20 Things I'll Miss about Tanzania

I officially depart Tanzania three weeks from today and I have a ton of mixed feelings. I've been busy wrapping up my work projects and packing up my life while saying goodbye to friends and trying to plan the next phase of my life. 

While I'm super excited to come home and start checking things off my top 50 things to do list, I've also been trying to spend some time reflecting on the things I'll miss. So here's my top 20 list of things I'll miss about living in Kilwa, Tanzania:

1. soda from a glass bottle
2. soda with real sugar
3. scuba diving in warm water
4. living on the beach
5. running on the beach
6. the Indian ocean
7. fried, fresh fish
8. time to read books
9. getting sleep
10. flexible work schedule
11. being able to speak a language no one understands
12. everyone greeting one another on the street
13. buying a whole TV series for $4
14. children getting unreasonably happy seeing a white person (dancing, singing, jumping up and down, etc)
15. having a housekeeper for household chores
16. never being self conscious about how I smell, how dirty I am, or what I’m wearing
17. fresh food
18. tomatoes year round
19. women burping profusely in public
20. being surrounded by so many opportunities for improved efficiency

Honduras v Switzerland

USA v Algeria

What a great match and of course our team had to wait until the 90th minute to score.

GO USA!

Bring on Ghana!

South Africa v France

Honduras v Spain

On the way to the match with a great group of Hondurans. I wish the USA had better country cheers than just "U S A" but it's better than nothing :)

World Cup Update: USA v Slovenia

An American Moment at the World Cup

GHC on Fox News

There's a video clip at the end of this Huffington Post article on Global Health Corps from the Fox News report aired on Sunday night (June 13th). I can't download video while in Tanzania to see for myself but I've been told they used some video footage I took for my blog.

You can watch the whole story on Hulu (it's the last story on this episode).

Here's a clip from the story:

Africa World Cup

The 2010 World Cup started two days ago and is gripping this country (along with the world). I've never really followed futbol until last years Confederations Cup where the US played brilliantly and made it all the way to the finals. Since then I've been watching the English league (the favorite of most Tanzanians, go Arsenal! ) and have been getting more and more excited as the World Cup has been approaching.

This Friday I'm headed to Johannesburg for a week to catch games live! My first game is USA vs Slovenia on the 18th. I'll try to post some videos and pictures from my experiences there ASAP.

GO USA!

Also, congrats to Ghana today for achieving Africa's first cup win!

For an interesting mix of social justice and the World Cup check out this site.

Happy Sunday.

Tanzania Needs More Mamas

The Economist recently released an article about the challenges international organizations have faced when attempting to do business in Tanzania entitled “What’s the Hurry?” It resonates with my experience and offers some validation to what has felt like the most challenging aspect of my work thus far. The last paragraph captures the gist:

Mr Kikwete (the President of Tanzania) has at least tried to give the appearance of curbing corruption. A Bank of Tanzania official was acquitted of puffing up the cost of building a bank from $73m to $357m but found guilty of “abusing power”. Visiting businessmen, however, say they are still deterred by red tape, a weak legal system and a lack of skilled labour. Above all, they say, Tanzanians seem to lack a sense of urgency.

Call it a lack of urgency, a lack of motivation, or failed incentives, the real problem is that things do not get done. I can’t remember how many times deadlines have been missed, commitments have not been met, or meetings have been delayed by weeks, all while constituents assume a complete lack of responsibility or remorse. Inaction and failed follow through is business-as-usual and even a small amount of pressure against this culture can be viewed as being pushy and culturally insensitive.

When I’ve outwardly exhibited impatience during my year here, I’m invariably reminded by a Tanzanian around me “This is Africa” read "what do you expect?" But my travels to neighboring East African countries and this article suggest the lethargic pace of life is actually a culture more distinctly Tanzanian than African or East African. Some Tanzanians, however, are paving the way for a cultural paradigm shift.

