Maternal & Child Health in Kilimanjaro, Tanzania

The second major theme woven through my weeks with the Community Health Department is, as I have learned, also the very foundation of community and public health: the care of mothers and children. Pregnancy and childbirth, as the places where life begins, are the absolute earliest possible opportunities we have to educate about, advocate for, and promote lifelong health. When communities are empowered to engage with awareness and healthcare initiatives surrounding maternal health, it is the very definition of “upstream” medicine. The care of mothers in pregnancy and child birth, then, bears not only extreme relevance to my aims with this scholarship but also, on a MUCH larger scale, to the healthy future of emerging generations all over the world.

At KCMC, my engagement with maternal and child health involved working in three different projects:

Antenatal Care

The first of these projects was a weekly clinical experience at KCMC’s Antenatal Clinic. Working alongside Tanzanian medical students and midwives on a Tuesday morning, I had the opportunity to greet the pregnant or post-partum women arriving at this clinic, take their weight and blood pressure, weigh their babies with the antenatal nurses, and practice my Swahili with greetings and easy conversation about how ridiculously hot it must be to pregnant in this tropical climate or how ridiculously adorable their fresh-out-of-the-womb babies were. More than anything, I loved the human-ness of this experience: the palpable buzz of energy that accompanies mothers and mothers-to-be who will do just about anything – walk just about any distance in just about any temperatures or amount of rainfall – to fight for the health of their children. This love and energy is, from my treasured observations in this room, a cornerstone and driving force in these public health services. Each new mother arrived with a hand-sewn hammock/bag that their baby could sit in and be hung from the weighing scale, and these bags – something I have seen in no other healthcare setting before – were made in the entire vibrant rainbow of local Tanzanian fabric, and served as another totally beautiful marker of the home-grown love for these children.

After these initial checks, pregnant mothers received regular checkups: ultrasounds, laboratory tests, vitamin and medication adjustments, diet and lifestyle education, and an opportunity to express questions and concerns. Newborns also received check ups, assessing their growth and general health, looking for any early red flags of ill-health or developmental delays and, when on schedule, receiving the WHO-recommended sequence of childhood vaccinations. Nervous first time parents were given education on the side-effects of vaccinations – like fever and general un-wellness – to ensure that parents are not scared off of the vaccination program and continue to return for the long-term health of their babies. This small clinic was a total hive of protective and preventative healthcare activity every week, and I loved it!

Maternal and Child Health Monitoring

Another of my weekly assignments in the department was to collect data on maternal and newborn health outcomes from the various relevant hospital departments, and compile it with incoming data reports from all over the Kilimanjaro Region. Even though data collection might sound like a little bit of a dull grind, I got a total rush (nerd alert!) from seeing all the numbers come together each week and watching as the “big picture” of such a crucial area of health unfolded in front of me. In order to develop this picture I started every Thursday morning, armed with a notebook and pen for some old-school data collection, to the Neonatal Unit and NICU. Entering this unit is like leaping headfirst into a kaleidoscope. Benches line its narrow corridor, and these benches are filled shoulder to shoulder with the backbone of Tanzanian society: the mamas. Sharing a few bare-bones mattresses in a corner by night, mamas with babies in this tiny unit stay here 24/7 for the time of their child’s admission, so that they can always be on hand to breastfeed. They sit by day, exhausted, crowded, and traumatized to tears by the illnesses of their babies, but dressed nevertheless in an incredible and optimistic array of stunning Kanga and Kitenge – the local fabric that makes Tanzanian women living works of art. From these seats, they hand-pump their breast milk into tiny frail mouths or small metal dishes. It’s really quite a sight to see and I, personally, could never get enough of these beautiful, stoic mamas and the gorgeous, delicate bundles they held. Unfortunately, my job on this unit was much less beautiful and optimistic: recording the week’s admissions and deaths. It was by looking through these records to extract my data that I was reminded of why all these women were here: prematurity, labour complications, birth asyphyxia, gastroschisis, pneumonia… a whole host of complications that, despite the presence of this supportive rainbow of mamas bursting with nurturing milk and nurturing love, were very often incompatible with life.

I’d carry on from the Neonatal Unit to visit the two Pediatric Wards, where children were being admitted and dying from a whole host of terrible illnesses: pneumonia, sepsis, acute and watery diarrhea, meningitis, necrotizing fasciitis, hypovolaemic shock and secondary to sickle cell anaemia, HIV and AIDs, malnutrition, snake bites. Many of these conditions I had never seen before, and all of them I would love to never see again in a child.

I’d finish this process with a visit to the Labour and Delivery ward, slipping into a pair of crocs amidst the sounds of screaming women, screaming babies and – I seriously love you, Tanzania – the soaring voices of an African gospel choir CD that is played on repeat.  After locating the week’s birthing records, I’d  take down the numbers: babies born, babies lost, mothers deceased, hearts broken. It was both an exceptional privilege and an agonizing reality check to make these rounds, moving in and out of the different departments and learning about the heavy and horrendous problems they face for mothers and children in those first delicate years of life. I was always welcomed warmly by the charge nurses I began to form relationships with and encouraged to learn from and reflect on this data: what it means about clinical care in this region and how it can be used to inform improvements. Because records at KCMC are not computerized, all of this data collection had to be done by hand until the final step – a report submitted to the hospital director and municipal public health officer – which made it both laborious and prone to the errors of hurried handwriting. It was yet another good reminder from this year of the challenges of conducting medical practice and medical research in low resource settings, but also of the grit and resilience that people working in those systems exemplify when they get the job done regardless. No room for laziness here!

Technology & Totos

Toto is Swahili for child, and Toto Health is an amazing NGO working in Tanzania that uses innovative mobile phone technology to bring pregnancy and early childhood health education information to the mothers  who need it. In my third and final project pertaining to this maternal health theme, I worked my way through the Labour and Delivery and Obstetric Wards with my supervisor and helped women get set up with this program on their smartphones, which are as popular and heavily-used in Tanzania as anywhere else in the world. We helped them input the relevant medical information about their pregnancy or their new baby, and watched as they began receiving tailored text messages about how to protect and promote their health and the healthy development of their child.  Even in her 60’s, Sister Mayo (my supervisor) is seriously keen to dive in and learn about newly-available technologies that can expand the access of her patients to healthcare information; and I am endlessly inspired by that attitude. Throughout Tanzania and East Africa mobile phones are increasingly being used for vital information sharing – from weather updates for farmers to vaccination reminders for mamas – and joining this innovation revolution for mothers and babies is a tremendous stride forward in public health. As I said at the beginning of this post, mothers sit at both the core and the very foundation of community health, and the more empowered they are to access and use healthcare information, the healthier their children and the future of their entire community will be.

Community-Level Sexual and Reproductive Health Services at KCMC

What I’ve written in my last two posts about my time with the Community Health Department at KCMC included some of the really varied topics I was exposed to during my time there, from antibiotic resistance to diabetic health education, to environmental health and community rehabilitation. It was fascinating for me to get the exposure to this variety, and see just how broad a range of issues “Community Health” encompasses. During my 6 weeks with this department, however, three main themes emerged that transcended almost everything else I did and, I came to realize, really form the foundations of community/public health in Tanzania and what it aims to achieve.

The first of these is Sexual and Reproductive Health. KCMC, like many hospitals and health centres in Tanzania, has a dedicated Reproductive Health Centre (RHC) that is distinct and separate from the main hospital – with the aim of removing the fear and “something is wrong with me” mentalities of visiting the actual hospital. The two main projects I was involved in at the RHC were HIV testing and the Cervical Cancer screening program.

