Pathfinder Field Journal

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2010 Entries

Beyond Dedication

Tanzania: Friday, June 18, 2010

If asked to choose one word to describe Pathfinder staff and community-based providers, I would say dedicated. And by that I mean, not just your standard going above and beyond what’s required. Sure, many staff work far beyond their 40 hours (I often receive emails from colleagues working late into the night) and all are particularly passionate about Pathfinder’s mission to provide reproductive health care. In the past three years working here, I have certainly seen that regularly at our headquarters in Boston. But it’s even more than that.

In Tanzania, I saw that dedication in a new way. During field visits, it was highlighted by staff and community-based provider’s commitment to ensuring no opportunity was lost to improve the lives of the people we serve. What does that mean? A few examples…

The provider tested many members of the family showing the same compassion with each—from the young boy to his grandfather

Sometimes it can be a small gesture. While observing a home-based counseling and testing visit in Dar es Salaam, I watched as a young boy was carefully counseled and supported through an HIV test. The distress and anxiety on his face was heartbreaking. The provider, who had been trained by Pathfinder, was already sitting quite close to the boy in the small room, clearly wanted to do everything she could to help. She scooted her chair forward so they were nearly knee to knee and grasped one of his hands, quietly consoling and at the same time ensuring that together they would get through this. This small gesture of empathy was touching and signs of relief glimmered on the boy’s face.

A larger gesture soon followed. Later that same day after several more visits, the Pathfinder staff who were with me on the visit debriefed the counseling sessions we observed, acknowledging the positives while at the same time brainstorming solutions to the challenges. Pathfinder has been piloting this home based approach with skeptical public health officials and all involved are working hard to document the model and bring it to scale throughout the country.  During the debrief I learned that the provider, originally scheduled to see a few members of one family, stayed far longer in the neighborhood. So many people wanted HIV tests and she couldn’t bear to leave when there was such demand. The provider’s dedication to helping those around her went far beyond her scheduled visit.

The same was true of Pathfinder staff I visited on other areas of Tanzania as well and included an incredible amount of compassion. In Arusha I met home-based care clients of Pathfinder’s Tutunzane program who shared stories about Pathfinder staff, in their off hours, helping them to the hospital when they were too ill to get there themselves. Or in Shinyanga, I discovered a Pathfinder staff member had assisted a young girl orphaned by HIV who was struggling to deal with sickle-cell anemia, malnourishment, and other challenges. The Pathfinder staff member, along with a neighborhood committee for orphans and vulnerable children, supported by Pathfinder, ensured she made it to the hospital when she was having a sickle-cell episode and established follow up visits to monitor her care at home.  

Our staff are not only Pathfinder staff, but members of the communities we serve. And their dedication to improving their communities is truly inspiring.

On another level I also noted how Pathfinder staff took advantage of every possible opportunity to improve services and service delivery whether in a clinic, or through conversations with providers and government officials. For example, while waiting in the reception area of a regional government official (we were there to say hello and let her know we would be visiting project sites), we happened to see a Tanzanian Member of Parliament. When he said hello as he walked past, our Tanzania staff took the opportunity to stand up, introduce themselves and advocate for increased funding for HIV, family planning and maternal health care. The MP listened carefully, thanked our staff and who knows, might now be more inclined to learn more should a critical vote come up.

I saw this initiative taken again and again—whether with another Member of Parliament we encountered or through conversations with medical staff in the clinics we visited. While walking through a local clinic where many of Pathfinder’s home-based care clients go for services, Pathfinder staff chatted with the clinic director about the needs we had seen in the home visits.

Sure, one could say, that’s part of any Pathfinder’s job. We partner with governments and we work hand-in-hand with service providers. However, what I saw in the two weeks I spent in the field was more than just running through a checklist of what needed to get accomplished. It was an unparalleled compilation of focused determination, deep empathy, incredible respect, heartfelt compassion, and a bit of raw grit. Seeing that intense dedication—beyond dedication—was a stunning reminder of why I love working for Pathfinder and why I believe so many of our programs are successful in truly supporting those we serve.

