I was in Aspen earlier this week working on some of the challenges facing healthcare and the health industry in the US, but it’s time to switch gears.

From my 2008 trip to Rwanda with the ONE Campaign

Sunday, I leave for Rwanda to lead a one week group trip with my friend Dr. Paul Farmer to see some of the work being done byPartners in Health (PIH) in the country. I haven’t been in countrysince 2008, and I’m anxious to see the progress PIH and other groups are making in health.

Since the spring of 2005, Paul’s PIH organization has been in Rwanda working closely with the government and the Ministry of Health to reach the rural, underserved areas of the country. PIH began by focusing on HIV/AIDS work, but has now expanded to full healthcare offerings. Today, over 800,000 people are served by PIH’s 40 health facilities.

But the health challenges in Rwanda are still vast! Next week with PIH we’ll be considering many aspects of health in Rwanda, but one in particular that I’ll be looking at while I’m there is nutrition.

I firmly believe–and have seen firsthand!–that global health diplomacy works as a real and powerful currency of peace worldwide. And a healthy start to life–a mother enjoying a safe and healthy pregnancy leading to a safe birth and healthy infancy–is crucial to building a foundation that leads to stable communities and global peace.

Food insecurity and malnutrition account for more than half of the deaths of children under 5 in developing countries, and Rwanda has had its fare share of nutrition challenges. In 2005, 18% of children in the country were underweight.

But Rwanda’s government has made real progress in child nutrition since 2009. That year, a Presidential Initiative launched to address malnutrition. The country also joined forces with the US in the Feed the Future initiative.

A 2010 health survey showed that chronic malnutrition and stunting affect 44% of children under the age of 5 in Rwanda.

In September of last year, the Right Honorable Prime Minister, Dr. Pierre Damien Habumuremyi launched a 1,000 Days Campaign, focusing on food availability and a balanced diet for pregnant women through the first two years of life of their babies.

The first 1,000 days may seem like such a small window of opportunity for global change, but the data are clear that childhood undernutrition has long-lasting consequences.

WHO models estimate that over half of adults in the prime working age group–20-29 year olds in Rwanda–have been affected by childhood stunting. Many of these adults wear the visible badges of malnutrition: shorter height or lessened muscular development. And for just as many, malnutrition has exacted a mental toll as well, diminishing the cognitive function of the working age population.

Along with the rest of what we’ll see–including a bit of gorilla trekking and possibly gorilla surgery–I’m anxious to see what progress Rwanda’s 1,000 Days Campaign has made, and the returns realized on nutrition investment.

I’ll be sure to keep you updated.

November 30

Yesterday and today I participated in a training called “Helping Babies Breathe” (HBB). The training materials are produced by the American Academy of Pediatrics, and our training was put on by a number of American doctors who do HBB trainings all over the world. I was lucky enough to be able to also participate as a trainer in the training, which was a lot of fun. There were about 40 people at our training—mostly nurses, though there were also a couple of doctors (but sadly no midwives). I had 6 women (all nurses) within my small training group.

The HBB curriculum teaches participants how to resuscitate a baby in resource-limited settings (i.e. all of Haiti). Using a Neo-Natalie blow-up baby I taught my group the basic steps of drying a baby, suctioning his/her mouth and nose, performing stimulation, and using a bag and mask to perform ventilations—all in hopes of resuscitating a baby who is born not breathing.  We practiced various scenarios including: a baby born with clear amniotic fluid, with meconium, with the baby crying right after having been suctioned, and with the baby not crying or getting a high heart beat after correctly being ventilated for a number of minutes.  Each of the participants were given training materials to use back at their specific clinics/hospitals to train additional staff, as well as a number of bags/masks and bulb suction devices to now use to resuscitate babies.

It’s amazing to think that such inexpensive/relatively low-tech products like a bulb suction device and a bag/mask can have such a dramatic difference on a baby’s outcome. It’s also very sad to think that without the proper training even in the presence of such devices, many providers here don’t make use of them.

I’ve had to resuscitate a number of babies at HIC, and each time I’ve been the only provider helping with the resuscitation. Often the nurses have told me that a baby looks dead—and why should I try to save him/her? When I have responded that the baby has a heartbeat, and is in fact not dead—which is why I’m working to get him/her to breathe again—they have laughed and thought me foolish. That mentality however, I think—I hope—is slowly changing. As the nurses I’ve consistently worked with have seen the fact that with proper resuscitation a baby can be brought “back to life”, they are at least telling me that they now see the utility in not automatically giving up on a baby, but instead trying to work to make him/her breathe. 

