Had to Comment on the Healthcare Here - November 24, 2015

Today a mystery was solved!

In the brief phone conversation I had with the Selamta Executive Director right before I boarded my plane in DC (here), I failed to mention her true sign off line: “Oh…we learned last night that Yohannes is in the hospital. It says it was for ‘stomach surgery’…so we assume that means appendicitis – but could you check once you arrive?”

Considering I went straight from the Kigali airport to a wedding when I first moved to Rwanda (check it out here), the request to go to the hospital right when I landed wasn’t too far out of the ordinary. So, after the initial money exchange and errands, down I walked to the Bethel Teaching Hospital with Abel.

[Side note to mention that the hospital was in better shape than I had expected. I didn’t want to take any pictures there – so sorry, but it was a 5-story building with a winding ramp up the center atrium – all pristine white and reasonably organized. Inpatient was on the 5^th floor (well – I was misled – they said it was on the “4^th floor” but then my post-plane, sea-level altitude acclimated self almost cried when we walked up one flight and I saw a sign that said “Floor 1”.)]

In the inpatient unit, there was a chalkboard with the patients’ room numbers, names, diagnoses, DOB, etc. It seemed very similar to a US hospital (I’m not sure they need Hospital IQ yet) – Yohannes was listed in room 404 (LIES – really 504) and with a “Perforated PUD”.

STOP. Put yourself in my shoes and do not Google the answer. Because Google was not available to me at the time. Does a “PUD” in a foreign country that doesn’t even use the Roman alphabet for its native language look similar enough to “aPPenDix” that you’d agree with what you’ve been told? That the patient had appendicitis?

Med school students – I feel your judgment. I don’t care. You’re the profession that's most likely to suffer from #confirmationbias

Yohannes was unsurprisingly holding court from his hospital bed (maybe this is surprising since you have no idea who Yohannes is – but let me tell you – it’s not surprising). He had about 5 visitors when we arrived and there was a steady flow of visitors throughout the miserable 1.5 hours that I was there.

Why were those 1.5 hours miserable? Because I had arrived at 8am (midnight EST) after ~no sleep during my 16 hour flight and I was sitting on a hard chair in an Ethiopian hospital surrounded by people who didn’t really know English and whose focus was the kid recovering from surgery in an Ethiopian hospital – not the white girl sitting on the side.

At one point, this very confident woman showed up. She walked right in, pulled his chart off his bed and started flipping through it. Then she inspected his IV drip and drainage bag (stuffed into a black plastic bag, tied to the side of the bed), felt for a fever, and started saying something to his mother. Of note – she was also dressed up all nice and had her nails done and hair styled perfectly. I figured she was a Selamta kid who was in nursing school – and looked down at my dirt-laden nails and travel outfit with shame – and started regretting my career path – why do I have such useless skills? How will I ever be able to help anybody with Excel shortcuts and “leadership”??

Okay – let’s bring this back from my existential crisis – I also figured that if she was in nursing school she probably knew English – so I went for it and asked her the diagnosis.

Boy, did she know English. She rattled off her response. I again caught “perforated” and a word that had some P and D sounds. It wasn’t appendix but I wasn’t exactly sure what it was. I decided it was a fancier word for “spleen” because – that’s in that part of the body – and also has a P.

DON’T GOOGLE! Do you remember from 7^th grade biology what the spleen does? Yeah, I didn’t think so.

Anyways, I nodded along and pretended I understood everything she was saying. Especially after we exchanged some greetings and I learned she’s the actual nurse for Selamta and I told her that I work at “a pharmacy” in the US (no introduction has ever been more misleading – she probably assumed I knew exactly what she was talking about).

When I remembered to Google it later, I searched for “ruptured PED” – which isn’t what he has but returned enough search results about a medical thing (a pipeline embolization device) that I #confirmed my assumption that “PED” was just some inexplicable Amharic-to-English acronym translation for spleen or appendix.

My mother was very concerned when she arrived today and asked me what the diagnosis is. Apparently a “ruptured spleen I think” is a VERY BIG deal. She went straight to the source of the nurse, where we got MYSTERY SOLVED: the patient had had a ruptured ulcer in his stomach (peptic ulcer disease)!

Unfortunately, this wasn’t actually joyous news – because like a ruptured PUD is a much, much worse diagnosis. But at least…now we know?

PS – Wonder if my time spent in a hospital allows me to bill this as a “work trip”?

Girl Power - November 23, 2015

I have a confession to make: for all that I love and support female equality (especially in developing countries), I have a difficult time discussing it (especially in developing countries). Which is why I think that one woman who I met this week is so incredible.

On Monday I had the pleasure of visiting the two main schools that Selamta kids attend: the local Alpha school and the distant magnet-like Yeha School of Science and Technology.

During my visit to Alpha, my (female) guide just happened to mention the bathroom process – because we passed a group of boys sprinting back to their classroom from the bathroom. Everywhere you look in the literature about female equality in developing countries, you see references to girls who stop attending school when they start menstruating. The topic was there…I didn’t even have to bring it up: all I had to do was ask how they handle the bathroom process to make it easier for girls on their period. And yet, something about me felt too awkward – questioning “What if she doesn’t have a good answer? What if she doesn’t understand the question? What if she’s offended I bring up menstruation?” – so I held back.

Sorry for the teaser: neither me nor that female guide is the incredible woman I met this week. I met HER at Yeha – the school we headed to after Alpha.

This girl is also not the incredible woman that I met this week - but damn - isn't she beautiful? This was taken during a 2nd grade English class at Alpha. After the initial giggles when I walked in with my guide, most of the students went straight back to the lesson - it was incredible how they were all so eagerly engaged! Except for this one girl - she did not take her eyes off of me - she wanted to make sure she knew what was up!