The idea was that I would learn some of the clinical skills required in healthcare screening programs and collect and manage data from these activities. While that did all happen, what REALLY and most-notably took place in that small centre were deep, life-altering, fully-immersive cultural and personal experiences in which I was unbelievably privileged to have the story of each visiting woman laid bare in front of me. I still get goosebumps thinking back on the courage of these women and the stories of pain and vulnerability I bore witness to. More than anything I learned about HIV or cervical cancer, I learned intimately here about the impacts sexual and reproductive health have on the lives and narratives of real, beautiful, individual people.

Cervical Cancer Screening

Thanks to public health campaigns throughout the Kilimanjaro region, the women I met here were voluntarily presenting for screening. This awareness and motivation to attend screening is still, however, the greatest challenge of the program – according to the doctor I was working with. I don’t know about you, but I didn’t realize until this year that not only is cervical cancer the third most common cancer worldwide, but 80% of cervical cancer cases occur in the developing world. Can you believe it is the leading cause of cancer death in developing countries, causing 190,000 deaths per year? Initially, I couldn’t.

I was also surprised to learn that it is relatively straightforward to screen for, using acetic acid (vinegar)! The vinegar, when applied to the cervix, will cause colour changes if pre-cancerous cells are present. KCMC is currently investigating whether this visual test alone is as effective for detection as the visual test combined with a more expensive and laborious Pap smear. While I found this process all so scientifically interesting, I really struggled to participate at the beginning. The tests themselves were very traumatic to watch at times, and I still break out into a cold sweat thinking back to a few of the experiences I had.

Firstly, standards of confidentiality are very different in Tanzania (and, by and large, many of the other countries I have visited this year) to those we exercise is Canada and the U.K. Appropriate doors and curtains for privacy are not always used and, as a woman lies on the table completely undressed from the waste down with her legs in stirrups, doctors and staff of both genders move in and out without introduction or, seemingly, much consideration for the very sensitive conversations happening in that room. I am not trying to say that I know better, nor that Tanzanian culture (generally very open, inclusive, and communal) should necessarily conform to western medical standards. What did impact me heavily in these situations, however, was the noticable fear, shame, vulnerability and isolation I saw in the eyes of the women undergoing screening in these conditions. Coming from a very conservative culture, where many of them had walked in covered up completely from head to toe – and even the most liberally-dressed wouldn’t feel comfortable showing their knees – this rapid transition to nakedness in front of strangers was understandably challenging. I felt it both very difficult, and also guilt-inducing, to add to that crowd of strangers with my presence.

Further, I have learned through this experience and through discussion with others since then that, in Muslim cultures, there can be a concern about the purity of women when objects like the speculum are inserted into their vaginas. Again, culture and religion, and concepts of modesty and purity, were thrown into contrast with medical best interests – exposure, examination, insertion. This cultural and personal fear was compounded for these women with shock, as the cold speculums were inserted, and often a great deal of physical pain. Female Genital Mutilation is still practiced in Tanzania and the Kilimanjaro region, and this alteration of the female genitalia left some women – to my horror and heartbreak – biting down on cloth and gripping my hands to stop from crying out in pain. This extreme physical pain, caused by a risky and damaging cultural practice, got to me the most. After my first experience with this, I walked out of the room – seeing stars – sat down on the clinic’s front steps, and promptly fainted. Bearing witness to this unnecessary and deeply intimate pain affected me viscerally.

All in all, I think cervical cancer screening is vitally important in empowering women to get informed about their bodies and take ownership of their health. I think the work KCMC is doing to this end is fantastic, and I am proud that each and everyone of these women showed up, despite the fear, and made the decision to get their answers. Still, I walked away feeling “not quite right” about the process, and hope to continue reflecting on how respect for patients, their cultural and religious beliefs, and their comfort can continually be integrated into this process in settings like Tanzania and all over the world.


HIV Testing

When women present themselves for cervical cancer screening at KCMC they are also required to undergo an HIV test, because HIV is a significant risk factor for cervical cancer. This is done using finger prick blood samples with two separate tests, and only if the results of the two tests differ is the test confirmed with a full blood draw and lab test. This system is great, I think, in – by removing the use of big needles – creating a less-stressful and more community-based atmosphere that puts patients at ease. Still, there was FEAR. There was heart-wrenching panic in so many of these women’s faces and voices, which also meant that sharing moments of intense relief when the results came back negative were some of the absolute richest of my experiences.

There were also stories. My job in that room was to collect the epidemiological data about the screening, and that I did. I also collected, through the staggering privilege of just being present, a collection of personal narratives that cut straight to my heart. Sr. Mayo, the community health nurse I was working with, summed it up to me: “the biggest HIV problem for these women is our men. Men are not faithful here, and we are not happy with them.” Apparently, men do not accompany their partners to this screening because they know that if they do, they must also get tested. There is, according the RHC staff and CHD nurses, huge resistance to seeking HIV testing and treatment amongst Tanzanian men. This became pretty evident to me as I recorded the sex ratios of the patients who came to see us :I saw approximately 100 women and just 2 men over 6 weeks.

Sr. Mayo, a total hero of narrative medicine, let these panicked, hurting women talk their hearts out – sometimes for hours – giving them a true safe haven to tell their stories and explain to us the reasons they had come to be so desperately afraid that they had contracted HIV. It was through this process that I heard stories of women forced to have sex with men they didn’t know, and women forced to have sex with men in their own families. I met women whose husbands had many wives who had already died of HIV/AIDS, and whose husbands were cheating, employing prostitutes, and taking new wives. I met a woman who already had 6 female children, but continues to be abused by her husband – showing me her bruises – until she bears him a son. I met women from Moshi’s prison who were not given a moment’s privacy to share their fears; to maintain their dignity. I met a woman married to an HIV+ man who did not tell her until after their wedding that he was HIV positive, and refused to use condoms. I saw women who had been brutally beaten and mistreated and abandoned, and women terrified of using birth control because their partners won’t allow it. Story after story, these days made me ache.

Interestingly, the government’s manual/school resource for the prevention of both HIV and early pregnancy is called “The Training Manual on Abstinence and Being Faithful.” As I read through the manual in between patients, I realized that – at all levels – promiscuity, infidelity and the behaviour/position of men in Tanzanian culture were being regarded as the key causes of HIV transmission. Further, it was indeed abstinence, faithfulness, and the adjustment of cultural norms and societal treatment of women that were being advocated for as solutions to HIV instead of, as I had assumed, a focus on condom use and safe sexual practices. A whole chapter of the manual is devoted to culture – and to the specific rituals, rites and practices in different Tanzanian cultures that promote or challenge women’s rights and the concepts of abstinence and faithfulness. It discusses male dominancy and power dynamics in traditional relationships, polygamy and the practice of having multiple sexual partners, transactional sex in conditions of poverty, drug and alcohol abuse, and the imbalanced requirement of women to preserve their virginity before marriage when men are not required to – among other cultural practices.