One woman I’ve had the pleasure of working closely with this year from the district health management team in Kilwa defies the prevailing work culture in Tanzania. Innocentia Mangosongo, or Mama as everyone calls her, is the district head of maternal and child health though she clearly stands out as the leader of the male-dominated health management team. Tirelessly working 10 hour days and most weekends, I’ve observed Mama’s passion and vision driving the impressive progress being made to Kilwa’s health system. She leads by example and sets high expectations for staff members throughout the district. And, against all odds, things get done!

While long delays for business deals are undoubtedly frustrating, inaction and delays in the health field, unfortunately, have truly dire consequences in Tanzania. Kilwa is lucky to have Mama Mangosongo but many parts of Tanzania aren’t as fortunate. With time, my hope is that more Tanzanians continue to step up to work in a proactive, determined way because there’s no telling what a country full of Mamas can achieve.

Barbara Bush on Good Morning America about GHC

Here's the transcript of the interview but I couldn't find a good link to the video (search around a bit and you'll find it, just don't have the bandwidth here...).

An Eye Towards Sustainability

With only two months left to go in our fellowship, Goodluck and I have been focusing on how to ensure the work that we have done to increase data accuracy and system support is sustainable and maintainable by the health system’s own infrastructure when we leave.

We have recently been able to establish that the project we designed and implemented over the last 10 months to increase data accuracy has had a long term, lasting impact on the staff we enrolled in the program. I explained in an earlier post that during our data workshops we tested participants at the start and end of the workshop and established a resulting increase in data accuracy of over 200%. Although we designed our program to include additional visits to staff members to help cement the learning, I’ve continued to be concerned about long-term skills retention.

Last week, every facility from Kilwa was invited to a training on a new set of PMTCT (maternal health) data tools that we helped get translated from English to Swahili so that staff members could actually understand the forms they’ve been asked to compile. We took this opportunity to give them similar data tests that we gave them during the data workshops they attended up to six months ago to see both the long term efficacy of our previous training program and also the effect of the translated tools. Health workers achieved the same scores at the start of this training as they achieved at the end of the data workshops. In other words, the 200% increase in accuracy was maintained over time. Additionally, after sharing the newly translated tools, we tested them again and saw another significant increase in accuracy. All totaled, combining our training program and the translated tools facility staff has achieved close to a 300% increase in accuracy that we now expect to see sustained well beyond our fellowship year.

Another sustainability-focused program we’ve worked on has been to partner with the district health management team to design a decentralized management structure of mentors. The goal of the decentralized structure of mentors is to ensure consistent supervision and support throughout the district with data accuracy and supply stocking. District managers are supposed to provide this support but lack the time and funds to visit every facility each month, oftentimes failing to visit for months at a time. To solve this problem, we identified Kilwa’s most organized and passionate staff members and invited them to a weekend workshop to introduce the mentorship program, run them through in-depth data, lab, and health services training, and ask them to commit to taking on the extra responsibility to help improve the overall system of support for Kilwa health facilities.

I was skeptical about how our proposal would be received, considering all the difficulties we’ve run up against with overworked, poorly motivated staff members. I’m happy to report, however, that while there was an acknowledgement of the increase in work this would mean for each of the mentors, they fully grasped the significance of how much this type of system was needed and were excited at the opportunity to be involved. We’re looking to roll out the first two rounds of mentorship activities with our 12 mentors in June and July and adjust the program as necessary so that it will be fully functional in August when our fellowship year has been completed.

Goodluck and I are working with Clinton Foundation staff and Ministry of Health officials to roll out our programs to surrounding districts with the hopes of replicating the results we’ve achieved in Kilwa. There’s also a good chance that Goodluck will be staying on with the Clinton Foundation in Tanzania to help continue leading efforts to improve data quality and health systems. While I’m excited about the possible broader impact of the expansion of our programs, I’m mostly encouraged to know that the work we’ve done this year has had some significant impact, even if just to the Kilwa district.