Yeha is a Science and Technology school about 30 minutes away from Selamta. Twelve Selamta kids started attending this year. Given the distance, requisites, tuition, etc., it would be impossible for all Selamta kids to attend Yeha (and admittedly, of the 12 there, some aren’t too happy about it because they had been going to Alpha for ~10 years), but the school is AWESOME. The Director showed me chemistry/physics/biology labs, a computer classroom, and an IT lab (where they deconstruct computers) – and we didn’t have time to go to the biodiversity farm across the street! The halls are covered with educational posters and pictures of world leaders who have visited the school. And there’s a bunch of tortoises on the school grounds that are raised by the Kindergarten class every year.

I couldn't get the best pictures at Yeha because the classrooms/labs were locked (we got there after the school day ended) - but this "tree model" for Global Impact pretty much captures how all the hallways looked!

Doesn't this pictures just make you want to go back to school and learn??  

Anyways, as we were leaving, we ran into the elementary school English teacher. None of the Selamta kids at Yeha are in elementary school so she was unaware of the program. As we explained to her the Selamta model she said “bless your hearts” and then jumped straight into asking:

“How many of your 12 students here are girls?”

I did not know – but I learned that the answer is three.

“That is not enough. Girls need to be studying science and technology. You need to send more girls here.” And she didn’t give up – she asked me if I could come back to speak with the girls in the school about what it’s like to be a woman in science (disclaimer: I have had a hard time correcting people from thinking I’m a pharmacist #cvsproblems) – she told me that she has a Girls in Science Club.

And all the while I was kicking myself for:

1.       Not having nearly as much courage as she has – I didn’t even feel comfortable asking the guide at Alpha about female menstruation

2.       Not having asked myself at Selamta about the breakdown of girls who attend this school (but don’t worry too long about that part – I made sure that the point was not lost when we got back in the car)

Reflecting on this encounter brings a smile to my face. I am so happy that the local drive for female equality exists – and I am so happy that the girls at Yeha have this woman as a role model!

PS – I would be remiss to not mention two other points about #feminism with this Girl Power post:

1.       In every single house that I have visited, the girls have been preparing the meals while the boys basically hang out. I do keep on asking the boys if they ever cook and they do keep on telling me that “yes they do” (so they’re not embarrassed to say it) – but I still haven’t seen it L

2.       I visited Axum House tonight with my parents – I might ask my mom to write a guest blog post about the Axum mom because she’s seen her grow since her very first day at Selamta (when she didn’t even know Amharic!) to the strong, proud mother she is today!

Nerd Fail

My not-so-big confession about living with an MIT alum is that I am always conflicted between teasing him for being such a nerd and fighting feelings of inferiority for not being a nerd on nearly the same level. Example:
Perhaps you remember the story about my iPod blaster breaking ~5 seconds after I plugged it into the 240W outlet. Whoops. After telling Marvin of this sadness, he took it from me and told me that he’d fix it. A few weeks later, I saw parts of it lying on his bed. It looked impressive. I asked him how it was going.

“Oh yeah…I’m not sure I’m going to be able to fix this…I think my ammeter might be broken.”

External response: “You brought an ammeter with you from the US? …

Internal response: “That’s so cool! I can’t believe he has such confidence about fixing this! I can’t believe he thought ahead to bring an ammeter to Rwanda! I totally wish I thought it was fun to play with ammeters – then I might have similarly been heavily recruited by Goldman to work on their electronic trading systems! Marvin’s so cool!”

External response cont’d: … Nerd.”

Sometimes it’s too difficult for me to hide my jealousy or, rather, my competing nerdiness. Such as when Marvin starts discussing Macros and I can’t hold back: I just want to learn how to use them, so I start peppering him with questions while the rest of the staff, who got lost at “open Excel”, put their headphones back on.

Most recently, Marvin made a comment about the keyboard set-up that he uses: it’s designed to be more efficient than the standard QWERTY keyboard.

Here’s my moment of nerdiness: I HATE QWERTY keyboards! …and most other people don’t know what they are… (They’re standard keyboards that have “QWERTY” in the left of the top row…look down.) Talk about stupid inefficiencies and conforming to industry standards – did you know that QWERTY keyboards were PURPOSELY MADE TO BE INEFFICIENT? And yet here we are in the age of technology and efficiency…still using the damned things. Literally, they were designed to slow down typists by placing frequently used letters in awkward locations because typists were typing too quickly and kept on jamming up the type-writers. (On that topic…I also hate using 2 spaces between sentences, because that practice was initiated for the same reason.)

Back to the office…

So when Marvin mentioned his more efficient way of typing, I was quite ecstatic…even though this was obviously another example of how my JV nerdiness (knowledge of how inefficient QWERTY keyboards are) compares with his Varsity nerdiness (installing a more efficient keyboard on his computer to address the inefficiencies of the QWERTY keyboard). While everybody else passed us the judging looks that are usually associated with our conversations about decision trees and HTML script (check out www.wwhps.org – my newest pride is the “Our Model” section), I scrambled over to Marvin’s workspace (consists of 4 computers) to learn how to download this magical keyboard onto my computer.

Oversight: Despite being designed to be inherently more efficient, my new keyboard (the “Dvorak” – as compared to Marvin’s “Colemak” keyboard, which is designed to be more efficient for programmers who use symbol keys more frequently) forces me to write at about 10wpm because surprise-surprise I haven’t been using it for 10 years and don’t naturally know where the keys are. (Although it is a little fun to guess, based on how frequently the letter is used, where it should be on the keyboard – especially given that I didn’t re-label the keys when I made the switch.) Compare this with trying to pick up a new language, whose grammar rules make more sense than the crazy rules in English, in a day – expecting it to be natural because the language is supposedly easier. Yeah…I’m pretty stupid.

I struggled through one night of typing lessons, a few painful g-chat conversations, and one page of the 25 page Annual Report before giving up, giving in, and making the switch back to QWERTY.