No one from HIC came to the HBB training—despite the hospital having received a number of invitations—which is sad, but the training has inspired me to use any downtime during my night shifts to train the nurses I work with. Hopefully with such training—and seeing my example of resuscitating every possible baby—the night shift nurses will learn the HBB techniques and will be able to pass it on to the other maternity nurses, and save lots of babies lives in the days/months/years to come.

Likewise, I hope that the providers who were trained in the past two days go back to their institutions and train others—or at least serve as an example and spark some discussion—and in doing so help babies who might otherwise not been given a chance.

 

Motherhood is a dangerous journey to take in most of the world. Nearly 300,000 women die each year from complications due to pregnancy, and 99 percent of those women are in the developing world. In Malawi, an estimated 510 out of 100,000 women will die giving birth. But Chief Kwataine, a former English teacher, has become well-known in the country for his work developing safe motherhood activities for nearly the last twenty years.

Watch this short, two-minute video to learn more about how women's (and children's) lives are being saved in Malawi. It's well worth your time.

November 22

First off, Happy Thanksgiving. I have an incredibly blessed life and am thankful for many things—but most relevant to this post is the fact that I’m thankful for the Frist Global Health Leaders Program.  Because of it, I have been given this amazing opportunity to come to Cayes and work at HIC. It has been—and I’m sure will continue to be—an incredible experience, and I am so grateful for the Program and for having been selected for it.

HIC as a hospital is trying to improve its HIV testing rates (a goal that I think is true in most hospitals in Haiti).  As such, testing rates are now closely scrutinized, and it has become clear recently that the maternity has pretty low rates of testing women while they’re here to give birth (last month was about 25%).  That low rate is in large part due to the fact that most women who come to the maternity have already been tested once during their pregnancy—sometimes multiple times—and so don’t need to be tested when they come to give birth. (The women who have had prenatal consultations typically bring their prenatal card when in labor, and that shows if/when they were tested and the results.) There is still however, a portion of the pregnant women who haven’t been tested—typically those who haven’t had any prenatal consultations—who do need to be screened when they arrive to give birth.

Between the hours of 9am to around 4pm those women who haven’t been tested can easily get tested, as there’s a woman who tests pregnant women—typically it’s those women who are at the hospital for their prenatal consultations, but she happily tests ones here to give birth too (and I’ve sat in and watched her counsel women and she does a great job). The problem however, is that when this woman isn’t at the hospital the pregnant women who haven’t been tested, can’t get tested. So for most of the afternoon, and all of the night shift, we aren’t able to test women who haven’t been tested during their pregnancy. This is particularly difficult given the short amount of time that the women stay in the hospital after they give birth (an average of 6 hours). I had a woman on Tuesday come in, give birth around midnight, and then want to leave at 7am. I tried to convince her to stay until 9am to get tested—she sadly stayed until around 8am (I checked on her before I had a delivery and she was there, but when I finished with the delivery and went to see her again she was gone).

We’re trying to work on ways to address this problem—but as far as I can tell it comes down to the lack of money to pay someone to offer testing during “off hours” and the lack of motivation on the part of the nurses/doctors/midwives. Until a real solution is found I’m just going to try to beg women to stay until they can get tested in the morning (which I was successfully able to do on Wednesday). 

 

November 15

Most days (or I should say nights rather)—I forget I’m working in Haiti. We have normal, beautiful deliveries with happy, healthy moms and babies. I got to catch twins the other day (!!), and the first was breech—which was quite exciting/stressful for me, as breech babies typically are sectioned in the U.S. and so the breech delivery skill-set is a dying art. Sure we have the occasional loss of power, or we run out of gloves, but overall things at the maternity run in a manner pretty similar to how they would back in the U.S.

And then there are nights where I am harshly reminded that I’m in a developing country, in a hospital with limited resources, where standards of patient care are—at times—very different, and where things happen that wouldn’t occur in the developed world. Below is a sad, frustrating, and a bit graphic example of such a case.

