Post-Travel Perspectives: Working for the Kigezi Health Foundation in Kabale, Uganda

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Neil Verma

I traveled to Uganda and joined the Kigezi Health Foundation primarily to expand my knowledge of global health disparities, community empowerment and rural medicine. Adequate nutrition remains a challenge for several families in the Kabale area with several diseases having clear associations with malnutrition. My work involved studying the impact of rabbit breeding in low-income families as a means to provide adequate nutrition and additional income. The ultimate goal remains to expand knowledge and resources to address public health issues and maximize population health.

My father and grandmother were born and raised in Kabale and these personal ties to Uganda have specifically drawn me to this community. My family’s experiences have provided me perspective on the impact of disease within this community while fostering my desire to provide medical service to the local population.

My experience with the KIHEFO reinforced my desire to engage in rural medicine and global health, addressing healthcare issues through improving the social determinants of health and community empowerment.

I had limited proficiency in Ruchiga–the local language–and a greater proficiency with the local language would undoubtedly help address the cultural and linguistic barriers and build rapport with patients. Local medical professionals are already faced with a demanding clinical workload, and learning the language and cultural practices partially alleviates the ethical responsibility of having the clinical staff host foreign medical trainees. Cultural attitudes towards medicine also have an impact on healthcare delivery in Uganda, particularly given that 80% of the population exclusively seek out traditional healers as their primary care providers. The KIHEFO has attempted to partner with traditional healers in order to encourage Ugandans to seek out modern medical services. The differences in particular disease treatment protocols and regimen add to the ethical conflict between my own perspective on healthcare and the approach in Kabale. To cope with these realities, I have relied on a network of former global health students and local professionals to better understand Ugandan healthcare along with their unique approach to addressing disease and suffering in a resource-limited setting.

My work with the KIHEFO will contribute to an academic relationship with McGill University and provide a mutually beneficial opportunity to expand knowledge and resources to address public health issues such as malnutrition and HIV prevention. Furthermore, an ongoing partnership between both parties will allow for expansion of available medical resources, services and additional opportunities for knowledge exchange and learning. The benefits of partnering with North American universities are already visible in the KIHEFO’s maternal clinic, which enjoys the use of a donated portable ultrasound machine. As services continue to grow, medical trainees and residents rotating through Kabale will provide additional training to local staff and counselling to community members in order to improve quality of care and maximize population health.

As a practicing physician, I will be able to use the knowledge gained working with the KIHEFO to advocate for policy changes locally and globally that also focus on the social determinants of health including food security and housing that will reduce health inequities. Learning the practice of rural medicine in Uganda allowed me to develop my awareness of the organization of healthcare in a resource-limited setting. It will give me the skills to strive to become a physician who remains conscious of the challenges of healthcare delivery and to provide the most efficient patient care.

As I have embraced the significance of public health to communities, I am optimistic that I will continue to engage in global rural medicine initiatives and devote myself to career and life as an advocate for global health.

My work with the KIHEFO presents challenges and learning opportunities that will improve my understanding of the disparities in global health, the value of community empowerment in healthcare and the challenges of rural medicine in a developing nation. These skills will serve as a foundation for my desire to pursue a career focusing on global health service and the development of global health policy.

Neil Verma was the recipient of the Ashworth Student Travel Award. Neil is a third-year medical student primarily interested in understanding the social, cultural and economic aspects of health and disease to improve global health.

“Tīng bù dǒng”: Reflections on conducting international field work with language barriers

Sierra Clark

While conducting my Master’s thesis field work in rural China this Summer, the most common string of Chinese-Mandarin words that were either said to me, said about me, or I said myself, were “Tīng dǒng”, which roughly translates to “I hear you but I don’t understand you”. That phrase most concisely characterizes the communication challenges I faced, while also reflecting mine and others willingness to communicate across a difficult language and cultural barrier. My blog is a reflection on the challenges, but also unique opportunities that arise, when conducting research based international field work in the context of a language barrier.

Photo 1

Sierra standing in front of one of her favourite views in the region. The study site is 1000-13000 meters above sea level on the edge of the Tibetan Plateau.