Today, Marvin asked me how my Dvorak was going.

“Yeah…” I told him, “…I’m back to QWERTY…It was just kind of hard to make the switch when I had so much work to do.”

“Oh,” he said, “yeah…well I did do it while working 90+ hours a week at Goldman, but I guess I understand.”

Obviously, there was only one response for me to fall back on at this point: “Nerd.”

Mother Child Week

Last week was “Mother and Child Health Week” throughout Rwanda. Which contrasted nicely as I was “reading” (ie – listening to) Jodi Picoult’s House Rules on my iPod.

Let me flesh out that comparison:

Mothers, potential mothers, and children under 5 receive amazing healthcare in Rwanda. Absolutely all preventive visits are free, even without insurance. Community health workers are employed to track pregnant women and children: to give the women vitamins and mosquito nets, to track the children’s growth, to remind the mothers of vaccination appointments at the health center. During Mother and Child Health Week, these efforts are multiplied…let’s just say tenfold as a hyperbole.

This focus on mother and child health has produced impressive results: its maternal mortality rate was 383/100,000 in 2009 – down from 750 in 2005 and much more impressive than the 440 in and 560 in neighboring Uganda and Kenya, respectively. Similarly, under-5 mortality is down from 152 per 1,000 live births to 103 – much less than the 130 in both Kenya and Uganda.

These results do come at a cost. Health centers are pressured/forced/required to achieve 100% vaccination coverage – under threat of not receiving vaccinations the following year if they do not. According to herd immunity theory, only about 85% of a population needs to be vaccinated against a disease for the others to be protected from it. Yes, these vaccines are free for the recipients (under 5), but they do come at a cost to somebody/something. I wonder if it’s the best use of NGOs’ monies to demand – and then pay for – 100% vaccination coverage, when 85% will do the trick.

(A particular frustration of mine is that vaccines are free only for children under 5. Rwandans must pay for – and most insurance does not cover – booster vaccines (tetanus for example) or annual flu vaccines. The international focus on the “under-5 mortality rate” has seemed to decrease national focus on the under-10, under-15, or “preventable” mortality rate. I wonder if aid money could be better spent vaccinating 85% of children, and also providing discounted vaccinations to the older population.)

In Rwanda, it seems, that the only reason a child would not be vaccinated is because the health center is too far away, or because the vaccination day falls on a particularly lucrative harvest day/market day, or because the mother forgot the appointment (hard to keep track of these things when your society doesn’t use calendars).

And finally, the connection to House Rules…a book (so far) about an autistic boy. Being about an autistic boy, the point of vaccinations causing autism is obviously discussed. In the US, it seems, there are 2 reasons a child would not get a vaccination: the mother cannot afford it, or the mother has the luxury of choosing to not vaccinate her child, for fear of autism. And given public school requirements…it might actually only be the fear of autism that keeps children from receiving vaccines.

And I laugh. Because this seems to quintessentially capture the difference between Rwandan culture and American culture. While Rwanda struggles to achieve its goal of 100% coverage, trying to overcome the hurdles of distance, ignorance, and enforcement (when you’re also struggling to get 100% attendance at primary school…do you really want to add requirements – such as vaccination – in order for them to attend?), Americans struggle to avoid vaccination requirements – by enrolling their children in private schools, or fighting lawsuits.

I did make the point earlier about herd immunity – so I don’t think that these “overly-protective” parents are putting other children at risk by not vaccinating their children (unless the over-protective ones start to exceed 15% of the population). But I just had to smile, when the argument against vaccinating a child came onto my ipod, as I was tallying Shingiro health center’s vaccination coverage rates (94% in 2009!) because it is…so…American…to fight vaccination.

Dear America, I miss you.

English Lessons

(Straight from my blog posting at wwhps.org)

Name: Eli(zabeth) Mitchell

Position: Data Manager, Communications Coordinator

With CCHIPs Since: August 2010

When I started looking at opportunities to volunteer abroad after college, I had one criterion to follow: I did not want to teach English. (Okay, I actually had many others that led me to realize that CCHIPs was the best opportunity for me – but not teaching English was a pretty firm standard I set for myself.) Even though I loved teaching ESL when I worked in Mississippi, I felt that teaching English in a foreign country only helped arm people with the tools needed to leave that country – quite counter-intuitive to development.

Rwanda’s recent adoption of English as a national language, however, creates a need for English teachers, even among individuals who want to work in and help develop Rwanda. This, paired with the motivated nurses at Shingiro and Kabere health centers has created the ideal teaching situation: the nurses are motivated to learn English in order to understand official documents or official presentations, which are increasingly done in English; I am happy to teach them because I know they will be able to use it in their current jobs – and because teaching brings back great memories of coaching lacrosse or of teaching at St. Paul’s School’s summer program.

So every Tuesday I head to Kabere Health Center and every Wednesday to Shingiro Health Center. Following Dr. Nathalie’s medical training, I commence an English lesson. As I already said: these lessons are quite ideal for any teacher. Unlike others who might be teaching English to a large group of unmotivated and distracted 11 year olds in an overcrowded, hot, and loud classroom – I teach to a mature group of motivated nurses who all take notes and ask questions and try to practice their English as often as possible. Even after the lesson, in the car ride back to town, they will continue to try to converse in English and are unafraid of pointing at objects to ask what they are.

Although I’m not quite sure where English lessons “fit” into the CCHIPs model of developing rural health centers, I am happy that I have the opportunity to work at Shingiro and Kabere each week, and to interact with the nurses. Their eagerness to learn, during English and during Dr. Nathalie’s lessons, and their good spirits during the car ride home serve as my weekly inspiration for my work, and a reminder of its importance.

Highlight of the Week: The Ministry of Health announced that they will adopt the CCHIPs Management Organization Structure in all health centers by March 2011! CCHIPs will work closely with the MOH between now and then to finalize position descriptions for managers and ensure that both groups are approve of the finalized organigramme.