The term “social vaccine” was introduced to me at one point this year, at the time referring to maternal education levels as being a protective “vaccine” against childhood malaria. While I strongly believe that physical/medical measures, such as vaccinations and condoms, are vital in preventing disease transmission, this experience with HIV testing was a great opportunity to think about what cultural and social factors play into the spread of HIV and other infectious diseases and have the potential to, to an extent, “vaccinate” against them. Medicine is, after all, about people – and people are bound together by culture arguably much more strongly than they are bound by biology. When it comes to a disease like HIV, spread by intimate human contact, it is important to remember that culture and society are what govern our ideas and beliefs about he we interact and come into contact with others: the two are undeniably linked. More food for thought from this year, for sure!

It was also interesting to note that this clinic was specifically called an “adolescent/youth friendly” reproductive health centre. From literature I read inside the clinic, I learned that there is currently a big push ongoing in Tanzania to encourage young people to recognize their reproductive health rights and the utilize the services available to them. Health services are striving to be more welcoming for youth and adolescents, and to increase the provision of psychosocial services to care for the specific emotional needs of youth seeking reproductive healthcare.

While that all sounds great, I have to report that I did not see anyone under the age of 20 (with the VAST majority of patients falling between 25-40) during my 6 weeks at the clinic – and I do wonder what that means in terms of the successes of improved adolescent access. In a study recently carried out in several Tanzanian regions, over 80% of adolescent respondents identified “too embarrassing” and “not enough privacy” (!!!) as reasons for not attending reproductive health services. Also, while 82% of respondents said that they had heard about HIV/AIDS prevention strategies, 58% of girls and 73% of boys responding to that same survey reported not knowing how to use a condom — at all. These numbers, I think, highlight two of the concerns I have already mentioned from my time in the clinic, in an adolescent-specific context. The first of those concerns relates to inadequate privacy affecting patient comfort, and the second pertains to the suggestion of potentially inappropriate HIV prevention strategies: especially for young people, it is hard to think encouraging abstinence would be as effective as encouraging condoms and safe sex, for example. Yet again, I am no expert here, but I am certainly taking these lessons away with me and doing my best not to forget my feelings and impressions during these interactions.


HIV Care

Finally, it was important to me – after spending so much time at the RHC – to learn about what happens next for the patients who test positive for HIV.

Adult patients, I learned, are referred to the HIV Care and Treatment Clinic, and children and families are sent to the amazing Child Centred Family Care Clinic (CCFCC). The theory behind the CCFCC is that, because family is the core unit of Tanzanian society, treating families as a whole instead of individual patients is the best way to provide holistic, integrated, timely and effective multidisciplinary treatment. Culturally appropriate care? You betcha.

I loved every single moment I spent in this clinic, learning about the challenges and triumphs in long-term HIV management and how the disease impacts families and communities. It was heartening to see that a disease that carries such a significant burden and stigma, and causes so much fear and psychological trauma (as I witnessed first-hand during testing), is being treated at KCMC with such sensitivity, compassion and collaboration. I won’t be forgetting any of the doctors or families I met in this clinic any sooner than I’ll be forgetting every brave woman who came into the RHC for screening. Reproductive and sexual health impacts absolutely everyone, and requires hospitals to have a whole arsenal full of culturally-appropriate approaches to facilitate and encourage communities to engage with their services.

Community Health in the Kilimanjaro Region, Continued

Sorry for the delay folks – it’s been a busy month in the UK and now settling in to my final project in Guinea, but I’m back on the blog! 🙂 

Following on from my last post, I continued to learn about the roles and responsibilities of the Community Health Department at KCMC by participating in different activities – within and outside of the hospital – every day. One of the main health education programs currently being carried out by the CHD in the hospital, for example, is aimed at increasing knowledge and awareness of blood glucose management for patients with Type II Diabetes and their families.

Hospital-based Health Education

Type II Diabetes Mellitus (T2DM) is on the rise around the world, and is expected to reach even pandemic levels by 2030. This increase in the prevalence of the disease is especially pronounced in Sub Saharan Africa’s developing countries — like Tanzania — due to urbanization, changing lifestyle practices and increasing life expectancy; positive changes which, unfortunately, contribute to an increase in the burden of chronic diseases across the board. In fact, as much as 18-24% of deaths in Tanzania can now be attributed to Non-Communicable Diseases, like T2DM.

Because Type 2 Diabetes is a ‘silent’ disease, many patients – especially in a country like Tanzania where access to healthcare/screening programs & awareness of medical conditions is generally low – will not present for diagnosis and treatment until they develop severe complications, such as loss of vision or infected ulcers. Therefore, the work of Community Health Workers at KCMC and throughout Tanzania is to:

  • educate communities about the early symptoms of diabetes to aid in better and earlier detection
  • educate patients, families and communities about lifestyle risk factors for diabetes and everyday, community-based ways in which patients can strive to maintain their health (diet, physical activity, etc.)
  • educate patients and families about risks (like hypoglycaemia) and complications (such as diabetic ulcers) that can arise from T2DM and how to avoid, detect and manage them.

This is no small job! Sr. Mayo — my mentor in the CHD and a serious powerhouse of a lady — has led the diabetes education classes every Wednesday morning for the past 30 years. Her passion for the project and the patients reverberates through her every word as she leads the engaging sessions, apparent even to a non-swahili-speaking observer like me. Sr. Mayo told me every week that she “just couldn’t miss” the diabetes session, and that it was the highlight of her job. Equally, it was clear to see that the patients at the sessions, who were all waiting for their appointments at the Wednesday morning diabetes clinic, loved Sr. Mayo and eagerly leaned in to listen, ask questions, nod, laugh, and learn. Sr. Mayo stays on after the main presentation every week to respond to individual questions and concerns from patients, and has come to know many of them very well over years of visits. She told me that she adjusts the curriculum and personalizes it each week based on the number of familiar faces and the questions/concerns that have been raised. (Amazing!)

A selfie with Sr. Mayo!

Another thing I love about Sr. Mayo is that, even after 30 years of working in this role, she is not satisfied with the service she provides and is constantly looking for ways to improve: to reach more people, with clearer information, in more places and through more mediums. This is where I came in, helping Sr. Mayo to prepare clear and informative powerpoints on diabetes that could be played on the new TV screens that are located in three waiting areas throughout the hospital. Even in her 60’s, Sister Mayo strives to learn about and understand technology and its role in public health, and she dreams of having a projector one day in order to use visuals and video material to supplement her diabetes education classes. The ‘students’ form a colourful, vibrant and boisterous community and she meets them with equal enthusiasm and a forward-thinking, creative spirit.

Comprehensive Community-Based Rehabilitation

Other elements of the CHD’s work took me totally outside of the hospital environment. One really notable highlight was joining a group of medical students from KCMC University College on a community advocacy trip to a partner organization of the hospital: the Centre for Community-Based Rehabilitation (CCBRT). Visiting this organization was a real crossroads for my learning experiences in Moshi: a place where the rehabilitation practices of the OT department met the community-based approaches of the CHD. It was also an even bigger crossroads for me, however, where I was able to bring together everything I had learned in Myanmar, Laos and India about the staggering and devastating impacts physical disability can have, and see those lessons embodied and tackled in a Tanzanian community context.

During this visit, I learned that CCBRT uses a holistic, family-centred approach to disability management and prevention (through early and extensive maternal care) in one of Moshi’s poorest regions. Where they began by visiting families and providing therapy training in homes, the organization soon discovered that mothers/caretakers did not have time during the day at home to be trained in their child’s rehabilitation – because they had other children, livestock, farming and cooking to attend to. This lead CCBRT to develop an intensive 5 day program, which allows mothers to devote that specified amount of time to comprehensive training before returning to their daily lives, where CCBRT follows up with them and their children’s therapy. Personally, I thought this responsive approach to the needs of this specific community was really inspiring! 