To provide some context: I arrived in China in May 2016, equipped with a lonely planet guide book to Chinese, a translation dictionary on my phone, and an undergraduate research assistant who was fluent in both languages (she was with me for 1 month out of 3). I had also prepared this year by playing Chinese language games, keeping a journal in Pinyin (way of writing Chinese using the Roman alphabet) and I listened to Chinese podcasts (with little success). Needless to say, I felt pretty good about myself and ready to take on Zhōngguó [China]. My confidence in my abilities was soon shattered after I arrived. I had been teaching myself the wrong pronunciation for almost every letter (or combination of letters), and I was utterly failing at enunciating the tones correctly. When I reached my small village in Sichuan Province, an additional barrier arose as I now had to translate from English, to common Chinese-Mandarin, to the local dialect spoken in Sichuan. I had the help of my research assistant for one month (she literally saved my life), and I lived with a Chinese colleague who was functional in English, but soon enough I was on my own with the challenge, but also the amazing opportunity, to tackle this communication conundrum and hopefully learn something from it.

I am now a master of the game Charades

Standard communication when there is a language barrier is difficult to overcome, and trying to communicate research terms, research equipment, and research protocol is even more intricate in this context. When communicating with the field staff in Chinese, I was at a loss for how to ask for things like: “where is the flow-rate calibration Rotameter” or “does the grease on the impaction surface have any air bubbles in it?” (the grease catches the larger Particulate Matter (PM) particles so that we can collect PM in aerodynamic diameter <2.5 μm on our filters for analysis). Additionally, I implemented a questionnaire that asked questions about participants use of the intervention cook stove (1) and their likes, dislikes, and preference for it over other stoves in the household. It took me and the team a week of piloting, and five iterations, to finally get a questionnaire that could be translated into the local dialect and the questions were locally and contextually relevant. However, even months after the piloting phase, I am still finding that some questions and responses are interpreted differently then I intended them. For example, a stoves “a. cleanliness” was meant that the surface was clean (i.e., devoid of grime) but many participants interpreted that to mean the stove emitted less smoke. Troubleshooting these issues in the field with the team required patience and persistence, and an ability to find creative ways to communicate the solution to each other (did I mention phone translation dictionaries are amazing).

I also ran into troubles when I was the one collecting the data directly with the participants. Often I took on the task of taking blood pressure measurements. Our standard protocol was that participants had to sit quietly in a restful state for five minutes before the measurement began. Sometimes when I tried to communicate this, I ran into more trouble when when I said to the participants xiūxí wǔ fēnzhōng [rest five minutes] or bù shuōhuà [no talking] as they would get more excited because a wàiguó rén [foreigner] was talking to them in Chinese! I found using my body to indicate what I wanted was very effective. I could direct someone to stand on the weigh scale, sit down and put their right arm on a pillow, rest for 5 minutes, and tell them that their blood pressure was low [bù gāo]/ a little high [yidiǎn gāo]/ high [gāo], all by becoming a master at the game Charades.

Both lǎoshī [teacher] and xuéshēng[student]

Photo 2

The field staff are preparing the equipment for the day. They are cleaning the Personal Exposure Monitors (PEMs) and placing filters inside them. When the PEMs are attached to an active pump and worn around the waist in a waist pack, they collect data on how much air pollution (PM2.5) someone was exposed to over 48hrs.

I took the ease and convenience of casual conversation in a familiar environment for granted before I came to China. I now know that when you are the one speaking the foreign language, the time that people give you is precious. My perspective changed after I asked my neighbors to repeat their sentence for the 4th time, when they patiently listened while I tried to stumble my way through a terribly pronounced sentence (which likely made me sound like a child), and every word was enunciated wrong so when I was really asking for the toilet they probably heard me say “why is the dog wearing my t-shirt”? The village became my classroom and the villagers were my teachers.

I also came to appreciate the way that I was learning Chinese in Sichuan. If I was working with a tutor in Canada, or speaking to someone who had excellent Chinese and English, there would be no mutual benefit (except for the monetary transaction for their services). Recently, two of the field staff I work with have really taken to learning Yīngwen [English]. When I first arrived, they could say a total of three phrases: “hello”, “goodbye”, and “it’s lunch time!”. Two months later, if I talk slowly, enunciate purposefully, refrain from using jargon, and play a little game of Charades, I can get almost any point across. When we hop into our van and head out to do our work for the day, we each come equipped with our “how to learn Chinese/ English” books. If I ask a question in Chinese, they will try to respond in English. If I want to know the Chinese name for something, they then need to know what it is in English. I love this mode of learning. Neither of us are experts in both languages, we are Lǎoshī in one and Xuéshēng in the other. Its fun, its playful, and its mutually beneficial. The other day one of the staff told me (written on her phone translator) that she was “gradually learning to love the English language”, and I could have jumped for joy I was fēicháng gāo xíng [E: very happy].