Best Meal of the Week: Toss-up between Marvin’s pre-melted double-grilled cheeses and the cookies I baked last night. 

Biomass Expert and Political Target

I think that when my public policy group decided to do our project on the standards of biomass boilers in New Hampshire, we all secretly believed that it was the least politically polarizing topic of the given options. Little we were expecting to find ourselves in a political bloodbath* a few months later. Even more, the side that was tearing us apart was the side that we all personally agreed with.

I had flashbacks to when I received that email tearing apart our biomass boiler presentation when I walked into the District’s data manager’s office earlier this week…because who ever thought that adding and dividing some numbers to put into a 6 month report could be so politically controversial. Let me rephrase that, given that the 6 month report was written before I even started here, all I actually did was make sure that numbers in it looked pretty and matched each other. But when I walked into the data manager’s office, I was bombarded with questions and accusations about how we came up with our numbers in the report. In a panic, I pulled out my computer and started clicking through the 10+ tab interlinking Excel sheets that Lauren had meticulously created months ago, explaining away why we used certain denominators or numerators or absolute values instead of relative values in as simple English as possible to a group of people that doesn’t actually understand English and all the while realizing that at least it was a good learning experience for two reasons:

1.       Listing assumptions is really important – especially when somebody is forced to explain your calculations 4 months later.

2.       I can appreciate now why accounting might actually be a stressful profession with multiple results drawn from the same data. Love ya Pops.

*By standards of the NH State Legislature.

Voting

Sorry I’m not as dedicated as this guy.

I actually did not vote in Tuesday’s election. But really, not for lack of trying. First, it took me about 2 days to download all the forms off the nh.gov website. And then it took me another 2 days to figure out how to print the recipient material ONTO an envelope. They were very specific that taping, gluing, or stapling the form onto an envelope would negate it and the USPS would just throw it out. So at this point...I was already sending in the materials a week later than I intended. Risky business in Rwanda, for time-sensitive materials.

And then I took it to the post office [Royal “I” = somebody on our staff who speaks Kinyrwanda.] and learned that it would cost 5,000 francs to send…because the “prepaid postage” for the international absentee ballot is only prepaid if mailed within the US.

At this point, I decided to update myself on the NH Senate election and learned that I couldn’t even vote for Bill Binnie. And so my decision was made…it wasn’t worth $10 to abstain from voting.

With all the excitement of turning 18 and being able to vote…I’ve only taken advantage of it once…to vote for the school budget…and I’m pretty sure that that tally resulted in a re-vote anyways.

Two Fun Facts about Rwandans

1. Rwandans don’t get acne. They just don’t. Therefore, it is completely acceptable to point at somebody when they have a huge zit that they’re obviously trying to hide and say “what’s that?” No societal standards of pretending to ignore zits. None at all. In a 24 hour period, I had every Rwandan on our staff and every Rwandan on the house staff ask me what my zit was. Fabulous. (Life update: still getting acne at 22.)

2. I recently learned that “Rwandan time” is actually different than “American time,” or however you would call time that means midnight is 12am/pm. It turns out that conveniently…1am Rwandan time actually coincides with 1am EST. This is because in “Rwandan time,” the day starts at first sunlight, around 6am. Hours are counted from there, so 7am is actually 1am, one hour after sunrise/the start of the day. This actually makes sense to me, yet I only learned about it after 3 months of being in Rwanda. What’s coolest about it is that according to America-time, Rwanda is 6 hours ahead of EST  I’m now on east coast time!

My Favorite Language!

Nope – that’s not evidence of my badassness requiring bail out of a Rwandan prison, it’s actually the receipt that I have to bring with me when I start French Lessons at 9am tomorrow (yep – that’s Saturday morning).

After almost 3 months of pretending to understand French by smiling my way through conversations, every once in a while saying “ahh oui oui je sais,” I decided that, concretely, one of the best things I could do for myself in Rwanda would be to actually learn French. It would perhaps be the most transferable skill I could bring to another job (or at least that I could use to insist that another job let me travel).

So, yesterday morning, I jumped in the car with our logistics coordinator and went to go sign up for my French lessons… at the Ruhengeri Prison. Even though I’ve already written a blog about this, let me quickly reiterate the fact: prisoners in Rwanda are FRIGHTENLY unmonitored. You would never actually call the prison a prison, by any standard of the word. Our compound of a house if more secure than the prison: we have barbed wire, we have a guard, we have a gate that closes AND locks. The prison had…kind of a wall that separated the inside from the outside, but no physical gate…and one guard who sheepishly asked me if I had a cell phone on me. When I said no, he didn’t question any further.

When we drove up, a group of prisoners was hanging out in the parking lot, outside of the non-gated entrance and out of “reach” of the one guard.

While my first reaction was awe, I was quickly brought back to reality when Elie said hello to one and shook his hand. I followed suit. And then, the shock hit. I could not stop myself from thinking “you’ve killed somebody – maybe a whole family – with a machete. And now I’m shaking your hand.” Shake hands with the devil much?

Elie navigated his way through the prison, to the “classroom” building, where a group of men who were once professors, teachers, doctors gathered. The one who appeared to know English best (fluently) spoke to me: (Apologies to those of you that don’t know French, but this conversation is hilarious if you do.)

Him: Que langue est-ce que vous voulez apprendre? (What language do you want to learn?)

Me: *desperate glances at Elie to no relief* Umm…le francais? Je pense? You just asked me what language I want to learn…right?

Him: Ahh d’accord. Et en que jours est-ce que vous avez les temps pour apprendent? (Okay. And on what days are you free for learning?)

Me: Trois ans. (Three years. – I assumed he asked me for how long I studied French.)

Elie laughed and told me what he said.

Me: Ah…toutes les jours?