Posted by Jaime-Alexis Fowler

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Where the pavement ends and HIV prevalence begins

Tanzania: Thursday, June 10, 2010

*Originally this piece was written on May 29th, but due to internet connectivity in Shinyanga was unable to be posted until Jaime-Alexis returned to the States. All videos were taken by Jaime-Alexis.

We set off from Arusha at 7:30 am this morning after being delayed half an hour negotiating boxed lunches for the long drive ahead. Our destination? Shinyanga, a remote region about 600km southwest of Arusha at the center of the mining industry in Tanzania—and consequently health issues as well. Pathfinder implements HIV home-based care in the region which we’ll be visiting on Monday.

‘Belts on?’ Raphael, Pathfinder’s Arusha office driver turned to ask. There were four seatbelt buckle clicks. Then the truck moved into gear with the four of us—myself, Paulo, Pathfinder’s new Arusha office finance officer (we were dropping him off to meet his wife and children for their move to Arusha the following day), Raphael, and Sala Lewis, a photographer coming along to document Pathfinder’s work in Shinyanga—down the wobbly road leading from Arusha. The sky was heavy with moisture and a thick fog laid low hiding Mounts Mero and Kilimanjaro.

We drove for about an hour, Sala and I chatting in the back about Pathfinder’s various projects as Raphael negotiated the bumps and deviations in the paved road. We were moving along at quite a clip and I thought the staff in Dar es Salaam had exaggerated the difficulty of the long drive. Then I noticed the truck start to slow. Suddenly we pitched forward. I looked up and saw the pavement had ended.

Ahead lay only a rutted dirt road. I asked Raphael and Paulo, ‘Will the road be like this to Shinyanga?’ and pointed at what lay ahead. ‘Yes, for many kilometers,’ was the reply.

Yikes. This was going to be a long drive. We bounced and bumped for hours, Raphael keenly navigating the dips and dives of the road. We passed a small town with heavy security—where as it turns out the Vice President of Tanzania was visiting that day and myriad communities, men on bikes, cows being moved to new grazing by young herders, women with firewood stacked high or large water containers on their heads. All quick snippets of life in rural Tanzania as we lurched haphazardly along the drive. 

We turned, and twisted down roads. Suddenly we began to see trucks. We passed the slower ones to get ahead of the dust swells and tried to steer clear of the oncoming ones barreling towards us. One or two here or there on the dirt road. Then, a larger town. And paved roads began again. Now not only a handful of trucks, but hundreds. Large industrial trucks making stops in town for supplies—or a break with a friendly female face.

And suddenly I saw not just the town, but the spread of HIV. If you look at a map of Tanzania, the HIV outbreak is heaviest in areas were industries like mining and truck driving thrive—or ports like Dar es Salaam. The epidemic follows the path of the truckers who wind through Burundi, Tanzania, and Botswana on their way moving goods down and back to South Africa. As these drivers move through communities, so does HIV.

Of course this is not the only means of the virus being spread. However, one cannot help but notice the surge of vendors surrounding the drivers and help but think the world’s oldest industry is not a part of those vendors clamoring for the drivers’ attention.

After 10 hours, we arrived in Shinyanga to be warmly greeted by our head project staff here, Ntungu. Tomorrow we set off to explore Shinyanga and Monday we’ll see firsthand what it’s like to be HIV+ and poor in this remote region of the country—an area that’s severely underserved.

(Also, as a sidenote, part of the purpose of the drive was to transport the vehicle we were in so that the Shinyanga Pathfinder office has a means of transportation to project sites.)    

Posted by Jaime-Alexis Fowler

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What it’s like to be HIV positive and Poor in Dar es Salaam

Tanzania: Tuesday, May 25, 2010

Today I traveled around Dar es Salaam meeting with men and women of all ages who are HIV positive (Dar has a prevalence rate of around 9 percent). Some are those being served by Pathfinder programs, some hope to become a part of a Pathfinder program, and almost all are urban poor. They live in areas with high unemployment—often in one room situations that house multiple members of a single family. Several homes we visited overlook an area where goats roam freely through impromptu trash heaps and the skyline of a major hospital looms behind it. All the occupants faced various forms of stigma and expressed concern for the state of their futures.