Global Health Corps [GHC] has taken a chance in sending people like Goodluck and me into the global health field to try to create new, innovative solutions to persistent problems without having any experience with health care. As we’ve come up against seemingly never-ending roadblocks and unpredicted challenges throughout the year, I’ve doubted my efficacy and value to the cause of global health. However, going through the challenges and coming out with meaningful results has made me appreciate GHC’s model that much more. We need people who have enough energy and passion to persevere through bureaucracies, inefficiencies, and stale solutions to find a better way to do things because there’s always a better way.

Another GHC Article

This time it's on CNN. I even get a shout out in this one.

GHC at the National Press Club in DC

GHC President Barbara Bush gave a great speech about GHC yesterday. View the video here.

The Value of a Good Experience

Goodluck and I have been trying to understand what defines a good health facility in Kilwa to be able to replicate the model to other facilities. In my last video I described how it’s hard to analyze data by health facility because, for example, we don’t know if increased diagnosis at a given facility implies poorer health for their surrounding communities or better service provided to attract more patients to get treatment. Based mostly on qualitative evidence gathered from on site visits and patient interviews over the past month, however, we’ve concluded that higher aggregate numbers aare almost always an indication of exemplary medical services being performed. But what does “exemplary medical services” mean?

IDEO CEO, Tim Brown, summarizes a popular concept coined in Daniel Pink’s book A Whole New Mind saying, “once our basic needs are met − as they already have been for most people in the affluent societies of the West − we tend to look for meaningful and emotionally satisfying experiences. The value of services lies in the emotional resonance they create.” The implication is that when basic needs are NOT being met, i.e. in most third world countries and certainly all of the communities Goodluck and I serve in Kilwa, the human mind doesn’t care about emotionally satisfying experiences. Fulfilling basic needs is the primary driver behind what the mind desires.

In reference to our health facilities, I’d expect “exemplary medical services” then to mean that the necessary drugs are always on hand and ailments are successfully getting treated. And that’s it. This would also imply that each health facility we work with who has low statistics doesn’t have proper drugs in stock and that the medical staff are misdiagnosing patients who therefore aren’t getting treatment.

Goodluck and I know this is not the case. We’ve been delivering medical supplies to all facilities through the year and patient numbers remain the same. The medical knowledge of health staff, though indeed varied, doesn’t vary with the number of patient attendance (we’ve moved well-skilled health staff from a strong facility to a weaker one and after a year still haven’t seen much increase in attendance).

What we have seen is that health facilities with staff who enjoy working together, are organized with paperwork and office supplies (including drug stocks), who clean their facilities (even the cobwebs by the roof), who maintain equipments such as patient beds, and who even groom their grounds with rakes and flowers, are the facilities getting the most patients. These are the marks of exemplary medical services and they contradict Daniel Pink’s notion that only certain groups of people can afford valuing emotionally satisfying experiences. He would contend that the experiential enhancement of an inviting landscaping would provide little value in terms of increasing attendance at health facilities in Kilwa, Tanzania because it’s not fulfilling a basic need. Our experience here has suggested, however, that everyone values emotionally satisfying experiences.

What I think Pink misses in his analysis is that the definition of basic needs changes for people in the third world. Not everyone in Africa is living a stress-filled existence worried about fulfilling basic daily needs. Tanzanians in my village seem to have come to a knowing realization of what their life is like. They can depend on food sources based on the season and the amount of rain in a given season. They know the best places to get water to drink so as to avoid fatal illnesses. They know that any electricity service is always temporary. And they don’t celebrate the birth of a child because they know there’s a real possibility that the child will die in its first 6 months.

Basic needs being met in the US and basic needs being met in rural Tanzania look completely different. But from the point of view of the respective communities, basic needs are being met in the majority of cases. The implication being that it is incredibly important to think about how to create safe, enjoyable, satisfying emotional experiences when trying to achieve successful services of any kind. And in the context of critical experiences such as public health services in the third world, where there aren’t private alternatives to create natural competition, the responsibility lies on the system managers to seek out facilities who are creating this type of experience and hold them up as the standard experience all facilities should be striving to provide their patients.