Him: Je vous donnez un examen. Qu’est-ce que vous avez fait hier? (I will give you a quiz. What did you do yesterday?)

Me: Hier? Umm…j’ai allé a la centre de santé…de Shingiro…pas la centre de santé de Kabere ou de Muhoza…y…et…j’ai teach Anglais a les…gens…people…et… (Yesterday? [I only said this to check if it sounded like “yesterday”…and to stall while I remembered how to construct past tense verbs…to those of you who know French…I obviously failed.] I went [using a 5 year old’s verb construction] to the health center…of Shingiro…not the Kabere health center, or the Muhoza one [blatantly trying to speak for longer by using English words in a French way]…[Spanish] and…and I taught English at the people…people [English…just in case he didn’t understand me] …and …

He finally stopped me there.

Him: Consolate (girl I live with) is much better than you are.

Me: Well yeah. She’s from Rwanda and she studied French in college.

Him: You can only join her class if you take personal catch-up lessons.

Me (to self): You mean come to the prison of genocidaires by myself without a phone to call anybody in case something happens? Fabulous. Can’t wait. This better pay off and some job someday better send me to France.

Some Pictures!

Making use of that digital camera I got for my birthday...here's what Rwanda looks like:

Lauren, Travis (Zack's brother), Me, Marvin, and Zack at Volcana, a nearby bar -- that also happens to be the most expensive in Musanze. Convenient.

Marvin, Kelly, Me, Lauren at the convent overlooking Lake Rohondo. I may look like an idiot in actual athletic clothing...but I was much more comfortable than Marvin!

When we spend full days at the health centers...I have to get creative with my work space. Here I am after I turned a consultation room into an office!

A porch meeting with Zack.

Being an incredibly attentive English teacher for the nurses at Shingiro Health Center.

I'd like to describe my teaching style as "laid back" rather than "lazy" for sitting on the table and drinking tonic.

Trying to determine just how ridiculous I looked in my *new* pink aviators using my *new* digital camera as a mirror. Say hi to Peace Corps Brandon in the background -- both of us escaped to La Palme (hotel) to use the fast internet for the afternoon.

Reality Strikes

Before coming to Rwanda, I was warned by a “veteran” to not ask anybody about their families “because you cannot assume that they have a family – after the genocide.” I’ve taken this advice to heart and, in general, assume that everybody I meet lost family in the genocide.

Forgetting that during the genocide, the perpetrators constituted 85% of the country.

First reality strike: it’s true that most people lost family because the genocide. However, the reason for this, more often is that their families are in prison for being genocidaires, than that their families were killed in the genocide. I had to use my hand to keep my jaw shut when I learned about this over dinner one night. Given the simple math, this is something I should have assumed…yet it’s just easier to think of everybody as being a victim in recovery, rather than a perpetrator in regret.

Second reality strike came when I actually saw these prisoners. Almost every blog or personal reflection I’ve read about Rwanda talks about seeing the prisoners in their bright pink jumpsuits and how they are a constant reminder of the genocide. Given that I live in and hardly ever leave my isolated-not-exposed-to-Rwandan culture compound, I had not come across these groups of prisoners that I’d heard so much about until this week. I was driving into town with a few co-workers to buy bus tickets, and our car was right behind a truck full of prisoners. A huge truck. Absolutely packed with prisoners in their signature pink jumpsuits.

I had similarly been warned that prisoners in Rwanda are remarkably un-secure. That guards hardly feel the need to lock doors, because life on the inside of the prison is much kinder than the hate and guilt on the outside. Even so, it was shocking to me to see this truck full of prisoners, remarkably unguarded. Not even a gate or a lock keeping them in. And despite the fact that they’ve all admitted to killing/slaughtering others, nobody on the streets seemed fazed by their presence.

For me, however, these two incidents – within 24 hours of each other – served as a harsh reminder of Rwanda’s brutal history.

For me, Rwanda does not personify “genocide.” It is true that when I first learned that Wyman Worldwide worked in Rwanda, I immediately thought of Hotel Rwanda. After that…I couldn’t think of much else. But since I’ve been here, I’ve encountered so few concrete evidences of it, that it’s easy to forget; and, consequently forget that Rwanda is not only a developing country, it’s a country in recovery. Realizing that “your father killed a man, or two, or three…or more,” makes it all a little more real, and makes life tumble into perspective.

Today’s Work Frustration

In an effort to remind you that I do primarily spend my time here working, rather than just using my weekend adventures to cover blog updates for the rest of the work week, I figured I should start sharing a few more work stories. Hope this decision doesn’t bore you to death.

Today, as a team, we reviewed a PowerPoint on the success of CCHIPs’ nutrition program. The two people in charge of the program are going to present it tomorrow at a district meeting of NGOs as an example in their discussion of how to eradicate malnutrition in Rwanda once and for all.

Here’s the good thing: I am a huge fan of our nutrition program. By government order, all children under 5 must be weighed and tested for malnutrition/edema once a month. The next step for the government declares that all children who are severely malnourished must receive Plumpy’nut supplements…which is great and all, but they’re usually out of stock and even when they’re in stock, I think we can all acknowledge that Plumpy’nut is a short-term solution to a long-term problem.

CCHIPs foresaw this short-coming and designed a demonstration cooking and demonstration kitchen garden program, in addition to facilitating the national Plumpy’nut program. Mothers (by the insistence of CCHIPs – originally there was an issue because mothers were sending older siblings) of mildly and severely malnourished children come to the health center one day a week for a demonstration cooking. This demo shows them how they can cook a healthier, heartier meal using foods that are readily and cheaply available. The kitchen garden shows them how they can use their plots to grow a greater variety of vegetables. (One huge shortcoming with farming in Rwanda is that people are hesitant to do anything differently than they’ve always done it, and therefore don’t take advantage of the opportunities with multiple rainy seasons.) They then get a hearty meal, plumpy’nut for the road, and some new knowledge to bring home.

