reproductive health? Whose friends know as little as they do about sexual health? Whose cultures or families may discourage the discussion of anything related to sexual health?
Is it time to use a rights-based approach to sexual and reproductive health education? The International Planned Parenthood Federation (IPPF) defines a rights-based approach to comprehensive sex education (CSE) as “to equip young people with the knowledge, skills, attitudes and values they need to determine and enjoy their sexuality – physically and emotionally, individually and in relationships.” Is it time to use innovative outlets such as girls sports programs to teach women and girls about CSE through models like Girl Determined or Moving the Goalpost? If youth were taught about their bodies, sexual health, reproduction, and how to have safer sex, would we see ripple effects resulting in reduced incidence of HIV, unwanted pregnancy or maternal mortality?
Cynicism dismantled, I am ready to promote access to sexual health education as a human right. As we move forward into the Sustainable Development Goals, sexual health is on global radar. I see the movement for health equity growing, and am optimistic that we can expand our view of health to include education and discussion around more sensitive topics such as mental and sexual health. As advocates for social justice, we will continue to “bend the arc toward justice,” as Dr. King once said, embracing the arc in its many forms- and the arc I’m most excited to bend is the arc of access to sexual and reproductive health, human right and all.
June 4th 2012, 9: 40 PM: Thursday night the phone rings, a voice answers ‘Hello this is 990 how can I help you’ ‘Please help me I can’t do this anymore he did it again please please help me he’ll kill me if I don’t get out of this’ The voice spells desperation a cry for help ‘I can’t take it anymore he beats me every time is ask him where he slept.’
February 18th 2014, 15:12 PM A caller rings 990 with this disturbing story ‘My husband has been sleeping with my 16 year old sister now she’s pregnant when asked her who the father was she couldn’t tell as she was afraid , she told me if she mentioned this to anyone she would be killed by my husband’.
These are just some of stories of people affected by gender based violence (GBV), this is ugly vice that needs to be mitigated for Zambia to achieve gender equality and empowerment of women. No one should have to live in constant fear, shame and pain, unfortunately most women are paralyzed by this vice and have to contend with social, economic and legal factors that at times make them seek help and get justice. Most women suffer in silence as they go through this devastating ordeal, In Zambia some women have held on the belief that receiving a beating from their husbands is a ‘sign of love’ why? The culture in which men are placed highly than women leaves room for abuse of power in relationships. Unfortunately this belief is spread by traditional marriage counsellors.
Economic disadvantages leave women dependent on their spouse for financial support, who at times may not permit them to earn a living. However, this doesn’t mean economic empowerment equals automatic gender equality and zero GBV. Even women who are financially stable and successful can be victims of GBV. True empowerment happens when as collective we stand together and support one another to live fully without fear. One incident that disgusted me was the story of a teenage girl who was stripped for dressing in skimpy attire; one can only imagine how this girl must be traumatised. This is not the way to do things, particularly for a country that prides itself as a Christian nation. I very much doubt those values are being upheld in any way concerning this issue.
The following statistics show what the effects of GBV have on women as discovered by the Zambia Demographic Survey 2007 Report. GBV has adverse effects on women’s health and further endangers the development of a nation if Gender equality isn’t an agenda for development. Let’s not accept such disparities and say it doesn’t affect me this could be someone you love, a mother, sister, cousin ,brother, son ,co-worker, stranger even you this is everyone’s fight …Together We Fight GBV!!
The Effects of GBV on Women
In some regions of Sub-Saharan Africa, women are 1.5 more times likely to contract HIV as a result of GBV and there is “behavioral evidence that men who use violence against their female partners are more likely than non-violent men to have a number of HIV-risk behaviors including MCPs, frequent alcohol use, visiting sex workers, and having an STI, all of which increase the women’s risk of HIV” (WHO, 2013)
- 47 percent of Zambian women reported experiencing physical violence since the age of 15.
- Women employed and compensated in cash (54 percent) are more likely to experience violence than unemployed women (40 percent).
- Urban women (50 percent) are more likely to be victims of GBV than rural women (44 percent).
