Thursday, November 10, 2011

Working Myself Out of a Job

It’s finally going to happen.

Several times I’ve told people that I want nothing more than to need to fire myself. I would love to be out of a job. I would love to not be needed. In a perfect world, I wouldn’t be. Interesting thing about being a doctor.

When I say that I want to work myself out of job, I’m usually referring to one of two things. The more common one in malaria. I often say that if there was no malaria in Tchad, I’d be out of business. It accounts for most of our pediatric hospitalizations (and deaths) and a good chunk of our adult medicine patients. Even several of our surgical patients need to stay at the hospital longer than planned, due to malaria. Losing one or two kids every week to the same disease is getting really old. I hope I’m not getting calloused to it.

The second way to lose my paycheck is to get involved in public health. Here at the hospital, I can only treat one patient at a time. Getting involved in public health, I can treat whole communities at a time. Better yet, I can prevent them from getting sick and prevent them from ever even needing my services at the hospital. The catch is that going out into the communities and teaching them this stuff doesn’t pay. Not a dime. In fact, it would hurt my bottom line. If they don’t get sick, they don’t come to the hospital. If they don’t come the hospital, I can’t order tests on them or sell them medicines or do their surgeries. I won’t make any money. I’ll be losing money. I might just need to fire myself. Awesome!

This has been my thought for a long time, ever since my food policy friend informed me, sarcastically, that, ‘As a doctor, you can only harm one patient at a time with bad decisions. Writing food policy, I can hurt scores if I make a stupid mistake.’ Of course, his insinuation was that the corollary would also be true, that good policy can save more lives than I can by seeing one patient at a time in the hospital. It was his tongue-in-cheek way of drafting me into the line of public health. Since then, I’ve toyed with the idea of getting a master’s or doctorate in public health. But after medical school and residency, the idea of more schooling is still a little painful. Maybe someday.

And ‘maybe someday’ is where my good intentions always seemed to end.

And then manna fell from heaven, right into our laps. Manna in the form of two women. In June, Minnie arrived from the Philippines. Although her degree is in psychology, she has vast experience in public health projects, as well as a resume spanning from licensed massage therapist (no, not the real reason we brought her here) to licensed artisanal chef (also not the reason we brought her here) and everything in between.

When Minnie arrived, I was pretty much hands-off and left her to her own devices. It’s not like I know anything about public health where I could actually be of any benefit to her. Minnie seized the bull by the horns and jumped right into it, taking the initiative to visit all 21 neighborhoods of Bere and meet with their local governing chiefs and officers. She presented them an amiable face to represent the hospital and asked them what we could do to help them. I won’t delineate all of what we learned, but much of it was surprising and much of it was embarrassing for the hospital, honestly. Minnie put some psychological salve on open emotional wounds and left people with a better impression of our hospital.

Our second-helping of manna was Marci, who just completed her Master’s in Public Health from Loma Linda University. Both Minnie and Marci have committed for a year, with Minnie potentially staying much longer and Marci trying to establish a program bringing us a new year-long public health graduate every year. Marci arrived just one month ago and has quickly and synergistically reinvigorated the work Minnie had already put into motion.

Whereas Minnie is a humble, meek, petite, quiet, organized, detailed person, Marci is a tall, gregarious, outspoken, big-picture, dreamer person. They complement each other perfectly. Two Marcis or two Minnies wouldn’t be as effective as one of each. Such a blessed pairing!

Since her arrival, Marci has developed a public health outreach project to address several of the needs voiced during Minnie’s assessment period. We will be starting one week of meetings in each of the 21 villages in our new Project 21.

Pardon my cutting and pasting, but I’ll insert some of Marci’s 14-page project proposal, which was approved.

