Daniel Hodson is a 2014 GHDI graduate and fourth year Peace Corps Volunteer serving in Medina Yoro Foulah, Senegal.
Fifty nine confirmed cases of malaria in November 2011.
What caught my attention was that these fifty nine cases were recorded during only nine days.
During the other 22 days, this home based management of malaria (HMM) provider lacked medicine, tests, or most likely, both. Having lived in a small, rural village for over two years and engaged in a range of malaria education and prevention activities in the village setting, the unavailability of first line tests and medicines was nothing new and not surprising. I had taken to describing periods with supplies as stock-ins rather than periods without supplies as stock-outs to emphasis the true status quo of those years.
What was surprising was the clinical burden reported by this community health worker (CHW) during the nine days he had the ability to test and treat (and therefore detect) cases.
October 2012 : 88 cases, 19 days.
Like the artisanal gold miners much farther to my east, I felt I had unearthed a treasure, and even amidst the innumerable lessons and countless breakthrough moments, exploring this community health worker’s consultation register proved an early, formative discovery, revealing a huge, unrealized potential to treat malaria cases if supplies were made available.
While it took perhaps a single hour to open the register, dialogue with Ndiery, and arrive at that realization, the task of ensuring adequate supplies for not just one HMM provider, but for all the 113 health facilities and community health workers in our district is far from finished sixteen months later.
As a Peace Corps Volunteer, now in my fourth year of what I am told is usually a two year contract, I am grateful for our unique role and perspective. A foreigner, but speaking a local language; well integrated into the health system, but not actually a part of it. The delicate dance means that through building relationships, I have had the opportunity, freedom, and privilege to work with every level of the health system from community health workers to health post staff to district leadership to national level decision makers. Sometimes I feel my role is simply to serve as a bridge among the levels, making the rural reality salient to higher levels and helping deliver the resources back down the hierarchy.
These communities have been my home, these patients my friends and neighbors, and the local staff my colleagues and mentors.
Too often, I sense the gaggles of international experts, NGO staff, or even national level staff from the capital cast local staff in the role of “other”. Peace Corps service gifts a different perspective; these communities have been my home, these patients my friends and neighbors, and the local staff my colleagues and mentors. I can describe to you the challenges of traveling to the health post to retrieve medicine, because I biked those paths myself. I can tell you the frustration of mindless paperwork, because I have stared eyes glazed over at those same forms. I can lend you insight into the thoughts of local staff, because they have voiced their honest minds to me in their native tongue. I will quickly describe the problems at each level, but I will also just as quickly defend the individuals at every level who work harder than I ever have, and who endure the system longer than I will ever be made to do.
Local language skills, intimate integration into the local community, and relationships built on common respect and trust have formed the basis of my Peace Corps service from the very beginning, and I hope these values will endure in my character beyond my finite time as a Volunteer.
Stock-outs and stock-ins
Though the task of delivering tests and medicine is a never ending process, we have made progress.
01 September 2013, I visited the HMM provider in Sare Moussayel, which sits just off the Gambian border in the far north of the catchment area of the health post of Badion in the health district of Medina Yoro Foulah in the region of Kolda in the southern half of Senegal, West Africa. It is a rural village centered on subsistence agriculture, and while the residents may sometimes make the 25-30 kilometer trek to Badion for government affairs or its health post, they carry Gambian currency, use a Gambian cell phone carrier, and process their grains on the Gambian side of the border.
Similarly to my visit to Ndiery a few months earlier, Yaya showed me his empty medicine trunk and official messenger bag, and we discussed the history of his work since he was trained in 2010. He tested about 35 patients that year; that is to say, he received about 35 tests. In 2011, he received at least two boxes of tests (50 total), and his records show he treated about 36 patients from mid-August to mid-September.
In 2012, he did not receive any tests or medicine, and there I was on the first of September in 2013, and Yaya had yet to receive any supplies.
Before I moved on, Yaya asked that we call some of the villagers together to do an informal training on malaria. Towards the end, as often happens, one man spoke and finally brought the prosaic discussion on point.
There are many problems, he said. The health post in Badion is far, and the roads are very bad (sand bush paths or pot-hole ridden dirt road). But people know malaria when they see it, he added.
I tried not to betray an audible sigh, for the man was of course entirely right on all accounts. I had encountered his comments, or similar ones, during many of the group trainings and home visits I had conducted in 2012. It is nothing short of awkward: You teach people about malaria when they have lived it their entire lives and know far more than you. You tell them to go to the nearest health facility; they tell how far it is and how difficult the transportation. You tell them about treatment options; they ask, buy western medicine with what money? You tell people some medicine is actually free (like first line antimalarials in Senegal), and they tell you it is never available.
The man highlighted what I had already learned; the main issue is poor delivery by the health system, not (lack of) education on the part of the villagers. Rather than the need for these villagers to change their beliefs or behaviors, I constantly saw the need in places like Sare Moussayel for higher level staff to reverse their affinity for the error of fundamental attribution and to change the broken system that had been failing to deliver supplies to villages like Yaya’s.
If they tried to take a sick person all the way to Badion, he said at one point, the patient would die en route. The government should build them a health facility in their village.
As demoralizing as the routine can be, this time at least I could draw their attention to a point of progress. You are right, I replied, and the government has recognized that you are far from the health post and in need of a health facility. Actually, that is why Yaya was trained way back in 2010, to identify, test, and treat simple malaria right here in your village. The only problem is…..
……he has had no medicine.
While in my first site in 2012, I was not in a position to do much of anything to address the issue(s). This time, as I was just beginning to disentangle the chains of supply that needed to deliver Yaya tests and medicine, I hoped (wondering if it was even possible) that I might one day return to Sare Moussayel and find Yaya well stocked with tests and medicines and treating patients.