Using this system, CCBRT serves a core client population living with:

– Cleft Lip and Cleft Palate: this was a problem I learned about extensively during my time with Interplast in Myanmar, where I had noted the dire need for multidisciplinary rehabilitation following surgery to allow children to develop normal feeding and speaking behaviours. This therapy greatly improves their quality of life and community integration. 

– Congenital Club Feet: not something I had seen before this year! During my time at the CCBRT centre I was able to see newborns with severe club feet, children in the process of progressive correction by casting, and even a four-year-old boy who had been through the process with absolutely tremendous results. The main challenge with this slow, progressive treatment plan is ensuring that parents are engaged and committed to follow through (ie. Family support is 100% crucial!), as well as community awareness for detection as early as possible. 

– Spina Bifida. This is a condition in which part of a baby’s spinal column/its surrounding tissues develop outside of the body through a gap in the back. It requires early referral to surgery, followed by intensive management training to avoid post-operative infective meningitis, encourage early mobilization with assistive walking devices, and provide competent care for bowel and bladder problems that arise from the disruption in the spine. This is a complex condition that requires really thorough community assessment and support. 

– Hydrocephalus: this condition, “water on the brain,” occurs when there is any interference with the normal drainage of Cerebral Spinal Fluid from the brain before a baby’s skill bones have fused – meaning that the bones will be pushed apart by the pressure and result in an abnormally enlarged head. CCBRT is involved in early referal of these children from the community to the hospital to have shunts put in, and educates parents to recognize symptoms of shunt blockage or infection. 

– Cerebral Palsy: having seen many cases of this in the Occupational Therapy department, I was overjoyed to see community initiatives to support these patients I cared so much about. CCBRT’s maternal care programs also aim to tackle CP’s causes, which can arise before, during or shortly after birth. Amazing! 

– Vesico-vaginal and Vagino-rectal fistula: in this instance, the community “patient” is the mother, not the child. Fistulas are holes in the walls between either the urethra and the vagina or the vagina and the rectum that occur when these tissues are compressed in childbirth, lose blood supply, and die. Besides physical discomfort, fistula can cause real psychological damage and social exclusion. They result in permanent leakage of either urine or faeces through the vagina, which is extremely embarrassing, debilitating for activities of daily living, and can lead families and husbands to abandon the women who suffer from them. For these cases, emotional support, challenging stigma and social reintegration are as, if not more, important than the physical rehabilitation itself.

In all of these cases, CCBRT works in collaboration with the community to strive towards full rehabilitation and social inclusion. This includes their beautiful wheelchair workshop, which creates custom and adjustable chairs appropriate for comfortable support, optimal mobility, and even improved communication through Swahili-language and illustrated “word boards” that sit on the front of the chairs and help users communicate their needs. 

A wheelchair in CCBRT’s workshop!

More than anything I took away about any of these medical conditions and their care, the main thing that stuck with me from this day  was the realization that this was an organization of AWARENESS and ADVOCACY; a voice for those with disabilities that spoke outside of the hospital walls and instead, directly to the community in which these people live their lives. 

During the invaluable opportunity I had to speak with one of the directors, I learned that CCBRT encourages awareness through TV and other media advertising, early exposure in community environments,as well as through partnering with hospitals (like KCMC) to ensure that students (like myself and my peers on this visit) and doctors across all specialties recognize the community need for this work and become ambassadors for it in the healthcare community. As awareness increases, the director told us, stigma, discrimination and abuse decline. 

CCBRT also works with the ministry of education and directly with schools to stop the refusal of children with disabilities and encourage those children to join normal classrooms where possible – a concept that is actively rejected in many Tanzanian schools, largely due to the fear that these children “bring class averages down” and make schools look bad. Even for deaf and blind children, who cannot realistically join normal classrooms, CCBRT has done groundbreaking work by establishing classrooms for these students *within* regular public schools. Efforts have also included making community churches and mosques more accessible to those with disabilities. 

Further, CCBRT facilitates adolescent support groups for teenagers with disabilities, encouraging the discussion of otherwise “taboo” topics like sexuality and menstruation. Apparently, teenagers with disabilities in Tanzania can often be taken advantage of and become vulnerable to sexual abuse and diseases like HIV. In a society where community-based reproductive health services already face significant challenges (more on this to come!), working to support this particularly at-risk population is vital. 

Finally, CCBRT supports patients and families in a range of economic and income-generating projects with livestock, small-scale farming and business opportunities, giving families of the disabled the dignifying chance to stand on their own two feet. 

I returned to the hospital that evening awash in inspiration, so heartened to see the disability issues I had learned about in the hospital rehabilitation department being tackled at the community level. Disability was in fact never one of my original goals for exploration when I set out on this scholarship year, but yet it has emerged in almost every project I’ve undertaken so far and created a huge shift in how I view health and wellbeing at the community level. That is, I suppose, the best thing about going out into the unknown – you never know what important causes will capture your heart and your mind! 

Community Health in the Kilimanjaro Region

My recent set of posts about the time I spent at the Department of Occupational Therapy at KCMC tells a big chunk of my Moshi story – but not all of it. After a tough goodbye to the Occupational Therapists and OT students I had come to know so well, I started a 6-week placement with the Community Health Department/Institute of Public Health that would become another significant and marvellous chance to learn about how hospitals can promote health for individuals, families and communities far outside their walls.

What does a Community Health Department Do?

The Community Health Department (CHD) is one of twenty clinical departments at Kilimanjaro Christian Medical Centre (KCMC). I asked to be placed in this particular department because of its name alone, and the fact that – with this scholarship – I wanted to learn about exactly that: community health. What this department did exactly, and how they influence and monitor community health, was actually largely unknown to me before I started my placement. The department name certainly does leave more to the imagination than the Labour and Delivery Ward, for example.

I can now report that this department does a lot. My time with the CHD community health workers took me to nearly all other departments of the hospital for health promotion activities, as well as to communities as far as a 2-hour drive away from KCMC for outreach programs and research. Being a major medical centre for Northern Tanzania, KCMC’s responsibility to reach the broader community is absolutely massive. For example, the CHD office I reported to every morning is home to a Radio FM service that dispatches health information to 25 hospitals across the Kilimanjaro region and Northern Tanzania, giving staff in the field an opportunity to obtain expert advice and assistance in emergency situations. The Radio system also coordinates visits of experts from KCMC to hospitals and clinics throughout the region for education and assistance (in collaboration with AMREF Flying Doctors), and provides information about disease outbreaks (as in the Ebola crisis in 2014) to surrounding communities. Virtual links span directly from that office all over the country via Radio, connecting this one hospital with thousands of Tanzanians who benefit from its expertise and guidance on health issues. Needless to say, I was pretty wow-ed by this phenomenal outreach system from the get-go.