Last night a woman was carried into the delivery room with an IV already in place and fluid dripping. She had been brought from another hospital that was about 45 min away from Cayes. She had had an obstructed labor for the past three days. As a result, when she arrived her baby’s head (the baby had died—how long ago no one knows) was right at her perineum, but wouldn’t come out. Her vulva was terribly swollen and she looked incredibly worn out (which was more than understandable given what she’d been through). She was still having contractions—probably due to the fact that she was getting pitocin through her IV—but they weren’t doing anything but causing pain.

We called the doctor on call to see what he wanted to do about this woman. It was clear to me—and the nurses—that no amount of pitocin was going to make that baby come out (unless the baby decomposed enough to be able to be pushed out with the pitocin induced contractions). I was concerned about her increasing risk for infection and for fistula formation—among other problems—and so was hoping the doctor would come in to perform a c-section (given that we had no vacuum or any other way I could think of to try to extract the baby vaginally). The doctor however, got mad at the intern for calling him, and said that the woman just needed pitocin and that was that. After the call, the nurses all lamented the doctor’s decision, but said that this was just how it was in Haiti—that women suffered. They were much more laissez-faire about it than I was—in large part I think because this is normal/expected to them, and (obviously) not for me.  I think also because I knew what materials we didn’t have, and how they could have changed the situation—and the nurses probably didn’t as well—that it made it that much more frustrating for me.

I struggled with trying to think of something we could do for her—but I couldn’t think of anything. (Being a new/inexperienced midwife is hard at times because I wanted to help this woman so very much, but have never been taught about how to address obstructed labor—I’ve only read about it and its consequences—and don’t have any experience with it (until now), or anyone to offer me advice as to the best treatment plan.)

In the end we—tragically—monitored the woman all night. She made no progress and didn’t get any rest because of her contractions. I happened to be at the hospital this afternoon (around 3pm) and saw her finally heading back for a c-section. I can only hope that she has no long-term consequences of this birth—though I’m not too optimistic about that.

I realize this is not an uplifting post, but it is a reality that any healthcare worker who has the privilege to work—or wants to work—in the developing world will have to continually confront. My hope is that with time the norms will change, and appropriate resources/trainings will be provided to decrease the frequency of such cases, and ensure that women don’t have to just suffer.

 


“If you don’t practice family planning, you will have a child on your back, in your belly, on your shoulders and in a baby basket on your head.” Malawi nurse Mercy Chikhosi Nyirongo describing the song and dance from a women’s health meeting in Madisi, Malawi 2013.

Behavior change communications take many forms throughout a lifetime . . . from the parent who scolds a child for doing something harmful, to government warning labels about health hazards. Somewhere in between are the messages from this video that rise up from women simply wanting to build healthy families by practicing family planning. With one in 39 women on the continent of Africa dying from pregnancy complications, it is easy to understand this group putting family planning at the top of their health priorities.

The channels through which these messages travel are increasing through the use of technology. Mobile phones, now accessible in over 90% of the world, provide a means for health education by caregivers who put messages into local language and context. The Reverend Betty Kazadi Musau, United Methodist clergy in the Democratic Republic of the Congo, utilizes a system that does not require Internet to reach her community. The results for sending text message cholera alerts is witnessed immediately:

“People are changing their behavior. They start boiling water to drink instead of taking unclean water from the river. They drink clean water. I think this is a life transformation!” [Listen to full interview]

Mercy Neely HicksUnited Methodist Communications provides best practices in the use of technology for wellbeing by working with global communicators and leading technologists. You are invited to attend the upcoming Game Changers Summit in Nashville, Tennessee which will demonstrate the link between technology and health, and help participants put a plan into action for the messages that matter to them the most.

The right messages reaching people at the right time can save lives and build a world where all – from mother to infant – can thrive.

For more information, contact Rev. Neelley Hicks at nhicks@umcom.org.

Download a free copy of Using Technology for Social Good

First off, an update on the two abandoned babies: they were not there when I went to work after my three days off. I was told that the girl (who was very cute and term) had been adopted, while the boy (who was a premi, but seemed very healthy—though of course small—to me) had died.