Over the course of the following four months, we worked to procure a sufficient amount of tests and medicines for our district and to deliver these supplies to all levels of the health structure, from the district health center right next to the district storeroom, to all the health posts, to all the health huts, and even to HMM providers like Yaya.
In January, I personally collected and reviewed the consultation registers of all 95 CHWs who had received supplies in 2013. For Yaya, his record showed far more days in rupture than with stock, so like I had seen with Ndiery six months earlier, all we saw was the potential:
Yaya received twelve doses in September and used them all in a single day.
Fifty three doses in October lasted only three days.
Sixty six doses in November lasted nine days.
In December, as peak season ended, he finally received enough supplies to cover the then declining need and treated 71 cases in 24 days.
In 2013, the district had endured a violent spike in malaria clinical burden, and for well frequented sites like Yaya’s, there seemed to be no ceiling to the need for supplies. The number of cases tested or treated literally only reflected the number of tests or medicines he had available to use.
In the spring, I scoured district records, obsessed, one might say, with finding enough information to better estimate our needs for the coming year and to more convincing justify our very real need for seemingly ridiculous quantities of tests and medicine. Fooled once, yes, but I was terrified to fail to avoid for a second time the kind of situation Yaya had experienced in Sare Moussayel.
In June, the district medical director and I presented to the National Malaria Control Program (NMCP) on the dynamic of malaria in our district, the true burden for which we now had evidence, and a new way to use facility based records to generate population based estimates of clinical burden. We used Sare Moussayel as one example of a community site with the potential to treat hundreds of patients over the course of a season. The NMCP appropriated us the largest quantities of supplies ever promised to our young district, enough we hoped for all of peak season, and so the task fell back on us to properly procure and distribute these supplies.
In July, I took home leave for the first time since joining Peace Corps in October of 2010 to complete the Global Health Delivery Summer Intensive at the Harvard School of Public Health. I learned to describe our task as needing to deliver supplies to a specific, underlying epidemiological need, rather than the drastically muted and superficial demand, noting how neither the need nor the demand had been satisfied in 2013.
In September, we distributed large quantities of supplies to all our health posts and included detailed instructions on the quantities to pass along to each individual community site. Because Yaya used his supplies so quickly in 2013, I struggled with my minimal math skills to generate any kind of reasonable, empirically derived estimate of the number of cases Yaya might be expected to treat in 2014.
In the end, my list of estimates for October and November reads 253 for Sare Moussayel.
In October alone, Yaya treated 240 cases.
What caught my attention this time was not the number of cases, for we had learned the potential was there all along, but how the number represents that Yaya actually had enough supplies to test and treat over two hundred cases in a single month.
23 November 2014. I finally stole the time to get back on my bike and check in with some of our community sites. I rode the 30 or 40k to Sare Moussayel and found Yaya just leaving the new health hut to head home for lunch. As of the 23rd, he had treated about 170 cases in November, and with 59 cases in the last 7 days, his caseload had not yet shown the sharp decrease that signals the wane of the high transmission season. But this year, there is less panic; I remind him we had already sent a large carton of tests and medicine to his health post earlier in the week; he tells me he had already been planning to head to the post for more supplies that very evening. Among the intangible points of progress this year, one might dare to sense a hint of trust or confidence sneaking back into the system.
In a kind of disbelief that the malaria burden could actually be that high, the running hypothesis around the district had been that Yaya was drawing a large number of Gambian patients, given his proximity to the border. Of the 59 cases in previous week, 20 were from his village itself, 57 were from other villages in the catchment area….and only 2 were from the Gambia.
Counting malaria cases, forecasting future cases, translating estimates into specific needs for specific sites, and physically moving these supplies from point A to point B – I have learned these to be very complicated tasks, no less so here in the southern half of Senegal.
Intense doubt is common. I constantly wonder and worry if I am doing anything right at all. And I regularly feel entirely lost. But, I try to draw motivation from the progress in places like Sare Moussayel and in the character of health workers like Yaya.
If supplies had not been delivered all the way to Sare Moussayel, what would have happened to the hundreds of cases Yaya has treated this year? A few patients would have surely made the long trek to Badion, many would have sought treatment in The Gambia, some would have endured the bout and taken another step towards partial immunity, and surely others would have died right there in their homes, never knowing how simply they could have been treated and saved.
Sare Moussayel is only one (albeit our most dramatic) example; at this writing, there are exactly 100 community sites throughout the district.
It can be hard to avoid the trap of seeing only numbers or indicators or points on a map, but it behooves us to always remember that these are real people in specific places with unique sets of resources, challenges, and needs, each with his or her own story.
In our district, I have been graced with the opportunity to travel to many of these places, to meet many of these people, and to learn many of their stories. It has been a privilege in equal proportion to share a meal or the mattress with villagers, community health workers, health post nurses, district leadership, and our district medical director and to share ideas with national level staff. The district first welcomed me with far more respect and trust than I had earned or deserved, and throughout the ensuing hundreds of solitary kilometers biked around the district to asses the status of the district’s stock or to confirm the arrival of tests and medicine, or during the quiet, yet anxious all-nighters to crunch numbers or divide up supplies, it has been an honor to finally have the opportunity to directly address one of the most limiting factors to health care delivery in southern Senegal and to give directly back to my host district.
Each rainy season changes the landscape dramatically. I may share with my host district a few moments, but the true heroes in this one particular story are the doctors, nurses, and community health workers who will live, work, and die right here, where my footprints will be so quickly washed away.
The contents of this blog reflect only the opinions of Daniel Hodson himself and do not reflect any position of the United States government or the Peace Corps.