Community Health Education
After analyzing the expressed and observed needs seen in the communities, ten topics were chosen for general education of the villages. These ten topics are as follows: breastfeeding, maternal health, clean water/water borne illnesses, nutrition/malnutrition, natural remedies, malaria, AIDS, tuberculosis, abuse, and personal and oral hygiene. Lectures on these topics will be prepared and presented by or with the supervision of a public health specialist or nurse with use of a translator for local dialects and French as needed. Large posters with be created to illustrate the topics of each lecture and other visual aids will be purchased such as food to illustrate information during the nutrition lecture. This method was chosen because of limited access to electricity and the portability of posters. The educational classes will be presented at a central location within each village that has been pre-agreed upon with the local chieftain. To encourage attendance, raffle tickets will be given out with drawings for food, and other topic relevant items such as toothbrushes. On the day the topic of water is covered reusable water bottles will be handed out. For the day nutrition is covered 30 bags of food will be raffled. On the personal and dental hygiene day 30 toothbrushes, each with a tube of toothpaste, will be raffled. Each village will have classes for three days, starting on Monday and running through Wednesday, with three to four topics covered per day. The classes will be presented from around 3:30 pm to 5:30 pm each afternoon. This timing fits with the approximate end to the work day and before dusk when the mosquitoes become a deterring factor. The estimated time for completing the community education portion of the project is five and half months giving one week per village and allowing for expat and local holidays.
In conjunction with the community health education lectures, a mobile dental clinic will go to each village on the morning and afternoon of the third day of lectures in that village. The dental clinic will provide free tooth extractions. The will be one dental provider working to extract teeth. Depending on the amount of work needing to be done on each person an estimated 30 people will be treated per village. Each person treated will receive a toothbrush and toothpaste.
Community Health Workers
First Aid Agents are persons who have been trained by the Red Cross for three months and have been given some follow up training. Their primary role is to be on call for emergencies and to help educate the people of their village about hygiene and prevention of diseases such as Cholera. It was requested for them to obtain more training. They also requested equipment to help them do what they have been trained to do. The program will have the village elect two First Aid Agents per village to attend training to become Community Health Workers. As part of the training they will be required to attend the lectures presented in their village. They will be assessed for their current knowledge of CPR and First Aid skills and given training or a refresher course on these skills. On the afternoon of the fourth day in each village the assessment and training of CPR and First Aid will be covered. There will also be a final training in groups of about 10 to 15 participant during the end of the sixth month. In response to their request for supplies they will be given a basic First Aid kit consisting of gloves, gauze and a mouth guard for CPR if they have completed the entire program. To increase the perceived value and involvement in getting a health worker for their village the program asks for 500 CFA which is about $1.10 dollars for tuition for each community health worker. Also, the village is to create a two wheeled stretcher for transportation to the hospital.
Midwives/Traditional Birth Attendants
Midwives vary in number for each village; some villages said they did not have any midwives while others have two or three. Midwives who were interviewed had been trained by the catholic mission with follow up training at the district hospital. From observational assessments by Béré Adventist Hospital staff more training is still needed which agrees with the expressed needs assessment from the villages and the midwives themselves. The midwives interviewed expressed the need for equipment as well as the desire for more training and were very open to being involved in a referral system with the hospital. This pilot project aims to fill all these requests and create a referral system in which the midwives can be empowered and supported in their roles, pregnant women will receive at least three prenatal visits (preferably four, distance from the hospital allowing), and the women at risk or experiencing complications will be brought to the hospital in a timely manner.
The training portion with be conducted in French and Nanjire, the local language, and will cater to the illiterate. The program will look to establish a base knowledge and assess current skills. Instruction provided will include but not be limited to the following topics: breastfeeding, discontinuing the cultural practice of removing the umbilical cord (a practice in which the umbilical cord is removed by compressing the abdomen with extremely warm hands repeatedly until the umbilicus fails off which is an unnecessary practice and is very likely cause for the high rates of umbilical hernias), the importance of stressing to mothers and families to not give water to babies under six months, kangarooing for premature infants, risk and complications and when to refer to the hospital, programs at the hospital, and the importance of prenatal visits. At the end of the pilot project training and as incentive to continue to work with the hospital the midwives will receive disposable gloves, scissors and a pink lab jacket. The lab jackets will give her something to wear for delivering babies and also give her a more medically authoritative appearance. In order to increase the perceived value of the program participation in the training program will cost 500 CFA which is about $1.10 dollars.
The goal of the midwife portion of the pilot project is to train and establish a working relationship between the midwives in the villages of Béré and the hospital. By working more closely with the hospital the midwives can become an extension of the hospital in the village. To establish this relationship, portions of the training will be done at the hospital to familiarize the midwives with the hospital layout, routines of the hospital and the staff. A referral system will be designed with mostly pictorial referral cards for illiterate midwives which would provide a record of the midwife’s assessment of the pregnant woman throughout the pregnancy. This collaborative relationship between the midwives and hospital will be assessed at the end of the pilot program for changes, more training and funding needed for successful continuation.
Women’s Skills Training
Skills training was requested by the villages. Project 21 will train 10 women from each village to create handicrafts which they can make from home with limited initial financial outlay and that will fill a hole in the market. The project will work first with women’s cooperatives then widows. These criteria will be given to the village and then they will be responsible to elect the women who will be involved in the training. Through focus groups and observational assessments it was noted that there are limited number of toys and no dolls or teddy bears market in this area of Chad. Purses are also valued items. From initial assessment clutch bags and the “Rungi Chungi” teddy bears and dolls are marketable in this area with the potential for extension to the local region and abroad. These will be the first projects undertaken to train the women on. The skills training will take place during the morning of the first and second day of the community health educational classes in each village. To increase the perceived value of the project each women will pay 200 CFA for two mornings of training.
The women will also be given a short talk on marketing and basic business. With continuation of Project 21 further business skills training for these women is recommended. Other skills could be also taught in the future as well.
To provide general health education to the 21 villages of Béré, Chad, as well as specific training for the midwives and community health workers and to build a collaborative relationship between them and the Béré Adventist Hospital and to provide skills training for village women.
Objective One:
To provide three day health education classes to each of the 21 villages in Béré, Chad, over the duration of five and a half months.
Objective Two:
To establish community health care workers by assessing and provide furthering education to two First Aid Agents per village during a one day lecture in each village and a culminating day of training for all at the hospital.
Objective Three:
To assess and provide furthering education to two midwives per village during a one day lecture in each village for the midwives and a culminating day of training for all at Béré Adventist Hospital.
Objective Four:
To train 10 women from each village in the art of making and selling handicrafts, specifically dolls, teddy bears and clutch purses.