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“Mission Control”

Another initial way I was able to learn about the incredibly broad expanse of endeavours undertaken by this department was at the department’s weekly Monday morning staff meetings, as well as during the daily tea break when all of the CHD staff gather around mugs of piping hot and extremely sweet black tea and peanut butter sandwiches. I loved the collaborative attitude of the department, and the eagerness with which each member of staff shared their projects and any new training they had been engaged in. For example, although I was never directly involved in it, I was fascinated to hear weekly updates on an Antibiotic Resistance project that the CHD was initiating after one of the department’s doctors attended a conference on “Antibiotic Resistance in Developing Countries,” where she had collaborated with delegates from as far as way as India and Cambodia. I felt that her attendance at this conference and excitement to share what she had taken away from it was a wonderful indication of how KCMC, and the CHD in particular, is reaching out for guidance and international input on how to make global WHO priorities – like combatting antibiotic resistance – KCMC’s priorities. This passionate young Tanzanian doctor reported weekly on her progress, designing first a point-prevelance study to look at current antibiotic use at KCMC and the surrounding community, followed by an intervention aimed at increasing adherence to global antibiotic protocols, followed by a final point-prevelance study to determine the effectiveness of her intervention. The intervention would, if proven to be effective, be extrapolated to other settings in the region — and I can’t wait to hear how it all turns out! Antibiotic misuse is a global problem that has been raised in many of the healthcare settings I’ve worked in this year, and community-level surveillance plays a significant role in efforts to address it.

Environment & Health

Another crucial part of the CHD’s surveillance work is looking at areas of the hospital that often go overlooked. By this, I mean the ‘in-between’s: the community and environment that exists in between every ward and between every treatment room. Where do patients go to the toilet between interventions? Where do families eat and wash their hands between visiting hours? Where do nursing mothers sleep between feeding times in the Neonatal ICU? Doctors, focused as they are on the actual interventions and operations, often overlook these ‘in-betweens,’ despite their indubitable impact on health. Once a fortnight, Sr. Mayo (the main Community Health Nurse I worked with during my time at CHD) did a round of these hospital areas and, while I was attached to the CHD, brought me with her. During these rounds, we collaborated with the staff in charge of waste disposal at the hospital to make sure garbage cans and recycling bins were located where they were needed and kept clean, with the correct signs in place to instruct even illiterate patients and family members about their proper use. This included bins not only on the wards, but also in waiting areas and at newsstands, canteens or mobile phone credit vendors. Waste left unaddressed in any part of the hospital, and especially in those areas in close proximity to infants or immune-compromised patients, poses a significant hygiene and health risk.

We also visited the hospital canteens, where visiting/waiting families come gather to eat fresh-flipped chapati and hearty bowls of mtori (beef and banana stew), and assessed both adherence to food hygiene standards in kitchens and the availability of soap and water for guests to wash their hands. While I believe these tasks might be out-width the job description of a community health nurse in Canada – where hospitals have dedicated food hygiene staff, cleaners and waste-management services – in Tanzania this role is really all-encompassing, and the CHD staff play a central role in monitoring and promoting health in all aspects of the hospital environment. The canteen staff all knew and loved Sr. Mayo, and greeted us with smiles and warmth as they showed off their clean counter tops. We left with our hands full of steaming hot chapati and avocados the size of my head, and I had a ridiculously enjoyable time doing these rounds. When I reflect on it now, I realize just how relevant and important these activities are: should the hospital not be the role-model for healthy practices in community settings, like where the worried and weary gather to eat, pray, sleep, read the news, top-up their mobile phone credit, and chat? Is that not the very definition of community health??

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Are hygiene and sanitation standards being upheld in all parts of the hospital?? Do we, as doctors and medical students, need to acknowledge and care about this?

During this biweekly practice as well as during various other parts of my time in Tanzania, I had the chance to reflect extensively on the concept of environment and health. This meant looking around at the hospital setting, but also looking much more broadly at the external environment Tanzanians interact with every single day. I was fascinated to see just how intimately people in Tanzania live in connection with their natural environment, with 80% of the population being directly involved in agriculture (according to the FAO). Both the head of the OT department and Sr. Mayo, my supervisor in the CHD, described to me how they use small-scale farms to grow food for their families, before and after their day jobs at the hospital. Growing one’s own food, I came to realize, means that environmental conditions like weather, flooding, droughts, and pollution are not distant, outside problems, but instead become directly reflected in one of the most basic determinants of everyday health and wellbeing: the food on your table. Through Team Vista, the organization that ran my hostel in Moshi, I learned that managing a productive farm in Tanzania is remarkably difficult, and stress about whether or not it will rain or how much water is in your well – a stress I have never before had to consider in my entire life – can be intense and consuming. Team Vista, in order to generate funds for their community projects in country, run a small community farm not far from Moshi town – and let me tell you, it is a labour of love. I never knew what hard work a single crop of lentils could be!!

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Daily traffic in the agricultural area near Team Vista’s farm.

Climate change and the resulting environmental conditions have a huge impact on weather patterns and seasonal wetness/dryness, and traditional farming methods and tools for predicting weather in Tanzanian are being thwarted by these recent changes. Two wonderful friends I met in Moshi were working in/studying agriculture extensively, and it was from them that I learned about the transitions, technology and tribulations being introduced to Tanzanian farms with changing climate and evolving knowledge. The human footprint on our environment has a direct and reciprocal impact on the wellbeing all humans who depend on the environment for our food — ie. all of us! — and while I had never really considered this before, now that I have learned about it I simply cannot forget it.

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In other ways, on a tour through Rau forest and a “Coffee Tour” in the Materuni region, I saw how local guides – and village/community members of all ages – are experts on their local flora. Much like the concept of ethnobotany I learned about in Laos, Tanzanian culture and society encompasses and embodies local plant life in a way that more developed countries, from my experience, really do not. Being able to read, recognize and relate to our natural environment is, however, meaningful for health all over the globe, and one of my new-found goals for the next four years of medical school is to continue to explore this theme in Canada. I didn’t know until this year, for example, that the University of Alberta actually has a Children’s Environmental Health Clinic devoted to research, education and clinical care surrounding environmental health issues. It is the first facility of its kind in Canada and I’m excited to visit soon, in an effort to build on what I discovered in Tanzania and Laos this year and deepen my appreciation of the environment/community health interface.

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Just a lil bit of biodiversity.

My Top 21 of 21

Coming full circle to celebrate my 22nd birthday in St Andrews last week and attend the annual dinner for R&A International Scholars, I had the wonderful chance to reflect on the university community, life-changing scholarship and international experiences that have made the past year of my life the best yet. This list truly doesn’t cover it all, but does serve as a little recap of some of my biggest and most-treasured highlights:

1. Graduating From St Andrews

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Elle Woods from Legally Blonde has been my role model for smart blonde girls defying expectations and totally – pardon my French – kicking ass in the academic world since I was 8-years-old. So, donning this bright pink hood to celebrate finishing the first gruelling half of my medical education was the perfect tribute to both Elle Woods and to my 8-year-old self, who never could have imagined it’d all get THIS GOOD. My parents and little sister were also in St Andrews for their very first time that week, and I was immensely lucky to have my whole family around me to mark this milestone.

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My people.

The graduation weekend was also about savouring sun-drenched and sacred final (for now) moments with the greatest friends I’ve ever known. St Andrews nurtured the strongest friendships I’ve ever had, and both the people and the place will always be home.

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Taking in our place ❤

2. Pre- and post-graduation Travels

The travel bug kicked in well before my scholarship year even began, and taking on Europe with my friends and family was the perfect introduction to life on the road!

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First stop: Greece with my gorgeous sistafriends!
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Family road trip to the Isle of Skye!

