Tuesday, January 26, 2010

Day 16: Chelstone Nutrition Clinic with Valid International

Highlights o Day 16 (Tuesday Jan 26)

Interviewing over 10 careworkers

Seeing the work of a nutritionist at a community clinic

After a shift in schedule, I started shadowing Valid International today instead of yesterday. Valid International's office in Zambia focuses on Community-based therapeutic care (CTC programs) in all 25 healthcare primary clinics in Lusaka. Many of these clinics are the ones that PCI also works in and therefore PCI and Valid interact and involve the same volunteers. PCI and Valid both have programs targeting Orphaned and Vulnerable Children (OVC) under the age of six. However, from what I experienced PCI focuses mainly with the volunteers in the HIV/VCT/ART department of the clinics. Valid International focuses on the Nutrition department specifically. Valid, much like PCI, conducts cooking demonstrations to teach mothers what and how to cook nutritious meals. While PCI and Valid International do not have the same coordinated partnership like Grassroots Soccer and Breakthrough Sports Academy have, their coordinated efforts will allow donations to PCI program volunteers be helpful to Valid International clinic volunteers (and vice versa).
Valid's main efforts in Lusaka pertain to treating malnourished children by providing mothers with Ready-to-Use-Food (RUF) or Ready-to-Use-Therapeutic-Food (RUTF). RUFs are calorie-dense and do not require any prior preparation, dilution, or reconstitution. The closest comparison I can think of is Cliff bar but in a paste-like form for severe acute or moderate malnourished children above the age of 6 months. Valid International in Lusaka is also in the midst of conducting trials on acceptibility effectiveness and cost effectiveness of Soya Maize Sorghum based RUTF; this research is comparing the widely used, popular, but expensive "plumpy nut" RUTF compared to the locally produced soy-maize-sorghum RUTF. The children enjoy plumpy nut, which is currently supplied through the Clinton Foundation, but Valid International would like to know whether this newer, cheaper RUTF is equally "accepted".
I joined Beula, one of the Valid research Staff, for a nutrition clinic at the Chelstone community clinic. They use the word "clinic" in the dual sense of a healthcare center and as a workshop. At Chelstone, there are 31 women (and their child) enrolled in the nutrition study. The "prerequisites" so to say to be enrolled is to have a malnourished child; sometimes the women are referred to the clinic while others attend after hearing about it. The referrals come from the community careworkers that survey their "zones" for children in need. Each week the women come to the clinic to get advice on what foods--that they can afford--provide essential nutrients (sardines, nuts, beans) and ways to cook them. Beula reminds the women that not all "good foods" have to be bought but can be cultivated such as the various common vegetables (pumpkin leaves, ben leaves, tomatoes, onions...). Meat is often too expensive so the nuts and beans are really pushed to get iron into their diet; iron deficiencies have seriously detrimental effects on child development. Mothers offer suggestions for each other and discuss the difficulties they are experiencing.
Then the record keeping and measurements begin. They weigh the babies ages six months to five years that are malnourished. They compare the weight to the baby's birth weight, age, and especially the weight from the previous week. They also measure arm circumference, which is a widely accepted indicator for malnutrition status. Again, each week they are looking for an increase in the arm circumference or at least maintanence of the same measurement. Then the Valid or clinic staff test the feet for edema by simply pressing the feet and looking for a quick return to normal form. They also ask the mother a standard set of questions about the child's habits and health from the past week--i.e. diarrhea, loss of apetite, losing noticable weight in the middle of the week, feet swelling all of which are signs of malnourishment.
The mothers' are then provided with RUTF supply for the week. The supply is free and varies in quantity depending on the needs of the child. It usually ranges from 18 to 30 packets of Plumpy Nut per week. (I love the name of the RUTF brand!) They keep diligent records of how many packets are distributed and even more attention is paid to the absentees.
It it noted when a mother does not attend the weekly nutrition clinic. After three consecutive absences the mother/child is classified as a "defaulter". The community careworkers are asked to visit the mother to find out why they have not attended the clinics and encourage them to continue to come. This is where the globalbikes come into play. As I mentioned earlier with PCI, the homes may be 5 kilometers to 15 kilometers away from the clinic. These bikes make it easier for the volunteers to visit all the defaulters after the nutrition clinic. Depending on the size of the admissions/clinic class, the clinic can last from anywhere from 4 to 6 hours. This puts the conclusion around 4PM meaning there is limited time left in the day for the careworkers to visit families. It's important for the careworkers to find out why the mothers have defaulted--did the child die? is the child doing better so the mother doesn't feel the need to come? is the mother sick?
While we were waiting for the Nutrition room to open up, I was able to interview a group of community care workers of the Chelstone clinic. It started as a group of four but quickly grew to a roup of 10 volunteers interested in talking with me. I know some of them because of the novelty of talking to a mzungu girl with a camera, but they all reiterated the need for transportation. I noticed a a tone of frustration when I asked them to elaborate. It seemed so straightforward to them as to why a bike would be beneficial; granted, I understand the value of a bike in these communities, but I need the video camera to hear them explain it. They were also critical of what good all this talking as going to do anyway.
To be honest, I understood their frustration. Here I am asking them all the things they need but I had not brought them anything. Would talking about their work to me be effective in improving their ability to do the work? I was disappointed to learn that the bike delivery had been delayed yet another day so these community workers would have to wait another day after their seven to ten year dedication to the community. I also knew though that Yvonne, Valid International Zambian country director, was navigating through some bureaucratic hoops at the moment to make it happen.
On the same token, I had reached a point of frustration with the blanket expectation put on every mzungu: I am white, therefore I have money or something to give... so how much 9was I there to give them? While that is a broad generalization it is still a very popular sentiment. In fact that sentiment would cost me my bracelet later in the day when a mother considered it a gift for her because her son liked it.) The conversation started to stray from bikes and requests like a subsidy for their efforts, raincoats for the rainy season, more free trainings. Again, it was insightful for me to hear but there was an obvious disconnect between what they believed I had the power and money to accomplish and my actual purpose for being there.
During the nutrition clinic an hour later, I realized these cultural nuances and the language barrier had officially gotten to me. I have become really good at picking up on gestures and facial expressions in order to determine the jist of what is going on around me, especially when people are talking about me. While the women were waiting to visit with the nutritionist I knew several women were discussing my presence. I just wanted to know what they were saying! Explain why I was there, that I care about their situation, that one day I want to be the nutritionist they were waiting to see. I wanted to play with their adorable children and talk about life in Zambia. Rewind a bit, I wanted to know what Buela had actually said to the group and what they were discussing. I was frustrated that Buela didn't lead the clinic in English so I could follow along more and get more information than I did. I could only sit idle and in silence for the entire clinic.
Me--idle. just watching. not talking. not helping. not fully understanding what was to come next. You all know I don't enjoy any of those sorts of scenarios!
I hate to sound ungrateful or that I did not enjoy today. Today I got to see what a nutritionist does in a primary healthcare clinic a developing country. I talked with a nutritionist while in Zambia. I quasi-heard the concerns of mothers with malnourished children. Cool stuff. Way cool. It only affirmed that yes, yes I want to do this for my profession. It's just that today was the day I had hit the cultural dividing wall...really hard.
Yvonne promised that tomorrow we would deliver bikes. But really this time. Let's hope so!

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