- 85 percent of women and 69 percent of men believe that a husband is justified in beating his wife for at least one reason.
– ZDHS, 2007
Statistics courtesy of Central Statistics Office Zambia, Zambia Demographic Health survey 2007.
If nothing is done to address this social vice, we could face many more challenges especially in terms of health and development of any nation. With the sustainable development goals set for 2030, goal 5 (achieve gender equality and empower all women and girls) needs to be seriously considered for goals 1, 3 and 4 to be met; gender inequalities can hinder the progress of any nation. Addressing this issue head on and involving everyone is the way forward, so let’s not accept such disparities and say “it doesn’t affect me”. This could be someone you love: a mother, sister, cousin, brother, son, co-worker, stranger. Even you. This is everyone’s fight …Together we fight GBV!!
While in a discussion with other fellows within one of the GHC retreats, I thought about the first impression people had on the similarities or the differences between the Millennium Development Goals (MDGs) and the Sustainable Development Goals (SDGs).
Here is my first impression and my thoughts about it:
The SDGs framework is becoming more in depth than the MDG framework.
The SDGs framework might have more goals than the MDG framework but it is because now other sectors are invited to participate in addressing overall global health issues which will allow the root cause to be tackled in a more productive way.
The SDG framework has around seventeen goals compared to the eight goals for the MDG framework, but at the same time the eight goals of the MDGs seem to show a global issue that might be possible (and/or easy) to address; yet after fifteen years of its implementation, the outcome of MDGs is not really satisfying at a global scale.
A group of countries designed the MDGs but forgot at the same time that other important issues also need to be addressed in order to attain the development goals. Now that other countries were invited in the drafting of the SDGs, it showed how the MDGs project was quite not a “success” in itself
I found that people’s first impression at the sight of the SDGs would be “this is way too difficult to understand” or “Why are health-related articles no longer as many and visible as they were in the MDGs?” or even “why this SDGs document seem to be a longer, hard/difficult and broader document than the MDGs document?”
The fact that the SDGs framework is longer, that the goals are developed, and that most of articles don’t only talk about health issues, doesn’t mean the SDGs are not better than the MDGs at all.
The objective stayed the same but goals had to be redrafted in another way, maybe in a more detailed and broad manner, in order to reach the objectives the MDGs were supposed to have reached a dozen years after.
I believe that looking at an image is actually noticing and identifying all the components of it but looking deep inside of the image allows to understand more its components and then to see the “bigger” picture behind the simple image.
I recall when I am looking at job adverts, in newspapers, website, etc. Much like everyone else, I always read a job advert from its beginning to its end, from the title, passing by the tasks, the qualifications and ending by the application deadline. However some jobs are giving more details by enumerating dozens of tasks. Honestly for this kind, I always read the qualifications part first and if I see I might be qualified for the job, I then take time to read all the tasks and the responsibilities; but if on the other hand I am not qualified for the job, I don’t even bother to go through all those tasks.
I agree that it is easier to draft a clear and relatively short document, but sometimes one needs to clarify and to detail the information in order to show how each and every component of it is important in itself and that in fact all the components are participating with each other to the understanding of the whole document and of its implementation.
SDGs are emphasizing and promoting a cross-sectoral participation in the poverty eradication where MDGs are tackling global issues. It seems to ignore links between issues and this in turn constitutes another considerable issue to deal with.
The lights from the buildings scattered up and down the street illuminated my path. Kigali is known to be a fairly safe city, with armed security and soldiers at various intersections. It can be a bit nerve racking seeing a shadow emerge with a gun, but at the same time it allows one to feel a bit more at ease when walking alone. Unlike most evenings, however, walking home this particular evening was different. I was almost home, when I heard footsteps approaching fast towards me. It seemed odd, but I kept on as people walked past me and continued on their merry way. It felt peculiar, being in a crowd, surrounded by people but still sensing that you are being followed. I slowed my pace hoping that the individual – whoever they may be- would walk ahead of me so that I wouldn’t unknowingly lead them to my home.