Photo 3

Sierra and the field team head out for the day to collect air pollution and health data in the Tibetan Plateau. Car rides are a prime time to practise Chinese and English for the team.

 

Acknowledgements: Much thanks to the wonderful field staff who continue to teach me new words every day, the villagers whom have included me into their lives, and my research assistant who helped me survive my first month. Funding for my research this Summer was provided by McGill Global Health’s “Norman Bethune Award’, The National Geographic Societies “Young Explorers Award Program” and Mitac Canada’s “Globalink Research Award Program”. Funding for the larger project was provided by the US Environmental Protection Agency (EPA) STAR program. The opinions in this blog are entirely my own and do not reflect those of the granting agencies.

 

Sierra is a second year Master’s student in Epidemiology and an Institute for Health and Social Policy graduate intern at McGill University. She is currently in rural China collecting data for her thesis on the air pollution and health impacts of a clean cook stove intervention which is aimed at reducing household sources of pollution. Sierra received her BA (Hon) in Geography from McGill, focussing her research on climate change and infectious disease in rural Uganda. Sierra is currently a National Geographic Young Explorer and a Mitacs Globalink International research award holder, and she is an active member of the Baumgartner Research Group at McGill. 

 


(1) Among a study population of 204 homes in 6 rural villages in Sichuan Province, we installed intervention semi-gasifier biomass burning cook stoves that take processed biomass pellets (processed at a nearby factory) as fuel into 117 homes (the other homes act as controls). The intervention stove emitted less PM2.5 during lab tests. We are now testing how the intervention preforms in real life conditions in the field: i.e., whether people use the intervention stove, whether people are exposed to less, the same, or more air pollution, and if their cardiovascular health is improved.

Elise in Haiti: Post-Travel Report

 
 
 
 
 
 
 
 
 
By: Elise Vuille-Lessard

Award won:

The Global Health Travel Award for Postgraduate Medical Residents

Bio:

I am a PYG-3 in internal medicine based at the Royal Victoria Hospital. What made me want to participate in the McGill Internal Medicine Global Health Initiative in Haiti was the idea of a long-term partnership between McGill and Haitian doctors and of capacity building, rather than a one-time intervention.

Project Overview:

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Elise in Haiti

This project is a one-month elective rotation where a team composed of internal medicine senior residents and staff from McGill works at Hopital St-Nicolas (HSN) in St-Marc, Haiti. This involves collaborating with local residents and staff as well as Zanmi Lasante/Partners in Health (ZL/PIH), the largest non-government health care provider in Haiti. The goal of this project is to maintain a partnership with ZL and the family medicine program at HSN (including exchanging knowledge, teaching, mentoring), while developing competencies for McGill residents in global health.

Lessons learned:

Change is so difficult to implement. Last year’s team had tried to implement the concept of a patient list on the ward, using whiteboards where you put the patient age, sex, diagnosis and plan. Unfortunately, the first day we arrived to the hospital, the whiteboards were empty. We re-emphasised this concept and did some positive reinforcement throughout the month, and finally the boards were being used when we left. Our fear was that residents would stop using them after we left, but 1 month later we were excited to learn that they were still in use. Change IS possible! I was sometimes discouraged thinking what we were doing was a wasted effort, that those interventions we were making would not stay. But when I learned that the whiteboards were still in use after we were gone, I suddenly felt like I had done something good and valuable.

Advice:

Students looking for a global health experience need to find a project that involves a long-term relationship with the local workers and try to avoid sporadic interventions. The main reason for that is that the time spent on-site is limited and maintaining the change afterwards becomes the most difficult challenge. One of the terms I learned with this project is “capacity building”, which includes finding ways of making an intervention sustainable.

 

This experience influenced my future career plans in many ways. I don’t know when I will participate again in a global health initiative, maybe not in the near future, but possibly later in my professional life. One thing this experience did reinforce is my desire to be a teacher. I certainly want to work in an academic setting and teach young people how to become better doctors, in regards to the medicine itself but also the human side of it.

 

Mental Health Recovery in Different Contexts: Lessons Learned from the Field

Jessica Maria-Violanda Spagnolo

The mental health recovery movement emerged in order to counter the overly biomedical view of mental illness that littered the era before deinstitutionalization (Anthony, 1993). After this era, community-based services for people living with mental illness were strongly encouraged, as illness is not merely the absence of disease, but a state of holistic well-being that goes beyond physicality (WHO, 1948). Therefore, mental health recovery includes ways of “living a satisfying, hopeful, and contributing life even with limitations caused by illness”; as well as finding “new meaning and purpose in one’s life as one grows beyond the catastrophic effects of mental illness” (Anthony, 1993, p. 527).