3. Canadian Summer

I could not possibly have been more overjoyed to be accepted into the University of Alberta’s MD Program last May, nor more grateful to be granted a year’s deferral in order to take on my R&A International Scholarship projects. Spending the summer in Alberta – with a brief stint in B.C. – was the perfect chance to check out my future home and, before a year of international travel, remember how fortunate I am to come from and return to such a beautiful and wonderful place.

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My backyard. I’ll be back for ya soon, ‘Berta!

4. Witnessing Sunrise Over Angkor Wat

This was my very first travel experience of the whole year-long solo adventure, and just thinking about that breathtaking moment of first light still gives me goosebumps.

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As a distinctly recognizable symbol of Cambodia, this picture of Angkor Wat also brings back far more memories of this country for me than just this one precious moment. Learning about the Khmer Rouge and the tragedies and reconciliation alike that shape Cambodia’s history was a pivotal and important part of my year, because it was my first understanding of just how much beyond science and medicine I would learn from this type of immersive travel. Cambodia was my entry point to the global human narrative, and a rich, living, and powerful one at that.

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Bracelets of friendship and solidarity at the Choeung Ek killing fields near Phnom Penh.

5. Ha Long Bay, Vietnam

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This was another larger-than-life-am-I-really-here-pinch-me-please moment, and is another photo that takes me right back to the smells, the sounds, the sights, and the HUGE feels. Vietnam captured my heart in so many ways, in both its colourful vibrant today and its heavy past. As in Cambodia, I learned about the living legacies of war and conflict and marvelled at the resilience of humans, society, culture and nature. It was unbelievably beautiful – and also just don’t get me started on the food 😉

6. Surgical Mission in Khawthaung, Myanmar

Diving headfirst into my first medical project of the year was terrifying, amazing, and likely my favourite experience of my life so far. In the months that have followed, my thoughts have returned again and again to the staggering need for surgery and anaesthesia all over the world and the immense impact this work can have, and I truly hope to return to this field again as soon as I can!

7. Experiences in an HIV Clinic in Yangon

The most exciting part about my placement with Medical Action Myanmar was its amazing opportunities for cultural immersion. Being the only foreigner at this clinic, I came to understand the true meaning of locally-driven and culturally-relevant care in an NGO model. Living in Yangon during this placement, exploring broadly and taking in the city’s energy and diversity, was also absolutely spectacular.

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8. Balloons Over Bagan

I don’t think this one needs a whole lot of description. Taking in sunrise over Bagan’s pagodas and the Irrawaddy river? Once in a lifetime.

9. Reunion in Laos

This was a serious highlight of the year, and I have so much to thank this woman for! Reunited after 5 years, I was immensely fortunate to join my middle school ballet teacher, Suzette, in Laos and experience first-hand her many passion projects. These projects range broadly from jewelry design and social enterprise to environment/elephant conservation and finding solutions to Laos’ unexploded ordinance problem. I was equal parts overwhelmed and inspired to see how much work there is to be done and get involved in!

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Enjoying the beautiful Lao environment with Suzette!

10. Medical Adventures in Laos

As was the theme for my time in Laos, I got to learn broadly here – from health education about clean drinking water to exploring the main issues facing Laos’ struggling healthcare system with doctors at the provincial hospital. Every single day brought something exciting and new.

11. Canadian Christmas

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After half a year of globe trotting, I have never been more poignantly aware of what a gift my beautiful family is ❤

12. Taking in the Taj Mahal

Tackling the bucket list, one world wonder at a time…

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13. Lifting Those With Leprosy

During my volunteer placement with Rising Star Outreach, I learned loads about the medical aspects of this infectious disease as well as the strong stigma that surrounds it and influences Indian society. Most memorably, however, my time in Southern India was one of my most profound learning experiences ever about preserving dignity and humanity in the face of disease.

14. Connecting with Sleeping Children Around the World

During my time in both India and Tanzania, I had the phenomenal opportunies to connect with passionate people volunteering their time and their hearts to SCAW, a charity that works to promote a good night’s sleep as an important aspect of public health and childhood well-being. Both encounters provided me with plenty to learn and even more to be heartened and inspired by. I really hope to get more deeply involved in their work in the future!

15. Community Based-Rehabilitation Services in Tanzania

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The entirety of my month-long placement in Occupational Therapy and Orthopaedic Rehabilitation at KCMC Hospital was absolutely life-changing, but no single experience as much as this home visit to a paraplegic patient who had opened his own small store and taken back control of his life after a serious injury. Witnessing this man’s motivation and empowerment within his community was meaningful beyond words.

16. Community Health Projects in the Kilimanjaro Region

I have yet to update the blog in full about these adventures, but the second part of my time at KCMC hospital was spent with 6 very fullfilling weeks attached to the Community Health Department. This project aligned wonderfullly with my original scholarship goal, allowing me to explore public health approaches to reproductive and sexual health, maternal and newborn health, community care for people with disablities, diabetes health education, and environmental impacts on health – among other amazing topics.

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The kind and courageous community health workers I got to work with!

The placement culminated in a 3-week fieldwork research project with Tanzanian medical students, in which we measured anthropometric indicators of early childhood nutrition in children and interviewed their mothers about their beliefs and behaviours regarding breastfeeding and diet. It was a muddy, full-on and exhausting project trekking out to villages deep in the jungle, but one of the most hands-on opportunities I’ve ever had to really assess and engage with the health of a community. More on this to come!

17. Safari!

Fulfilling a lifelong dream of mine, I had the chance to see all of the Big 5 – Lions, Elephants, Leopards, Rhinos and Buffalo – in the stunning Ngorongoro Crater and Serengeti National Parks. Need I say more??

18. Living in Moshi, Tanzania

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This place – this beautiful, lush, mountainous paradise – became the backdrop for some of the most difficult and painful parts of my year, as well as some of the most beautiful friendships, biggest gratitude and most difficult goodbyes. From steaming-hot grilled street meat to market-fresh mangos, to hilarious nights at karaoke clubs and sunny walks with dear pals, this place was delicious, colourful, rich with meaning and – by the end of my 3 month stay – home. Can I go back now??

19. Team Vista’s Young Women’s Empowerment Groups

This is also a topic I have yet to describe in full on the blog, but was a truly pivotal and powerful experience. Friday afternoons were always a highlight of my time in Moshi, heading down to Msasani Secondary School to meet with a group of 25 girls considered by their school to be “at risk” of failing or dropping out. It was an opportunity to talk, laugh, sing, dance and celebrate being strong, courageous and capable  young women. It was also an opportunity to discuss important topics like sexual education and period hygiene, women’s rights, power and relationships, strategies to excel in school/cope with stress, and cultural/societal norms that prevent women in Tanzania from achieving their full potential. These girls and these sessions filled my life with boundless light and taught me more than I ever could have imagined about what it means to be a young woman in this country.

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20. Zanzibar

A trip to Zanzibar was the perfect way to tie off my trip to Tanzania with some exotic beauty and relaxation. Can you even believe that blue??

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21. Returning to the UK 

On a nomadic year like this one, it was easy – at times – to feel ‘homeless.’ And yet, when I stepped off the plane in Edinburgh in late May, I was undeniably home in the most beautiful sense of the word. Returning to St Andrews, in particular, and spending my 22nd birthday at the Royal and Ancient Clubhouse where this whole scholarship adventure began was the perfect ‘homecoming.’ My gratitude towards the people who funded this adventure, the people who believed in my projects and believed in me to carry them out, and the dear, dear friends and family who have stood by me across all the distance and time – with skype calls and letters and messages that kept me going – is boundless. Scotland certainly is home to me ❤

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Thank you all for the greatest year!