Aisha telling her story

During my visits I heard heart wrenching stories. One woman named Aisha (whom I met as part of an HIV support group) told the group that when her family found out she was HIV positive, they wanted to take her children. She told them “No, I can still take care of them, I am their mother.” Unfortunately, she then became very sick and had to be admitted to the hospital. Her family took her children into their homes where the children live still today—despite Aisha now being healthy. She only sees them on the weekends. Aisha knows her family is well-intentioned, that they just want to help her take care of the kids, but she said whether or not she has HIV, she is still a mother and wants to be with her children. Her capacity to forgive and understand her family was incredible.

We were welcomed into homes accompanied by Pathfinder-trained and supported home-based counseling and testing providers. These are professional health workers, who work in the clinics around Dar es Salaam providing counseling and testing HIV patients. As part of Pathfinder’s community-based approach, they travel into the communities after hours to visit homes and provide the same services so that only the recipients’ “own four walls” are part of the process. Why is this so important? Stigma.

While many people do go into clinics for testing or treatment, they will often go far from their neighborhood so they are not recognized. Getting tested in a clinic can be overwhelming and nerve-racking when you live in a society where husbands will disavow wives for testing positive, or like Aisha, you fear losing your children or other valuables due to your status, and where families start preemptively making funeral arrangements.

However the home-based counseling and testing gives hope. The providers kindly walk the client through a series of questions and answers, help them learn more about HIV, and administer a simple, rapid HIV test on the spot so they can learn their results quickly in a setting where they are comfortable.

I have subjected my own arm to HIV testing and know the nerves that can accompany such a gesture. Even if you feel fairly confident of your result, it can still start your mind racing. I left the day appreciating the compassion of the providers, lamenting the stigma that HIV positive women and men face, yet hopeful that given the changes that have occurred through programs like Pathfinders, that being HIV positive and poor in Dar es Salaam is no longer a death sentence, but a manageable long-term disease. 

Posted by Jaime-Alexis Fowler

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Mothers Supporting Mothers in Kathmandu

Nepal: Monday, May 3, 2010

Neither a city nor a village, this peri-urban outpost is reduced to a number – 35. Kathmandu 35, a poor and neglected area on the outskirts of the city, is home to those who migrated to Kathmandu to escape the lack of security in the countryside. Most settled in the slums, because living there is relatively affordable, yet close to the safety and convenience of the city.

On Wednesday, February 10, 2010, in Kathmandu-35, I had the opportunity to observe the first meeting of a newly formed Mother’s Group. In a round concrete gazebo-like structure sat nearly 20 women, some old, some young, and some with babies. All smiled, chatted and waited to absorb new information from three other women: two female community educator/counselors and one female community volunteer. These women explained how future sessions would take place, and led a participatory discussion of postpartum family planning with an emphasis on the lactational ammenorrhea method and healthy timing and spacing of pregnancy.

The community volunteer explained the purpose of the session, asking the group members: “Will you go back to your homes and tell your friends and family what you learned here today?”

“YES!” the women exclaimed.

The community educator/counselor had been trained only three days ago by the Nepali Technical Assistance Group, yet were beaming with confidence. The Nepali Technical Assistance Group (NTAG has been working in areas like Kathmandu-35 since 1993, focusing mainly on Vitamin A distribution and community mobilization. NTAG began work in community-supported reproductive health and family planning (RH/FP) in 2007, with support from the Extending Service Delivery (ESD) project. Through its partnership with ESD, NTAG established nine Mother’s Groups in Kathmandu-35. At least one community volunteer and one or two community educator/counselors, trained and supported by NTAG, facilitate each Mother’s Group. The community educator/counselor teaches the group of mothers from the community to identify, through a household network, new mothers in the community within approximately 24 hours of giving birth. The community volunteer is then responsible for providing information to the new mothers on the benefits of breastfeeding and family planning to promote the healthy timing and spacing of pregnancy (HTSP). Mother’s Group members are also educated on the benefits of the lactational ammenorrhea method (LAM) and HTSP, so that they can spread the knowledge they have learned to other women and couples in the community.