Working at HIC has certainly taught me a great many things, none more so than how to multi-task. I’ve gotten used to—though certainly haven’t mastered—watching the perineum’s of two women who are pushing wondering who will give birth first and if I’ll have adequate time to change gloves to catch the second ones baby, to do the admission paperwork while making sure that a resuscitated baby is still breathing appropriately, and to triage patients while checking frequently for the presence of the baby’s head of a woman squatting and pushing on the floor. I’m forever impressed at what the nursing staff (as they are the main staff that run the maternity) do every day. As I say I’ve gotten used to this type of work environment, but it still stresses me out and makes me anxious. They however, are so used to it and so good at balancing multiple patients at once, that I don’t think they even notice it at this point. I think it’ll be a bit of a transition to go back to the U.S. and for each patient to have her own room (instead of an open room with three tables) and to have to certainly still have to multitask, but in a very different way.

This week I had the pleasure of visiting the Maison de Naissance (MN), a birthing type center about 30 minutes from Cayes. MN is located in a tiny town pretty far off the main road and provides much needed services to the women in the area (many of whom would never come all the way to Cayes to give birth and so would just give birth alone, or with a traditional birth attendant). MN had 7 post-partum beds, a two-bed birthing room, provides prenatal consultation serves, and birth control services (among other services). It was really nice to be able to visit MN and see a different type of birthing environment. Because MN is smaller than HIC, it was much calmer than the maternity ward I’m now used to—though I was told I visited on a very calm day. It was wonderful to see what good care the midwives were able to offer the laboring women and those who came for prenatal consultations.  High quality clinics like MN are invaluable—in my opinion—to Haiti as they provide skilled birth attendants and health care services to women in rural areas who wouldn’t typically make the journey to the nearest hospital, but nonetheless need/deserve such healthcare. 

 

The Hill

by Senator Bill Frist, MD

The United States has shown courageous leadership over the last decade on global health. Earlier this year, Congress once again voted to protect the budget for those critical investments that we make to save lives, prevent the transmission of diseases and end preventable child deaths.  During my time in Congress, we fought hard for life-saving global health programs.  We were able to work together with both Democrat and Republican presidents to launch and implement historic health initiatives in priority areas such as HIV/AIDS, malaria, vaccines, and clean water.  These programs have saved millions of lives, and proven that health is the best currency for peace.

But even as funding for global health soared, foundational programs promoting maternal and child nutrition were largely overlooked.  Yet the need for greater leadership and investments in nutrition could not be more clear.  Across the world today, 162 million children—1 in 4 children under 5 years of age—are physically and developmentally stunted, and 80 percent of those live in just 14 countries.  The combination of physical limitations and reduced cognitive development directly linked to poor nutrition sentences these children to lives of unfulfilled potential, and it creates a severe drain on their communities and countries.  A 2013 report from the UN Food and Agricultural Organization (FAO) estimates that the social and economic costs of malnutrition are unconscionably high, amounting to as much as $US3.5 trillion per year or $US500 per person globally.

Thanks to U.S. leadership on global health, child death rates have been cut in half over the last 20 years from 12 million to 6 million per year. With continued investments and unwavering leadership, child death rates could be cut in half again over the next decade. We must not save these children, only to abandon them in their most crucial developmental years.

Providing the right nutrients is fundamental to health, particularly during the first 1,000 days from a woman’s pregnancy to her child’s second birthday.  In the 2012 Copenhagen Consensus report, an expert panel of economists concluded that every $1 invested in nutrition generates as much as $138 in better health and increased productivity. Yet despite the severe costs associated with malnutrition and the extraordinary returns on nutrition investments, the world spends less than 1 percent of development aid on life saving, basic nutrition solutions.

The tide is turning. In the 2014 budget, Congress provided a funding boost to the global nutrition account, signaling strong bipartisan support to combat malnutrition.  President Obama has committed to developing a global nutrition strategy, and USAID Administrator Dr. Raj Shah, who has taken the lead on this initiative, just announced the completion of that strategy and the effort underway to develop a coordination plan across all agencies and programs that contribute to improved nutritional outcomes.   

Moreover, in June 2013 at the Nutrition for Growth event in London, the U.S. joined other world leaders and signed a global agreement that will boost global prosperity, prevent millions of infant deaths, and unlock greater human potential by working in partnership with developing countries to tackle malnutrition. This commitment is reflected in the Global Nutrition for Growth Compact, which has been endorsed by over 90 stakeholders.