I have always been interested in understanding how this concept is seen and understood around the world. This post will report on examples of the cultural representation of mental health recovery in local communities where I worked.

Picture 1 (McGill Blog)

Photo 1

At a shelter in a small village in the Caribbean, mental health recovery meant developing new skills by learning how to plant vegetables, pineapple, and flowers, as well as care for chickens. This manual labor encouraged the presence of a daily routine, which can easily falter when one is affected by illness; learning through trial and error, which promotes patience and perseverance; as well as interacting with others, which can often be a limitation caused by illness. Photo 1 shows the chickens that the residents took care of until they were either sold to local community members or were used to feed the residents at the shelter. These same residents highlighted the importance of religion in their lives, which helped them find new meaning after illness. For example, when asked what inspired them, the majority of the residents said “God.” This reality is also apparent when visiting the shelter, as the walls are painted with religious images and symbols by local artists (Photo 2).

Picture 2 (McGill Blog)

Photo 2

In a small village in Central America, where many refugees sought protection after experiencing hardships in another country, often showing signs of post-traumatic stress, mental health recovery was seen through the development of new social ties. Arriving as strangers, women leaned on each other for support as well as hope for the future. Their children, through play, would do the same (Picture 3).

Picture 3 (McGill Blog)

Photo 3

The beauty of the mental health recovery movement is that it ensures the focus is not solely on mental disorders or symptoms. Not once during my work in these 2 communities did the residents mention the word “sick” or “ill,” but spoke about what was important in their own, unique, personal recovery journey from illness: developing new skills; generating hope for the future, creating social support and networks. These things are what innately make us human, and are anchored in what can help people living with any type of illness enjoy a satisfying and fulfilling life, despite symptoms.

 

Jessica Spagnolo is a Doctorate Candidate at the School of Public Health at the University of Montreal. Her research focuses on building system capacity for the integration of mental health at the level of primary care in Tunisia. Jessica is funded by les Fonds de recherche du Québec – Santé (FRQS) and MITACS Globalink. Jessica holds a Bachelor and a Masters of Social Work from McGill University.

Jackie in South Africa: Post-Travel Report

 
 
 
 
 
 
 
 
 
Jacqueline Roberge-Dao

Award won:

SPOT Global Health Travel Award

Bio:

DCIM101GOPRO

Jackie in South Africa

I am Jackie Dao, about to graduate from a master’s in Occupational Therapy (M2). I’ve always been fascinated with travelling and meeting new people. A previous trip to rural Peru working at a centre for children with disabilities gave me the travel bug and motivated me to discover new cultures.

Project Overview:

In Cape Town, I had the opportunity to intern in the largest public hospital of the Western Cape, the Groote Schuur Hospital. I split my 8 weeks between 3 different rotations: neurology, paediatrics and general medicine. As the beds needed to be cleared quickly in general medicine, my role was to quickly assess and discharge with outpatient referrals, assistive equipment and/or self-management education. In neuro and peds, cases were much more intense which required intensive daily rehab for remediation of function.

A story I would like to share happened one day on the neuro ward. An elderly woman was admitted displaying total body paralysis, but brain scans revealed everything was working normally; the team didn’t know what to do. I spent three hours just talking to her about her life experiences and my own (therapeutic use of self). I learned that her husband had passed a couple of years ago, that she was carrying an enormous burden of responsibility for her multi-generational family, and that she had just been diagnosed with HIV. As we explored her grief, guilt and attachments, she revealed to me that this was the first time in many years that she was able to express herself and feel heard. The next day, I returned to see her and a miracle happened: slowly but surely, I was able to get her out of the bed – she was no longer paralyzed. We took a walk outside that day, and she cried thanking me. This made me appreciate that no matter where we are born or what experiences we’ve been through, we are, at our core, the same. And sometimes magical things can occur when we remember that love is real and that connection and empathy can go a long way.

Looking ahead:

This field work has influenced my future career plans in that I will be extremely willing to accept an opportunity that takes me abroad. I overcame many personal fears during this trip which helps me move forward and push my boundaries of what is possible in terms of working whilst travelling. I have witnessed disparities in health and realized the immense need for powerful figures that will advance the system and humanity as a whole.

 

See also the McGill School of Physical and Occupational Therapy (SPOT) blog, and their website!
 
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