Observationally, this program has been wildly successful in decreasing malnutrition and decreasing relapse from children who “graduate” the program. I also love it because it’s sustainable, hopefully prevents future children from becoming malnourished, and empowers mothers to not rely on government hand-outs to feed their children.

Here’s the bad thing: Thanks to national priorities and goals, malnutrition has essentially already been eradicated from Rwanda, at least according to the books. When reviewing the presentation today, we ran into some incredible frustrations that make the CCHIPs program look less successful than it seems to be, and were very torn about what to do about this.

For example, following a government mandated emergency screening of all children under 5 in May 2009, the numbers of malnourished children severely dropped for every health center; but this is more because other health centers stopped monitoring children than the fact that the number of malnourished children actually decreased. And even the data for the CCHIPs health center is hard to interpret because it seems that there was pressure during the emergency screening to over-report malnourished children, (at the time, Plump’nut was widely available and widely sought after) making our data look more suspect as well. And finally, even though I want to have confidence in the CCHIPs data, something just seems fishy when the numbers don’t add up: when the number of children in the program one month, less the number of children that graduate the program, plus the new cases identified…doesn’t equal the number of children in the program the next month. We had to acknowledge that it could just be the case that the poorly educated community health workers combined with the poorly trained-in-Excel nutritionist don’t create the most reliable dataset.

So today’s work frustration consisted mostly of mulling over the nutrition data available and figuring how we could best, accurately portray the success of our nutrition program, especially compared to other health centers who appear to have been more successful at decreasing the number of malnourished children, even without any system or program in place. …and it’s times like these when I really find myself wondering: would I face such problems at a job in the US? Would I spend my days concerned about the accuracy of the raw data to begin with, before even being able to start any analysis? 

Facebook Continues to Be Creepy

I miss my ads for Reagan-onomics and “I like bacon” tshirts. An inventory of my current facebook ads:

Affordable MBA, MSc, BA

Study in the heart of London for many courses! Reduced prices for African students.

Get you@myrwanda.rw email

It is Free. Be a Proud Rwandan and sign up for Rwanda Mail e-mail.

0.facebook.com

Injira kuri 0.facebook.com ukoreshe Facebook kuri telefoni igendanwa yawe ku buntu. Iyi serivisi iboneka gusa kubakoresha MTN +250-xxx-xxx-xxxx

Maggie Bell, Brendan McVeigh, and 2 other friends use Facebook Mobile.

Make your radio online

Quality streaming service at a flat rate of 20$ per GB. Call us at 0788299369 [that’s a Rwandan MTN number] for more information. Any one (sic)* can have a radio now.

NewsFixer

International news talking points.

We make websites110000FRW

Phone: 0788300369 Our office is at Muhima Kigali, Rwanda. Do visit us for a free consultation on starting your website.

Fake Degrees Certificates

Diplomas & Transcripts You Really Must Read This. Fake-UK-Degrees.co.uk [I think they must have tracked my blog about needing a diploma in English?] 

Jobs in Canada

Click now to APPLY FOR JOBS IN CANADA- updated job opportunities available. Submit your resume or CV.

*Did you know that when you put (sic) after something grammatically incorrect, word removes with wiggly line underneath?

Update on the Visa Saga: Part 3 (4?)

With my letter from Dartmouth stating a translation of my diploma in hand, I pulled my number tab and waited my turn at the Rwandan Immigration Office…much like people have to wait turns at meat counters at busy places that are not the Hanover Coop.

Then, figuring, I’d beat the system, I decided to pay my fine while waiting for my number to be called. The accountant is maybe the only office at the Immigration building that moves quickly. I was in and out of there so quickly…showing them the text I got that said I had to pay a fine and then writing my name down on literally a scrap of paper for them because I didn’t have ID. (They asked for my passport, I laughed, they were only half serious.)

Back up to the Immigration office. Number called. I pull out my letter and cell phone and show the text and the letter to the man behind the counter.

“Ah you see you have to pay a fine” he informs me.

I knew I would beat the system. I show him that I’ve already paid it, expecting that this is all that he’s actually interested in. Oh no, turns out the letter did not look professional enough. (Curse that US Embassy man who did not quite tell me how important a $50 “this is a copy of an illegitimate document” stamp would be.) Immigration man explains to me that Rwanda is a very official and international country. It will accept all forms in English and in French. Not even in Kinyrwanda. What kind of country would they be if they accepted diplomas in Latin? They’d be a laughingstock!

No – you’d be a country that accepts students from the best colleges in the world.

I ask what he suggests I do, if he won’t accept a letter from my college that translates the diploma that it wrote. And then I slyly put the receipt from the fine on top of the papers, again expecting that this is what he’s most interested in.

“Go to the Italian Embassy.”

“I’m sorry…why?”

“Because they speak Latin in Italy, so they will be able to translate it at the Italian Embassy.”

“Umm…Latin is not spoken in Italy…or anywhere actually.”

“Well then go to the US Embassy.”

“I just came from there and they told me they can’t help me.”

“Well then go to the Vatican Embassy.”

“The Vati –“ –I cut myself off, of course the Vatican has an embassy. Its embassies are probably larger than the Vatican itself.

I stare at the man who I KNOW has accepted Latin diplomas before and quickly consider my options. I have nothing to threaten him with. If I don’t get a Work Visa, it’s not really at a loss to him or Rwanda. I’d like to think that in my year here I will develop some revolutionary filing system that will significantly improve health care and reporting in the country…but…let’s be serious…even if that was realistic, man behind the counter at the Immigration office wouldn’t know/appreciate/believe that. I cannot bribe him, because such an attempt would surely get me imprisoned or exiled. And I cannot flirt because English is his third/fourth/fifth language. He obviously holds the upper hand in this discussion.