Freshly planted flowers at Somanga Health Facility

Challenges Analyzing Health Data

50 Things to do when I come home

My last blog post got me thinking of all the things I want to do when I’m back in the states. So here are the top 50 I brainstormed in no particular order.

50 things to do when I come home

1. go wine tasting
2. wear a jacket (it’s been too hot here)
3. take a bath or long shower with hot water
4. eat a cheeseburger
5. watch espn
6. bbq some meat
7. have a beer from the tap
8. play golf with my dad
9. surf the internet at faster than 14k
10. eat bacon
11. drink water from the tap
12. order something on amazon.com
13. get ready for the day without having to take malaria meds
14. spend an entire day out without sweating
15. hang out with my niece
16. see a movie at a movie theatre
17. cook ‘San Francisco pork chops’ for my family
18. have my waiter give me a recommendation on the food at a restaurant
19. go grocery shopping
20. drive
21. sleep with bedding
22. sleep without waking up to any number of bugs crawling on me
23. go outside at night
24. be anonymous
25. enjoy real customer service
26. buy something at a price that everyone pays, not just a white person
27. be able to have a conversation with a stranger
28. sleep in a bed without mosquito netting
29. sit in a meeting where I can understand what’s being talked about
30. watch HDTV
31. make a toll free phone call
32. watch a youtube video
33. eat a chocolate chip cookie
34. go to a baseball game
35. go to a dinner/house party
36. go to Costco
37. listen to pandora
38. go out to a fun/nice restaurant
39. go to a concert
40. print something on a printer
41. have a mentor/manager at work
42. get bottomless fries at Red Robin
43. rent a movie
44. get a milk shake
45. build a bonfire
46. camp
47. go to a public place without getting overwhelmed by B.O.
48. go on a weekend road trip
49. hang out with an old friend
50. Get a hair cut

A Year of Lent

Easter is now only two weeks away and over the past few years I’ve looked forward to Easter not only for the traditional Easter festivities but also because it marks the end of Lent, and more specifically, the end of a period of self denial of something I’ve chosen to live without. This year was different in that I haven’t chosen to sacrifice something specifically for Lent because I don’t have much to sacrifice that I already haven’t.

I chose to come to Tanzania for this fellowship year because I was compelled by the opportunity to get to work on tackling one of the worlds’ toughest challenges: HIV/AIDS in East Africa. However, though I’ve worked and traveled in the third world many times before, I didn’t realize how many American comforts I’d be sacrificing at the same time. Through the months of forced denial, I’ve come to affectionately call this my Year of Lent.

My first month living in the rural town of Kilwa, Tanzania was hard but I learned to deal with it. When the second month was harder than the first, I didn’t know if I was going to make it the whole year. But then something changed. I started to enjoy the simplicity of my life.

We have so many choices in the US of things to do that there’s an expectation that you do something fantastic with the time you have. At the same time, with so many choices, it’s often hard to decide what to do. Resting is not an option; "you can sleep when you die." Everyone goes to the movies. What can I do that’s particularly fun and unique?

I’m dramatizing it a bit but a pressure does exist to be interesting and do interesting things. The beauty of my life here is that I have very few options of what to do with my free time. There are virtually no choices and consequently there’s no stress to make the 'right' choice.

So my Year of Lent continues and my ‘Easter’ is four and a half months away at the beginning of August. Much as I’ve enjoyed the act of self-denial while participating in past Lents, I’ve also come to appreciate having a whole year of my life filled only by books to read, a beach to run on, and a bed to nap in.

I still find myself craving home and the things that come with it.  However, I’ll undoubtedly miss the simple life of rural Tanzania when I’m back.

Paycheck Problems

Following up on Feedback

Enough fun videos of animals. Here's another boring work video :)

I miss my family (who went back to the US after a long visit a week and a half ago) but Goodluck and I are starting to get a lot of momentum going with work so I'm excited to be back. Somehow from getting home last week till now I feel like the end of my fellowship is coming on too fast. Another great sign to me that life is good (mostly due to my work going so well).