The community educator began the activity by taping a sheet of paper, with HTSP written in Nepali at the top, and a horizontal arrow in the center. She then taped a laminated photo of a woman with a newborn baby on the arrow at the left side of the sheet of paper, or start of the timeline.

“This woman must wait two years before attempting to get pregnant again,” she said.  She then taped a laminated photo of a two-year-old boy at the other end of the arrow, at the end of the timeline. She asked the mothers: “How long must she wait until she gets pregnant again?” They responded, “Two years!”

She explained that this woman could use LAM to prevent pregnancy and provide nutritional benefits to her baby until the baby is six months old. Next, she tapes up a photo of a woman breastfeeding an infant, following the photo of the postpartum woman with the newborn. She explained the three conditions of LAM and asked the group members to repeat the conditions. They listened attentively and replied with the correct conditions, clapping, smiling and offering their complete attention. The community educator then put up a photo of a crawling baby and said that after the baby is six months old, the mother must switch to another contraceptive method to avoid getting pregnant too soon. As she explained the available methods, she displayed small laminated cards with the name and image of methods between the photos of the six-month-old and the two-year- old.

She asked a shy and tired-looking young woman to come to the front who had recently given birth. The community educator/ counselor wanted her to be especially aware of available postpartum family planning methods, handing her one of the cards for injectable methods and asking her to place it on the timeline.

Closing the session, the community educator/counselor explained the basic concept of the Mother’s Network: each mother in the group is responsible for at least five homes in her community. This means that if a female member of any of those five households gives birth, she will inform the community volunteer. The volunteer then knows to visit this home to provide postpartum counseling to the woman who has just given birth. The second community educator/counselor then explained a few forms and a log book the mothers would fill out during the next meeting. It is important to involve the mothers in the process and keep them informed as this increases their willingness to participate.

In Nepali culture, song and poetry is often used to share stories and information. In a matter of moments, the community educator/counselor spontaneously started singing a jingle about HTSP and the mothers quickly joined in. She then reviewed the HTSP messages and “slogans” on a large sheet of paper taped to the wall, having them repeat each message after her. The women seemed focused on the information, and eager to learn and participate in the education process.

After the session ended, I got a chance to speak with the women. I asked them what their husbands thought of their participation in this group. “They approve; they sent us here!” a few of them said.
The women need permission to attend these kinds of events from their husbands, so the husbands must allow the women to participate, the NTAG official explained. Both the women and husbands like the HTSP messages and understand the importance of protecting the health of the mother and baby, he said. This became clear as I observed the enthusiasm of the group.

The mothers in Kathmandu 35, a tight-knit community bound by shared experiences of resettlement and poverty, seem eager to promote the health of its women and families. I felt privileged to be a part of this for just one day and to see the excitement these women expressed. Through basic health education about HTSP, they are given the opportunity to actively support other mothers in their community to better care for themselves and their babies.

Posted by Kristen Stolka

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Empowering Public to Save Indonesian Women and BabieS

Indonesia: Friday, January 29, 2010 

 A day in the obstetric ward of Indonesia’s Tangerang Hospital is filled with the same sense of urgency as its home city, the congested, ever-mobile streets of Jakarta. Every other hour, a woman comes in needing a life-saving procedure. In one day, a midwife can assist 10 or 15 emergency deliveries-severe bleeding, ruptured membranes, retained placenta, pre-eclampsia, shock. They come by car and bus, with family members, friends or community midwives.

Most of the women referred to Tangerang Hospital, which is located on the outskirts of Jakarta, are poor and arrive to the ward straddling a tenuous line between life and death. Their conditions need to be managed within a six-hour window. After journeying from one, two or three hours away, Tangerang’s staff has only an abbreviated moment to save their lives.