As you’re reading this, you can probably see the costs start to add up. The overall budget for this project is over $10,000. However, we have already approved it and are going to move forward, as we feel this is such an important work. As we try to further the work of our church and hospital, we feel that this fits very well into God’s plan of providing for the health of His children. Not only will this help people live healthier lives to glorify God, this will build up a solid reputation for both church and hospital (which are actually inextricably linked here).
It’s taken us almost a year to realize it, but we now know that we’re not here to heal people in the hospital. That’s important, yes. But, we’re here to build relationships. And this will help us build relationships. Hospital to community. Community to community. Hospital to people. People to people. People to Christ. It’s all about relationships.
I’m not a fund-raiser by nature, nor is it something I particularly enjoy. But I’ve had enough people ask what specific projects they can give to, so I thought I’d offer this as one. Obviously, we don’t expect anybody to cover all the costs. Every little widow’s mite helps.
And while I’m on the topic of fund-raising, I need to give a little praise. We are planning on expanding our hospital and so far we have already received donations from A Better World Canada as well as Springfield First Adventist Church in Massachusetts. Both are funding entire buildings!!! As well, we’ve had several generous individual donors toward the ends of new buildings. And Association Medicale Adventiste de Langue Francaise has agreed to send a container or two full of equipment for the new buildings once their built. New, modern, functional, useful equipment has been a thorn in our side since arriving, and this will be very welcome. To the same end, we’ve had many other institutions be generous with their donations of supplies, such as Florida Adventist Hospital and Baystate Hospital. Thanks to one and all!!!
If funds are tight, please support us with your prayers. These are far more important than any money!
You will notice on our blog,, that we have a link for donations. This is through Adventist Health International’s website. We believe strongly in the mission of AHI. We feel that AHI is an organization worth supporting. By donating through AHI, you can be reassured that there is a strong measure of accountability following your donation. Just mark the donation for ‘Bere.’ And remember that your gift is 100% tax-deductible.
Olen Zain: +235 62 16 04 93
Danae Zain: +235 62 17 04 80
Olen et Danae Netteburg
Hopital Adventiste de Bere
52 Boite Postale
Kelo, Tchad
Volunteers Welcome!!!

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