Wildebeest Migration

This video doesn't do the migration justice but there are literally millions of animals hanging out on a huge plain. I think I have some good pictures of it that I'll post soon.

Lion, Lion Cubs

Safari Ride Narrated by Dad

Cheetah Crying for Mother

Giraffe Fight

Back from Family Safari

After going 7 months without seeing anyone from home, my family came to visit for two weeks and I had a great trip with them! I'll be putting up a series of videos this week shot during our Safari through norther Tanzania and southern Kenya. Enjoy!

Here's the first:

Tour of my House!

Valentine's from Cape Town

Redesigning "the meeting"

At my last job in the US we desperately tried everything we could to avoid having meetings. We tried a "no meeting day" or tried to establish a rating system to get rid of meetings that received low scores.

In contrast, people LOVE meetings in Tanzania. Why? Because meetings here mean money.

Tanzania has the puzzling common practice of paying people to attend work meetings. They're not paid for being the keynote speaker or even for presenting. They pay people JUST to ATTEND. So, as you might imagine, many of the training sessions or work meetings I've gone to have had many attendees but very little audience participation or engagement.

In response to this, Goodluck and I have tried different ways to facilitate learning and capacity building during meetings for health workers in Kilwa. Traditional trainings occur with large groups in a central location, requiring participants to travel there (and organizations to pay for their travel expenses as well as their attendance). Instead, Goodluck and I travel to them and do 2-on-1, on-site training with workers in the facility for shorter but much more focused and concentrated teaching sessions that we've found to be effective despite the short amount of time we spend in each facility (1-1.5 hours).

Despite the value of the on-site trainings, one of our goals is to build community between local groupings of health facilities as a means of establishing decentralized health management. Therefore, we do include one larger group training session in our training program where we pay participants to attend. However, we call it a Data Workshop instead of training and have designed a number of exercises and tests that have meeting attendees working together on analyzing data and identifying problems. In this way, we force participation and engagement much beyond the traditional sit, listen, collect money, go home that defines the current design of meetings/trainings.

We went one step further in our most recent data workshop this past Tuesday. Though Goodluck and I disagree with the 'payment for meeting attendance' method, we still comply with the culture. After all, it does seem to be a great way to ensure people actually come. However, we thought we could change the way an attendee earned their allowance and increase participant's interest in the material in the process. Instead of getting a flat allowance for meeting attendance, we gave our participants two data tests, one at the beginning of the day and one at the end, and told them that they'd earn bonus money depending on how much they improved (we told them this after they took the first test).

Participants' scores on this exercise had averaged ~2 out of 8 in the past and the first test of the day with this group was no different: they averaged 2.5 out of 8. After explaining our program to them, however, participants were much more engaged throughout the rest of the day's training and finished the second data test averaging 7.5 out of 8 as a group (a 200% increase)! The results meant both bonus money earned by participants and increased confidence in their abilities to improve how they collect and analyze data in their own facility.

On top of that, Goodluck and I are particularly excited about the fact that the district health management team in Kilwa has started to adopt and incorporate many of these practices into other meetings and trainings they run. They were also very interested to hear, and we're eager to report, the outcomes of our "pay for performance (not attendance)" method.

Goodluck and I are always on the lookout for ways to innovate and improve existing systems in our work and redesigning the meeting has been a great achievement for us so far.

Here are some videos of us mid-data workshop!

Day in the Life: Part 2

 

Goodluck and I went on facility visits all week last week and I snapped this picture of Goodluck, our driver, and a nurse we were transporting. Each day when driving to different locations we get stuck in the mud or sand at least once. It quickly becomes a community event as a group of African men appear out of nowhere to help us dig and push our car out. The .5 hour to 1.5 hour delay used to stress me out but it's a daily challenge I've come to expect and actually enjoy. A bunch of guys digging and pushing a car out of the mud? How fun is that? There's normally a big cheer from the group when we successfully get to solid ground and a lot of words of appreciation and waves as we shoot off to our next health facility.