Just as I was about to shake off my paranoia, I felt a sharp thud on my back as a hand slapped me across my back. Startled, I looked to my left thinking it was a case of mistaken identity! Before I could react further, the individual yanked my earring from my left earlobe, looked at it, tossed it towards the plants lining the sidewalk and walked off. It took me a few minutes to let out a loud scream – it felt calming to let out the amalgamation of fear, shock and disbelief that had quickly formed within me. Blinded by shock, I only caught a glimpse of my attacker before she quickly walked away just as she had arrived.
Before long, a crowd formed around me speaking in Kinyarwanda. I made out the word “musaza” which means old. Shaking, I repeatedly muttered, in English, the words “what did I do to her?” As I scoured around for my earring in the poorly lit street, a lone moto-taxi driver tried to help, shining the faint light from his phone on to the ground. Soon, a man stepped forward and told me in English: “Don’t worry, she is a musaza an old woman. She is crazy. Don’t worry. She is crazy” I held on to my chest trying to calm my racing heart. The spot on my back was throbbing, I was scared and just wanted to get to the safety of my home.
When I eventually made it home, it took me a while to finally be at ease. As I replayed the incident in my head, I wondered about the woman’s story. Who was she? What triggered her to pick me out of the crowd walking ahead of her? Later on, a friend asked if my earrings had been offensive, my only thought was that they were a bit dangly. Perhaps she was curious, watching them swaying back and forth in the gentle wind. Perhaps she was saving me from something that only she could see. I would never know. But one thing is certain; no one tried to follow her to see if she needed help. Was she safe? No one wanted to know her story. They were fine accepting that the musaza was crazy and that was that.
It is estimated that 76% and 85% of people with severe mental disorders in low and middle income countries do not receive mental health care and treatment. According to Rwanda’s National Mental Health Policy there are only five psychiatrists countrywide and at least one mental health nurse at district hospitals throughout the country. In Rwanda, Partners in Health, is working with the Ministry of Health to train providers using safe, evidence-based and culturally appropriate strategies to address gaps in treating mental disorders. Mental health disorders do not only impact an individual’s health but, particularly in the context of low and middle income countries, their overall livelihood- including poverty alleviation, educational attainment and susceptibility to being victims and perpetrators of violence. There is a strong need to implement and safeguard policies that preserve the health and dignity of people with mental health disorders. By 2030, mental health disorders particularly depression is expected to be the leading cause of disability worldwide. As we look to the Sustainable Development Goals (SDGs) we must revisit and incorporate the WHOs definitions for both health and mental health:
“Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.”
“Mental health is defined as a state of well-being in which every individual realizes his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to her or his community.”
We must remember that our mental health is at the very core of our being. Without it, we are lost and unable to live to our full potential.
“Billions of philanthropic dollars are being spent on things like HIV/AIDS or water or malaria,” said Liz Alderman, co-founder of the Peter C. Alderman Foundation (PCAF), which works with survivors of terrorism and mass violence. “But if people don’t care whether they live or die, they’re not going to be able to take advantage of these things that are offered.” (Rethinking Mental Health in Africa)
It may take some time for me to feel safe again during my next few months in Kigali. I may not be able to walk home without constantly watching “my back” (pun intended) again. I may even be wary of every old woman I see, or fast approaching footsteps that I hear, but as the phantom ache in my back subsides, my only reminder of the incident will be my single earring missing its pair. My paranoia and shock will subside. For the old lady, however, she probably is battling more everyday than we could ever imagine. Perhaps, the only time a crowd will form around her or close to her would be to label her as a crazy musaza, but not to provide her with the support and care that she needs.
This year I have been working as a health counselor in Newark, New Jersey at Covenant House, a shelter for homeless youth ages 18-21. One of my main roles is to assist our youth in accessing healthcare resources in the community. Since many of the young people who stay with us have not seen a doctor in years, the needs that we address are often extensive. We are fortunate to have our own mental health care team on-site, as well as a physician and nurse practitioner who visit us twice a week to provide health screenings and basic primary care. Everything else—from dental care to eye exams, prenatal visits to specialist care—is found in the community. That’s where I come in.