Gritting my teeth, I ask for directions to the Vatican embassy. “Right next to the USAID building,” I’m told. Irony.

When I get up to walk away, I am immediately surrounded by three other people who are about to file for their work visas and are now worried because their diplomas are in Latin as well. I can offer no consolation except that, conveniently, the founder of my organization lives in the same town as my college…so he’ll be able to figure it out and get something professional to me.

Instead of the Vatican Embassy we go to a hotel and watch a tennis tournament for a few hours. I might still not be legal in this country, but I think it was a good choice.

English Diploma

Here you go Jamie:

THE TRUSTEES OF DARTMOUTH COLLEGE

To all who read this document greeting:

Be it known that it has been decided to honor ELIZABETH BRAY MITCHELL and in accord with her merits
To decorate her with the title of Bachelor of Arts and that we have bestowed upon her the fullest power
Of enjoying all the privileges and immunities and honors which everywhere on earth
Pertain to this same grade. Of which act let our official seal and names be for a witness.

Conferred from the academic halls in Hanover, New Hampshire on the 13th day
Of the month of June in the year 2010.
 
...Too bad the immigration office won't accept it because it doesn't look official enough. A man at the US Embassy told me that he could make a copy of it and then stamp that, saying that it's a copy of something for $50. "But won't they more care that the original is legitimate?" "No. They more just want a stamp on it. Why do you think we can charge you $50?"

Randomness in Rwanda

(Sorry for the long pause in blog updates. Our internet got “fixed” last Friday, so I haven’t been able to get online until today.)

One of my more favorite graduation presents was a book. Not only was it my more favorite because it was given to me by my favorite person (hi KTL!), or because it was called “The Drunkard’s Walk”…but it also so confused and angered me one night that I ripped it into three pieces. That’s right…a book incited such a reaction in me that I tore it apart. That’s got to be the sign of a good present.

I still brought a third of it with me to Rwanda—as I explained to KTL, so I could read finish reading it before writing my thank you note. (KTL, consider this blog your thank you note. Check.) Besides angering me, this mathematic-theory-paper-disguised-as-a-book also caused me to laugh at a few points. It delves into the theories of randomness and of probability, explaining at one point how Mac had to make its shuffle option LESS random because the general population thought it was broken if the shuffle randomly played the same song twice in a row. It also discussed the probability of a randomizer returning a list of zeros to whatever power, etc. etc. I liked it and I promise it is relevant.

The set up: Celestin (former mayor) and I have already designed and gotten underway with our second community survey.

[Side note: When planning our meeting to launch the survey, Celestin said he’d want to schedule it for the next day. I asked him if it would be possible…since over 50 people, including some local officials, would need to attend the meeting. After a slightly confused expression, Celestin said to me “oh yes yes, I see...I will have to check to make sure I’m not busy tomorrow…yes yes…I should make sure that this meeting will not interfere with my plans.” Not quite what I was asking…but I guess that his answer still answered my question.]

Our plan was to randomly select 116 households from the health center’s catchment area. In my morning oblivion, I did not realize that the plan for doing this was to assign every household a number, to write all those numbers on pieces of paper, and then to pick 116 of them out of an envelope. I did not realize until the thousands of pieces of paper were cut and we were on our way to the health center, my laptop in my bag.

“Wait one sec,” I thought to myself, “I bet Excel can do this.”

Sure enough, all it took was searching the help for “random” for me to find the randbetween command. In a matter of minutes I quickly made a worksheet that chose random households by cell (bigger than a town, smaller than a county) and looked pretty too. The local authorities all accepted this method and were eager to hear which households were selected.

Then they were confused why the same household was selected twice, twice. They thought my randomizer was broken. I just thought back to the iPod shuffle story, and refreshed the worksheet to get a new number.

Then they were confused how two people in the room of 50 were randomly selected to survey themselves.

My favorite, though, was when the carefully randomized process became carefully not random. After announcing the assigned households, a flurry of hands went up to explain to us that certain respondents would most definitely not answer the survey questions, were unknown to the surveyors, were out of town, etc. etc. And so continued the process of Celestin asking them to survey their neighbors instead…which resulted in even more people suddenly realizing that their assigned households would not be able to answer the survey…so they were re-assigned to question their neighbors…and then I was informed of the changes made.

And so goes randomness in Rwanda.

But at least it resulted in 116 completed surveys being returned to us by noon the next day. ..and we’re off to begin the analysis.

Most Official Text I’ve Ever Received

Direct transcript (including improper spelling of my middle name and of emigration):

::migration.gov.rw::

ELIZABETH BRAV MITCHELL, Your Visa application is being delayed: Reason: Dear our esteemed customer,you are please requested to bring a translated diploma and pay a fine of 20000frw.thank you!

Immigration Officer.

Passport number: 306282464 [Is that safe? Can somebody steal my passport identity?]

Nationality: USA

Telephone: 250782468532

Email: Mitchell.eli@gmail.com

Directorate General of Immigration and Emmigration

...How do I explain to Rwandan authorities, via text, that a diploma written in Latin means that I went to a really good college?  

“Ndi umukorerabushake mushya wa CCHIPs.”

Oh yes…you’d best believe it…that above phrase is how I introduce myself. It means that I’m a new volunteer at CCHIPs. And you’d also best believe that I have no idea how to actually say it.

So begins the story of Eli Mitchell learning to speak Kinyrwandan, a folk language that describes relationships rather than creates new words. For example, the literal translation for “they are brothers” is “they are of the same womb.”

Honesty time: I was too slow to fulfill the Dartmouth language requirement. I only got HPs (~Cs) in high school French because I taught my teacher’s daughter how to play lacrosse. And I dropped Spanish 2 in college because my teacher told me I would not get the requisite B- needed to go on the Language Study Abroad. (Thank you, forever, Semester at Sea for still allowing me to see the world.) Everybody in my family is dyslexic and ADD.