Governments from Scaling Up Nutrition (SUN) countries and their development partners are also taking nutrition seriously. A total of 50 countries have joined the SUN movement to date, committing to driving forward their national nutrition plans at scale.

These plans and commitments are encouraging, but we must sustain and build upon the momentum that has been created over the last year on global nutrition. The president and Congress must remain resolute in their support for strong global health and nutrition funding in the FY15 budget and in prioritizing nutrition as a critical pillar in our foreign assistance investments.  They must work together to oversee the implementation of the new strategy, and to provide the increased resources that are necessary to reach the millions of children who continue to suffer needlessly from poor nutrition.

Investments in maternal and child nutrition build the foundation for the next generation to survive and thrive, and serve as a shining example of U.S. global leadership at its best.  

Frist, an acclaimed heart transplant surgeon, served Tennessee in the U.S. Senate from 1995 to 2007. He was Senate Majority Leader from 2003 to 2007. He is chairman of Hope Through Healing Hands and Tennessee SCORE, a professor of surgery and author of six books. Learn more about his work at BillFrist.com.

NATO soldier

Hope Through Healing Hand's mission is to promote health worldwide as a currency for peace. This Memorial Day, we'd like to say a huge thank you to all of our armed service men and women who have given sacrificially to protect our freedom and to promote peace around the globe. You are heroes in our eyes, and we thank you for your service.

Image from Nato.org

October 26

My name is Courtney and I’m a Certified-Nurse Midwife and Family Nurse Practitioner in Haiti. I’m working and living in a town called Les Cayes (or just Cayes for short), which is in the south of the county about a 4-hour drive from Port-au-Prince. I’m working at the Hospital of the Immaculate Conception (HIC), which is the main public hospital for Les Cayes (and for a significant portion of the surrounding areas).

I’m quickly getting settled into life in Cayes, and think that I’m really going to enjoy my work and time here.

As some of you may know however, Hurricane Sandy developed this week, and certainly made my first week here interesting.  Cayes is right on the ocean—meaning at sea level—meaning that with lots of rain (i.e. daily, hard rain for 3 days straight) much of the town floods. The hospital—tragically—is not at all elevated, so it succumbed to the same fate as much of the town (see photo’s of me walking to work and the hospital). The largest building—which currently houses the maternity and men’s and women’s surgical post-op—is the lowest of them all. “Luckily” in order to get into that building there are ~1.5 foot high concrete walls (dams of sort) build into the doors—meaning you have to step over them to get into the building and that they prevent water from entering the building even if the hospital grounds are flooded. Despite these barriers (which were working) the maternity and the birthing room still had an inch of water covering it (I was told it came from underground and seeped through the floor tiles). We (the maternity nurses and doctors) worked for a day like this, but eventually the hospital closed and moved the maternity patients to a Canadian ophthalmology hospital on higher ground. It’s finally stopped raining today, so hopefully things will dry out quickly and we’ll be able to get back to HIC soon.

Despite the rain and the craziness with moving hospitals I’ve thoroughly enjoyed meeting and working with the nurses and doctors that I have. They provide the best care they can, given the resources they have available to them (which are pretty limited by American standards).

 

October 28

One of the things that has struck me about my work thus far in the maternity (we’re still at the Canadian hospital, although the town has dried out completely) is how family friendly it is. There is one woman on the service who has been hospitalized for at least 4 days, and 3 of her female family members (including a 1 year old) have basically moved into the hospital with her. They sleep in spare beds right next to the woman (who is hospitalized because at 20 weeks she’s been having contractions) and seem to just spend there entire day hanging out with her.

When I got to my night shift last night that woman’s family were there—as always—and there must have been 15 other visitors (of both genders) who had come to see their respective friends/family members who were at the maternity.

Most of the time the visitors are women—but we’ve had a couple husbands come to support their laboring wives. Those men have dutifully walked up and down the hallway with their wives supporting them when they have contractions, and in general have just been with them. Although the women are alone in the delivery room those husbands who are present are typically waiting anxiously outside and peer in as soon as we open the door (after the birth).

I think that it’s great that the nurses and doctors don’t mind family members sleeping in the spare beds, and on the floor when there aren’t spare beds (as was the case with the number of patients/visitors we had last night). Additionally, I really like that family and friends are so involved, supportive of the woman while she’s hospitalized, and in the case of births so excited about the new baby.

 

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