 

 

The Menstruation Conversation

During my time in Laos last year, my mind was totally blown by just how much – and across how many disciplines – I could learn at one time, in one place. This included learning about everything from the health-related and social legacies of the Vietnam war, to elephants and environmental conservation, to textiles and jewelry and their vital role in culture. Tanzania has been a similar experience, where I set out on a hospital placement to learn about medicine, and ended up learning about topics as broad and fascinating as the role of gender in development and the interplay between technology and tradition in Tanzanian farming practices. These surprises have been the biggest blessing of this year by far, and have broadened my mind in more ways than I think even I can fully comprehend.

During my time in Moshi I stayed at Haria Hotel, a 100% not-for-profit hostel that supports Team Vista, an NGO that works to support sustainable development initiatives in Kaloleni, the poorest district of urban Moshi. Staying at Haria was a ginormous highlight of my time in Tanzania, and everyone working, living and volunteering there so quickly became family to me. Staying there also gave me the priceless opportunity to get involved in some of their community projects, where I was able to learn about development efforts in Moshi happening outside of the hospital/medical realm.

Working alongside Team Vista’s in-country manager, Phoebe, who is also an expert in gender and development, I was incredibly lucky to take part in Team Vista’s Young Women’s Empowerment projects at Msasani Secondary School. One of these projects, which I came to feel extremely passionate about, was a collaboration with Days For Girls that aimed to promote health, education and dignity for these secondary school girls through the provision of inexpensive and high-quality reusable menstrual pads. Sustainable and hygienic approaches to managing menstruation are vital to allowing girls world-wide to stay in school and achieve their full potential. Here are some of the facts:

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“There are 1.5 billion women of reproductive age in the world. 300 million of those women live on less than $1.25/day, and will struggle to meet basic needs, such as food, shelter, water, and hygiene solutions.”

~ Days for Girls International

To tackle this problem, Days for Girls has created sewing patterns and educational tools that allow tailors/seamstresses all over the world to manufacture reusable menstrual pads out of locally available fabrics and materials. The pad kits, when sold or distributed to girls who need them, promote hygiene, freedom and confidence – while also providing purpose and income for the women who sew them.

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One of the menstrual hygiene kits containing: 3x reusable pads with 3x washable, absorbent inserts, one pair of underwear, a bar of soap, and a plastic bag to carry used pad inserts during the day. Kits also come with washing/care instructions and menstrual health information.

^^How fun are these beautiful local fabrics??

I was able to attend two session with Phoebe and the local Team Vista staff at Msasani Secondary, in which the Days for Girls packs were pitched to students aged 12-16 in combination with menstrual hygiene health education. My role in the education session was to explain what menstruation is and what in means in terms of health. This was a tremendous learning experience, challenging me to take a biological concept and turn it into words that would be understood – language-wise but also culturally and socially. This meant not only talking about the basics – “you will bleed from your vagina once a month” – but also going into why this happens and why it is not a bad thingIn a culture where menstruation is not openly talked about at home or in school, girls need affirmation that getting their period is a perfectly normal and healthy experience; one that happens to virtually all women all over the world.

By that same token,  I talked about the importance of sticking together and standing up for each other as women when it comes to menstruation. Because it is something we all share, we can and should be able to talk to our friends, teachers, parents, sisters and mentors about it, and turn to each other when we need help understanding and managing it. This includes not only managing the actual flow, but also the physical and emotional changes and discomfort that come during that time. I worked hard to enforce for the girls that these experiences are also normal, including the shifts in mood and feelings of frustration and anxiety. These emotions are hard enough to cope with on their own as a young woman, and should never be accompanied by feelings of isolation or social exclusion- especially when we are all in this together!

Finally, I got a chance to talk about the health aspects of menstruation that I am SO passionate about. My very favourite experience was, after introducing myself as a medical student, asking “How many of you also want to become doctors one day?” Watching hands shoot up as a wave through the room and hearing the roar of affirmation and cheers almost stopped my heart right then and there. We gave the presentations in the biggest room in the school, to fit all of the students, which happened to be the science lab. Standing there at the front bench, surrounded by the very things – bunsen burners, Benedict’s Solution, articulated skeletons, etc. – that once inspired a younger me to dream of a career in the sciences, and looking around at all those girls who were jumping up and down at the idea of working in healthcare, was immensely inspiring and truly heartening. I took that energy and ran with it, stressing to these girls how easily they can start caring about and investing in their own health and the health of their peers RIGHT NOW.  Practicing and promoting hygiene during menstruation can be a perfect first step for them to become the advocates for health they dream of becoming, and their role in this – as women in healthcare – will help to breakdown taboos, stigmas, misconceptions and barriers.

After my intro, Phoebe went on to talk in detail about the kits themselves and how can be used to empower the girls and increase their opportunities to participate meaningfully in all aspects of their lives. Then, Hawa – the leader of Team Vista’s Women’s Sewing Group who make the pads – contributed a talk about the business aspects of purchasing the packs and what it means to her to make and sell them to these girls. Finally, Amina – the local schoolteacher Team Vista collaborates with for the Young Women’s Empowerment projects at this school – tied the whole thing together by a) recapping in Swahili to make sure everyone had understood the session and b) concluding with an incredibly powerful statement. The main take-away message from the session, Amina said, was that we, as women, must stick together. If the girls need pads, they should support a local business in their community and buy from Hawa. If the girls need help and support, they should turn to us and each other, so that we can all strive forward.

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Phoebe talks panties and girl power.
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One of my favourite pictures, ever. From left to right: Phoebe, Amina, Umi (another Team Vista staff member) and Hawa. I LOVE THESE EMPOWERED WOMEN!

My education on the global impact of menstrual hygiene did not end there, however. On March 8th – International Women’s Day – Haria Hotel, my Tanzanian home, hosted a spectacular event run by two NGOs working in Moshi – Last Mile and Femme International. Last Mile works to bring innovative and sustainable products – including solar-powered lamps, water filters, fuel-efficient charcoal stoves and re-usable menstrual products, to name a few – the “last mile” to the people who really need them. Femme International aims to empower young women across Kenya and Tanzania through menstrual health education and by cracking open the conversation on menstruation to deconstruct cultural taboos.

The event, creatively called “Cup-tails,” was a cocktail evening and information session designed to promote one of Last Mile’s newest products: the Ruby Cup. Having not known much previously about menstrual cups – arguably the most sustainable and cost-effective menstrual product out there, with a single cup providing hygienic period management waste-free for up to TEN YEARS – this session really opened my eyes and got me inspired. Managing our periods with sensitivity to the environment is important for everyone, not just women in developing countries, and switching to menstrual cups from tampons and pads is a really great way for all of us to make a difference. Ruby Cups take that difference one step further, however, with every cup you purchased allowing the donation of one cup to a woman in a developing country. Femme International’s recent instragram campaign, “28 Reasons why #MenstruationMatters” got me thinking even more deeply and broadly about these innovative products and why they are so necessary, including situations in which a concern for feminine hygiene is crucial yet overlooked. For example, how do women manage their periods when they are homeless, living in a refugee camp, or in the midst of conflict and humanitarian crisis??