These women are not alone. Every day, women risk their lives to give birth in developing countries around the world, because the services aren’t there to help them through their pregnancies safely.

This is why the Extending Service Delivery (ESD) Project runs programs that counsel women on the healthy timing and spacing of pregnancy and family planning, and invest essential resources in maternal, newborn and child health.

Indonesia is part of the project’s initiative in Asia and the Middle East, which offers very small grants, usually of $50,000, and limited technical assistance, to empower countries to save their women and babies. In most cases, ESD awards a local NGO the grant, and helps the organization to spread chosen best practices across the health care continuum by planning the expansion and involving a network of key stakeholders.
Because of this program, Tangerang Hospital has cut the number of women dying in childbirth by two-thirds, and the number of newborn deaths by almost 50 percent in a little over a year. It has emerged as a shining star, a model for care, and something the Indonesian government will try its best to replicate in the years to come.

Through replication and spread, the government will try to curb maternal mortality rates. Although there are fewer women dying in childbirth now than there were four years ago, Indonesia still suffers from one of the highest rates in Southeast Asia.
Indonesia’s JNPK - the ministry of health’s prime health training organization - chose Tangerang Hospital as the demonstration site for improving emergency obstetric and neonatal care, in a large part, because it expressed a great and dire need for the training.

A Typical Day

An amalgamation of young women with swollen bellies lay gaunt and fragile about the Tangerang Hospital maternity ward, awaiting care. A glance through the door of the postpartum room revealed rows of women, most looking younger than 20, recovering side by side without their babies. Some had lost them. Others were waiting for them to receive care in the emergency neonatal ward.

Damayanthy, a slight woman with long narrow eyes and delicate features, was one of them. Inside her womb, her baby was trying to come into the world feet first. Entry by butt or foot often results in the baby’s head getting trapped in the mother’s pelvis, or its oxygen supply getting cut off. Despite the risks, Damayanthy’s husband and mother-in-law wanted her to deliver “the natural way,” as she had during her other births. While the doctor tried to convince the family members about the necessity of the cesarean section, Damayanthy, by a miracle of her own making, brought a healthy baby into the world.

Like most of Tangerang’s patients, Damayanthy came to the hospital because she could not afford private care, and her delivery was not going well. When she was shuttled off to Tangerang for treatment, Damayanthy did not know what to expect of hospital care. She delivered her first three children - ages 9, 7 and 5 - at home with either a skilled - or unskilled - birth attendant or a community midwife, as 67 percent of Indonesian women still do.

Seventy million people in Indonesia continue to live below the poverty line. For them, access to life-saving health services is extremely low. Improving their access to emergency care at government facilities is integral to bridging the gap in services between the rich and the middle class, and the poor.

To transform Tangerang, JNPK trained hospital providers, community midwives and primary health care physicians to better manage complications through the timely referral and stabilization of emergencies, monthly on-the-job trainings and randomized competency-based testing. Community midwives and primary health care physicians were also taught newborn resuscitation techniques. Other best practices included placing partitions between hospital cots to enhance client privacy; developing an ER triage system that sends women straight to the delivery room; and various infection control measures. The ministry of health donated new emergency equipment.

None of this would have been possible without the commitment of ESD, and the international community to a “zero tolerance policy” for maternal mortality. This international agenda pushed the Indonesian government to launch its Making Pregnancy Safer Campaign, a national policy that prioritizes the health of mothers and newborns, and commits the government to trying to meet Millennium Development Goals 4 and 5 by 2015.

The government launched its “Social Safety Net” program last February, offering free care to women delivering at public facilities if they are classified as poor by the Indonesian government. Previously, deliveries ranged from $50 to $80 each. In 2009, more than twice as many women came to Tangerang Hospital for deliveries than during the previous year.

Indonesia’s public health community has realized that expanding improved emergency care across Indonesia is not just an ideal, but is feasible and mandatory. JNPK is now poised to train providers in three more hospitals, and surrounding communities.

Posted by Laurel Lundstrom

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