I have absolutely no reason to believe that I will ever be able to learn Kinyrwanda.

Yet, tomorrow at 10am, we’re going to head out to the local jail for two hours where they teach Kinyrwandan lessons.

Just in case I become highly competent in that two hour block, I’m going to take the time now, to tell you why Kinyrwandan is so confusing to me (besides the fact that nd/mb/nyrw are considered pronounceable, the average word is 10 letters long, and there is no grammar to speak of): so far, it seems that every important word begins with an “m.” As a reminder: I’m dyslexic. All words that being with an “m” look the same to me:

Muraho: Hello

Mwarimutse: Good Morning

Mwirwe: Good afternoon

Muramuke: Good night

Murakoze: Thank you

Murabeho: Good bye

Muhezo: Old man. (Very important word, because they are referred to very often. I will have a separate blog about Muhezos.)

Musanze: Where I live

Muhoro: More specifically, where I live in Musanze. Note the similarity to Muraho.  

Muhabuha: close-by volcano (pronounced “Murabura”)

Makumyabiri na rimwe: 21…very important because it’s my age

Si mvugai: I don’t understand

…okay…the last one’s a stretch…but I think you get the point that every Rwandan word I actually know begins with an “m.”

HIPPA in Rwanda (not Hippos)

I am unfortunately very practiced in the rules of HIPPA/IRB in America. My Presidential Scholar project was delayed almost a year because of HIPPA approval, and SPAHRC (too embarrassed to tell you what it means…) never got to play with our own data because HIPPA rules just would never let us access any.

It’s just not quite the same in Rwanda.

Fortunately, this means that we were able to conduct a community and outpatient survey with absolutely no hurdles. Unfortunately, my understanding of the purpose of HIPPA, coupled with my respect for rigorous economic studies…meant that I couldn’t fully appreciate/accept how we were able to conduct such a survey so quickly, without any prior approval. Ultimately though, it’s pretty damn sweet Kelly was able to design, conduct, and analyze a community-wide survey in her 6 weeks in Rwanda.

I’ve since taken over the analysis and reporting of this survey. I could tell you all about our results and ensuing recommendations, but that would be boring. Plus, my partner didn’t quite adhere to the 10 page page-limit that I set for him, so yeah…you wouldn’t read it. (But I will point out that statistical significance also does not matter in Rwanda because there’s absolutely no data on anything, so any data is automatically considered significant.) Instead, let’s focus on the entertainment of the lack of HIPPA:

Despite our informal “consent” at the beginning of each survey that explained to the respondents that their answers would not affect the care or quality of care that they received, all answered that they are “very satisfied” with their care and had “no complaints” and “no suggestions” etc. (Definitely not the responses you would expect to get in the US…)

Except for one gentleman, who was quite honest in his responses. Apparently, he has some disease that the health center cannot treat, yet due to the strictly regimented Rwandan health care system, he must always first go to the health center and wait to be referred to the hospital every time his disease acts up. He was incredibly frustrated that the people at the health center could not just treat his disease. (Wishing I remembered what it was.) This, Kelly and I recognized, represented a failure of the current, bureaucratic system.

We didn’t get 2 sentences into our analysis before Dr. Nathalie (the 25 year old doctor on our staff who works one day a week at the hospital) cut us off: “That silly old fool! He said that!?! He has a card that states he can come directly to the hospital to receive care, yet he continues to go to the health center EVERY TIME. Silly fool, silly fool, he just wants to be cared for at the health center but refuses to recognize that they cannot treat him. Ugh, I’m going to have the nurses explain this to him the next time he comes in.”

And there you’ve got it…it may be incredibly cumbersome, but I think there may be a rationale to following the rules of HIPPA. 

The Big City

Spent today in Kigali, the big city, to get my work visa and some extra pages in my passport. I had perhaps my first ever exposure to true bureaucracy…from Rwanda and the US.

First, I wasn’t able to get my work visa because we didn’t have a letter from our project director stating that we are replacing two American workers who will be leaving in the next year. We had letters updating the “volunteer inventory” for the organization, and other letters stating what exactly our duties would be at CCHIPs, but because CCHIPs at some point stated it wouldn’t hire more than a certain number of volunteers, our project director needed to explain that 2 others would be leaving…even though those records should be on file at the NGO office as well? I don’t really know…I can’t understand French that well. All I know is: no work visa.

And THEN the Americaland embassy that I was *so excited* to visit only allows American citizens in on Tuesdays and Fridays. Ugh.

At the beginning of the day, I thought this excitedly meant that we’d get to go back to Kigali in a week! By the end of the day I realized that Kigali is largely miserable and I’m not too excited to go back in a week. It’s hot and dirty and dusty and not fun and expensive and tiring…and I am most definitely now sick, so I’m going to blame it on Kigali.

After failing to accomplish anything on bureaucracy lane, we ran some errands for CCHIPs, which included mostly picking up office supplies. Marvin and I gaped at the prices of chairs and desks at a furniture store and refused to let our office manager purchase a filing cabinet that we insisted would be cheaper to buy at IKEA and then ship over here. I think that was my only true contribution to CCHIPs today though.

Then we had some FABULOUS Indian food for lunch. (I was psyched when I looked at the menu and realized that it was the same as Jewel of India. I was not psyched that they described their saag paneer as “chunks of cottage cheese”…the Jewel description just says “chunks of cheese”…which is much more appetizing.)

I was asleep in the back of the car before we even left the city and woke up when we pulled into the CCHIPs driveway. Sorry there’s not too much else to report…but the big city was just exhausting.

Website Update: there was a HUGE spike in website traffic yesterday! Like TEN TIMES as many hits as normal! Unfortunately…90% of those hits were from “robots”, so I’m not convinced that anybody visited? I hope to change it on Tuesday so give me ideas!