As I work to help people meet their wellness goals, some days I get to feel like a superhero. But the reality is I am not sweeping into this need-gap with anything novel. I connect people to resources that already exist; it’s as simple and as complex as that. Integrating advocacy knowledge and linking people to the right care in a dynamic urban environment is a great social and intellectual challenge. The phone is my superpower of choice, but being physically present in the community is just as important. Newark has some of the best resources for everything from HIV care to emergency dental services. Every youth’s needs are different and there is always more to do. I like to think of myself as a medical matchmaker—and when my job works, it is extremely gratifying.
The youth at Covenant House don’t necessarily need my help to sign up for insurance or find a doctor. They are independent adults and many have had to take care of themselves from a young age. Still, I risk providing a glamorized picture of this healthcare landscape. What I have learned in the process of stretching out my arms between providers and patients has only confirmed the universal lamentation that I myself had never experienced at such a profound daily dose: our healthcare system is the very embodiment of inefficiency, and to a rather insufferable degree. Navigating this system is one of the most daunting tasks a person can face, as well as potentially dehumanizing and frightening during an already difficult time of illness. I have seen the effects of healthcare failure time and again. Every time a client has returned with a broken bone and no cast, a script for vital $600 medication not covered by insurance, or paperwork that traces a confusing trajectory from doctor to doctor with no continuity of care, I have begun to sense the crisis of a future medical student delving into this circus-like arena: how am I going to treat my future patients?
This year, I’ve been collecting euphemisms for why a doctor’s office is unable to see my clients. In the language of medicine, they have been “too many too count.” I discovered there is formalized, proper language for turning away a patient. “We no longer accept… err, we don’t participate in Medicaid,” the receptionist often stammers, catching himself. Based on my experience, I was not surprised to find that New Jersey is the state with the fewest doctors who accept Medicaid. In that moment, like a chivalrous Don Quixote, I vowed, “When I am a doctor, no patient will be turned away!” Could this someday be the case?
This year, I found myself surprised if I sent a youth off to a specialist appointment and they came back treated. I began trying to cover all my bases with insurance companies and I kept my expectations cautiously low. The number of things that can go wrong in the process of getting someone past a doctor’s reception desk would appear endless: the patient’s straight Medicaid plan just switched over to an HMO and needs a referral processed; the doctor providing the referral is not the primary care doctor listed on the plan; the referring doctor can’t be found in the system; the specialist doesn’t accept the new HMO; the doctor is in New York but the Medicaid plan is in New Jersey. All of this is just for the consultation.
We play a similar game for medication, imaging, and medical equipment coverage. For example, some HMOs won’t cover certain birth control medications. Others need preauthorization for splints or nebulizers. It’s one thing to read about health care failure in articles, but it’s another to witness it play out over and over on the ground level and encounter the human impact of such barriers to care. If practice makes perfect, we have perfected the art of doing a lot of extra work (necessitating mountains of paperwork and circuitous phone calls) with little benefit to show for it, aside from a rise in healthcare worker stress. All along the way, people get sicker, give up on seeing that doctor, and even die waiting for care.
After jumping through hoops with insurance companies for a couple of months, one of my clients asked the right question—the simple question: “What if someone has a brain tumor but doesn’t have insurance?” The young people I work with get it, and that lessens my fear that we will become complacent and begin to think a lack of access to care is normal.
The Affordable Care Act has been crucial in increasing insurance coverage to those who would otherwise fall through the cracks. But when many of our youth receive their Medicaid cards, it comes in the mail with a user manual the size of a dictionary. They don’t often know what to do with their coverage, and they don’t have access to phone and internet to research and call providers, much less the time to go doctor-shopping. Lists of accepting providers are not well-updated, and their numbers are becoming fewer while patient loads are increasing.