I can't help but laugh about how different the daily challenges are for my friends living in the states. I will definitely miss the daily adventures when I get back.

Great Article about Product Design for Social Good

I just read a great article sent to me from my GHC mentor about product design and wanted to share: When Technology Flops: 6 Common Pitfalls for Product Design for Social Good

Pitfall #2 hit home for my project.

Pitfall #2: Using technology to solve a culture-based problem. Sometimes, the most fundamental issue isn’t tech-related. For instance, female infant mortality in many countries is largely the result of cultural value systems rather than lack of sufficient healthcare (although the latter is necessary as well). In these cases, well-designed medical devices aren’t going to solve the underlying problem of gender-based discrimination. Other forms of intervention are necessary for changing people’s mindsets.

Though there are many technologies that can and will help the health system in Tanzania, so much more work needs to be done that isn't based just in developing a technological platform or tool. Unfortunately, solving culture based problems requireschanging cultures which is often a much more difficult challenge to tackle with a more nebulous path towards a solution; especially when you don't know the culture you're trying to change that well in the first place.

Fortunately the Global Health Corps system for pairing local and American fellows has been incredibly helpful for navigating cultural issues and Goodluck and I are starting to see some real seeds of change.

Running Partner

I've been running on the beach by my house alone for a few months now. Goodluck has come with me maybe 2 times but most of the time I run alone and with my head phones in. Accordingly I expected running to be another way I'd feel isolated here. However, one of the main parts I've grown to love about the running is that even if you're running alone, it's social (especially on the beach in Kilwa).

There are not many other African's that run the beach other than a few boys on a local soccer team. But from about 5pm to 6:30pm each night people from the community come out to sit on the beach with friends and enjoy the sunset/twilight.

Being the Mzungu (word for white person in East Africa) I get plenty of stares but I say hi to everyone I pass and they smile and give me a thumbs up and a wave back. Sometimes I throw out a mambo vipi (what's up) and get a warm response. Sounds like nothing much but despite not being able to communicate, I've felt closest to the community when I run on the beach.

Today, a local man came out of no where and just started running next to me. I looked over at him and smiled and he nodded in acknowledgment and then we just ran in silence next to each other for the next 25 minutes. We passed a bunch of people on the beach but no one seemed to think it was odd that we were running together. I'm sure he just wanted to go for a run but because he chose to do it along side me I felt accepted.

It's hard to explain to some folks from home but living in a world as the "other" for the first time in my life has been harder than I thought it would be. But a simple experience like I had today becomes that much more meaningful.

Another Random Article about GHC

http://www.dallasnews.com/sharedcontent/dws/ent/stories/DN-peppard04_0104gd.ART.State.Edition1.4bbbb44.html

We'll have some more interesting press stories coming out in the near future in some publications you probably won't expect :)

Great GHC Interview with CGIU

GHC staffer Dave Ryan caught up with the Clinton Global Initiative University team about what the GHC organization is doing to address health issues in both the developed and developing world.

See the article here.

Here's a sample from the article:

"There is a need for skilled professionals who can provide the services necessary to build and implement effective health systems. The young leaders who participate in Global Health Corps have experience in a range of fields, including technology, supply chain management, monitoring and evaluation, and program consulting. We place them in organizations where they can implement innovative strategies to build effective health systems. We also nurture them so they can explore careers in the health care field that fit their skills."

Update from Rwanda

Here's a quick video I made from the conference we had in Rwanda. As I say in the video, if you are interested or know anyone who is interested in applying for a Global Health Corps fellowship please leave a comment, contact me directly, or just check out the website for more information: http://apply.ghcorps.org/

Keeping Vaccines Cool

It's been far too long since I wrote up an update but the last month has been pretty busy. I just got back from a great mid year conference with the Africa based Global Health Corps fellow team that I'll write more about soon. But here's a quick video I made last month (before I cut my hair) about one of the basic, but vital challenges facing health facilities in Kilwa.