Finally, while a lot of this post has focused on products – from pads to cups – that can empower women in dealing with menstruation, it is important to remember that it is actually SOCIETY – our attitudes, beliefs and actions – that truly empower women. Stigmas and misconceptions around the world result in traditional practices and societal norms that exclude women from participating fully in life while on their periods, and encourage shame and secrecy in the place of open and inclusive conversation on the topic. Products that allow sustainable and healthy management of feminine hygiene are crucial, but equally important is the education and awareness-building around menstruation and women’s health needs. Creating a world where every girl and woman has the chance to achieve her full potential, shame-free, is all of our work.

On that note, I’ll leave you with this spectacular Ted Talk on why gender equality – in all of its forms – is in EVERYONE’S best interest:

P.S. If you’re in the mood for even more reading on menstruation innovation, take a look at this totally badass space-gynaecologist (!!!) who is tackling issues of women’s health through research that promotes equality and opportunity for women working in space. The future is female, folks! ❤

Lessons Learned in Occupational Therapy

At the end of my month in Occupational Therapy I was asked to give a presentation to the staff of the Orthopaedic Rehabilitation Unit on what I, as a medical student, had learned and would take away from my time spent in Occupational Therapy. Preparing my presentation, titled “Occupational Therapy: A Medical Student’s Perspective,” was a really good opportunity to reflect on my time there, remember the true importance of expanding my medical education to experience other healthcare disciplines, and consider which aspects of the Occupational Therapy approaches to health are transferable to other areas of medicine and life.

I learned so many lessons in OT, some of which I’ve already talked about pretty extensively in this series of posts. For example, I learned what true patient-centred care looks like, and what it means to let a patient dictate the direction of therapeutic interventions based on their very unique functional needs. I learned what it means to focus primarily on function and meaningful quality of life, instead of science and diagnoses and drugs. I learned that occupation means far more than just “job,” and environment refers to far more than just “house.” I was reminded that patients and their lives are endlessly complex and we are unbelievably privileged to be involved in them, and to help make changes that matter. I learned that this complexity in our patients must be reflected by extensive multidisciplinary collaboration in our care.

Further, I learned that tribe and religion play a far greater role in healthcare decisions in Tanzania than any other country I had visited previously. I learned that cultural beliefs play a major role in shaping how people with disabilities are accepted in society, and what education and awareness it takes to influence those beliefs.  I saw firsthand that the love of a parent for their child is probably the strongest force in the world, and that the determination of parents to get the best for their children knows almost no boundaries. I realized that the vast majority of health and disease actually happens outside of hospitals, and that the goal in medicine must not merely be to get a patient discharged. We must care deeply about what happens to our patients when they leave the hospital and how communities aid them in rehabilitation, reintegration, and meaningful living.

One of the most amazing things for me to realize, however, was that these lessons I am taking away from OT don’t just apply to my medical studies/future career. A big part of this year for me has been looking beyond medicine, to absorb history, culture, politics, economics, environmental science — and countless other disciplines that impact international development and people/society’s ability to live healthy, fulfilling lives. It was actually an article I read in the February 2017 issue of OT Insight: Occupational Therapy New Zealand, which linked the skills of Occupational Therapists to the requirements for successful Community Development, that first showed me just how translatable and universal the things I was learning were. The article described an “Occupational Therapy Worldview” and described how the different components of that worldview can allow therapists to effectively aid communities in striving towards development goals. As a girl hoping to spend her career deeply invested in international healthcare development, I gobbled these words up and reflected on them extensively. The occupational therapy skills the article referenced as particularly transferable to development (and I believe we can extrapolate them even further, to various other fields) were:

  • A robust understanding that participation in meaningful occupations is interlinked with our health and wellbeing. In terms of both development and the pursuit of well-rounded health, people need to be engaged, participating, and doing meaningful things with their lives. We develop as people, communities and societies through this fulfillment.
  • An understanding that effective interventions must be client- or community-led. We cannot help people heal on our own agendas and we cannot expect communities to develop based on what we think they need. Like in OT, any sort of healthcare or community development requires that we stay humble and ask, “What does this community value and want? What development goals are meaningful to them?” We must acknowledge that communities are the experts on their own lives and recognize that developing healthcare systems – for example – with disregard to the people who use them and work in them is a doomed effort.
  • A sincere appreciation for the relationship between people and their environment. Communities of people do not develop independently of their infrastructural and environmental surroundings, just as patients do not rehabilitate from illness independently of their beds, toilets, wheelchairs or cars. Development efforts must not merely consider the environment itself, but – more importantly – how the community and its development relate to that environment.
  • An understanding of the concept of Empowerment. This means doing oneself out of a job. An occupational therapist aims to give a patient independence, so that they will one day no longer need a therapist to help them sit, stand, eat or use the toilet. Likewise, we must aim to develop communities with increasingly less outside involvement – striving to get them “on their own feet.” True development cannot coexist with dependance.
  • An understanding of the concept of Enabling. In occupational therapy this means removing barriers and seeing potential to make things possible, like with Energy Conservation measures (decreasing the amount of energy required to carry out activities of daily living) and increasing wheelchair accessibility. In community/international development, it can mean anything from microfinance grants to get businesses going to menstrual hygiene products that enable girls to stay in school.
  • A focus on strengths over weaknesses. In OT this means looking for ability where others might only see disability. What can this patient do and how do we support them in that? The fact that you are able to tie your shoes is more important than the fact that you might be doing it one-handed. For communities, this means asking “What can this community do? What innate resources do they have to draw on, and how do we build up these strengths?”
  • An ability to see the bigger picture. For occupational therapists, this means looking past any one ability or disability and seeing how it ties in to a patients whole, messy, complex life. In community development, this means looking at the whole community, and then looking even broader than that. For me, personally, this has meant looking individual patients in the eye and learning their whole story, but also looking at Tanzania, and even Africa, as greater wholes. This continent has a long and fascinating narrative that has shaped it in so many ways – culturally, politically, economically – and to contemplate health and healthcare here without seeing that broader context would be to see only a fraction of the picture. Further, healthcare systems cannot develop when held separate from the population who needs them. For me this year, seeing the bigger picture of Tanzania has meant talking to people from a variety of fields – from agriculture to business to community development – and striving to see Africa through their eyes. It has meant reading broadly, from the life-changing book Dead Aid to my current read (and a gift from the greatest pals), The State of Africa. It has meant realizing that I will never be a successful doctor and do meaningful work in this setting – my ultimate dream – if I do not understand this setting.

These lessons are not only applicable to medicine and how I will see patients as a doctor, nor only to community and international development. Skills that I nurtured in OT, like seeing the bigger picture and understanding what it means to enable people and communities, can and should be applied broadly in approaching problems in all walks of life. In a nutshell, Occupational Therapy has taught me some pretty world-shattering life stuff.

To finish off, Occupational Therapy taught me patience. It taught me that there is a place in hospitals for sounds other than beeping machines – that there can be singing and clapping and laughter. It taught me that we can share jokes and we can share tears. We can befriend our patients and we can share in their narratives. We can befriend our colleagues – as the Occupational Therapy staff and students so warmly befriended me – and we can celebrate our work. Because it matters.

“I’m here to tell you finding your purpose isn’t enough. The challenge for our generation is creating a world where everyone has a sense of purpose. It’s not enough to have purpose yourself.

You have to create a sense of purpose for others.

~ Mark Zuckerberg

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A staff vs. student soccer match at the Department of Occupational Therapy, featuring the timeless silhouette of Mount Kilimanjaro. While outwardly community-focused for their patient,s this department is a fabulous and thriving community in its own right.