Medicaid-accepting offices in Newark are often run-down, overcrowded, and located in areas that are not safe. Accessing care simply becomes too much of a nuisance. But even when one gets past these barriers to make an appointment, they still risk being turned away from the office due to an insurance technicality. Being sent away from the doctor when you are sick–this is what pains me the most. As a future physician, I don’t want to just treat patients who can afford to see me. That’s not what my classmates and I have studied and sacrificed for.
Still, there is hope here, because exciting change is on the horizon. Recognizing that our current system can’t get much worse should become our launching-pad to the calculated risk-taking we need to make changes–and indeed it has. Doctors are not waiting for a top-down approach to change; we are seeing new models of care pop up all over the country, such as the Ideal Medical Practice. A sense of urgency frees ourselves up for innovation, and selling a novel idea to society about what care can look like becomes easier in the face of a system that is fully agreed upon to be unsustainable. As science changes, medical care will follow suit, and we will need a model that is flexible enough to grow with us and our evolving concept of health. Understanding where our current system fails is key to forming the ideas for structures that work. That is why I am grateful for the fumbles and failures amidst the successes of my case management work. And in this way, I have hope that we will someday be able to throw the exam room door wide open to all who need to see the doctor.
After 24 hours of travel in various modes of transport – some more spacious and pleasant smelling than others – I reached the northern-most border of Malawi. The minibus came to an abrupt stop and its contents, animate and inanimate, tumbled out. I followed the crowd away from the depot and past rows of informal shops that deposited us in front of a long brick building labeled “Customs.”
Vito had his back to me as I approached but I was certain it was him; he looked just like his picture. He was an unassuming gentleman whose hair silvered prematurely. His smooth, compact body had all the bulk but none of the definition of his younger self; indicative of the gym addiction that, coupled with his strong Italian name, helped him compensate for his otherwise small stature.
The rumbles -and the occasional sputter- of his espresso machine brought him to life each morning. As a middle manager, he was well-manicured and meticulous; prideful but never flashy. He was dusting and readjusting the photos on his desk, dreaming of a comfortable, corporate future, when the news came through: his company had been acquired by a larger firm. They felt youth would revitalize the company and traded in their employees for newer models.
Unemployment sparked a brief midlife crisis; Vito reevaluated his worth and decided to lean on his strengths – resilience and reliability. In his previous capacity, those made him ‘safe’ and, therefore, unexceptional. Vito needed to re-brand himself; he needed adventure.
That’s where I came in. I can be dangerously good at the ‘adventure’ bit, but lack a partner specializing in safety and reliability. A few wire transfers and two months later, Vito made the harrowing journey from Japan to join me in Lilongwe, Malawi.
Vito the Vitz, Watson and Lucy the Rav4s, and Starlet the Starlet, are part of a unique breed of Japanese vehicles living out their golden years in Africa. They are purchased sight unseen; selected from a scrolling set of images that feature vehicles parked on Japanese tarmac under overcast skies.
At this point I should pause to mention that my elaborate personification of my personal vehicle (and likely this cute little alliteration) prompted my mother to declare: “you need a man in your life.”
In Japan, costly road-worthiness tests incentivize disposal of vehicles as early as three years after their manufacture. The result is a surplus of affordable, gently used vehicles available for export to right-hand driving countries. This caters perfectly to the growing African middle class. Japan exports over one million used vehicles annually; nearly 20% of those to Africa. Even after intercontinental ocean freight and lofty duty fees, importing a Japanese vehicle is worth the gamble of buying sight unseen.
At eight years old, my Vito is “Malawi new;” vehicles with a manufacture date of 2007 or later are assumed to have cleaner emissions and thus qualify for the lowest import duty. In practice, emissions are low on the list of the transport concerns; the quality of Vito’s construction, and my driving, is put to the test dodging potholes, pedestrians, and unattended livestock. Occasionally he and I take a late-night spin around the capital, stopping only for a lone hyena to cross our field of vision, illuminated by nothing but headlights.
Every used car has a history. I often wonder about his (the real one, not the entirely fictitious narrative I’ve shared with you today). I’m curious what his previous owner, and the many others like him, would think of his second life south of the Sahara.