Category Archives: Satellite clinic

Last Char Visit

*August 16, 2011

The boat carried us through the smooth water, to our last char, Kharjani Char. The char is relatively new, only about two and a half years old. Because of this, a permanent FCM hasn’t been assigned to this char of approximately 85 houses and over 700 people above the age of 18.

However, we picked up an FCM from a nearby char to join our crew of health manager, paramedic, translator, and Sareeta Apa on the boat. The FCM would aid the paramedic and conduct the uthan boitak (health meeting) today.

The clinic, a small shack with a side of reed, was only half-full when we arrived. There was a baby on the ground in the front, playing with a piece of trash. A small boy ran past me, brushing past my legs. On his chest, there was a burn mark extending the length of his bottom rib, to match the red color of his shorts.

Later, as I sat with my checklist at the uthan boitak, watching the FCM show women family planning posters, I noticed an old woman about five feet in front of me. She had a kind face, but worn with years, unhappiness deeply planted in her eyes. Protruding from her orange sari, below her chin, was a lump, bigger than the size of my fist.

I leaned over to Sareeta Apa, and asked her if she was here to get it checked out. After the meeting, as patients waited in line to be seen, Sareeta Apa asked. The patient was at the satellite clinic to seek care for headaches, not for the tumor, as she had already been living with the condition for more than three years. Can you imagine? Three years without medical support.

I asked her, through my translator, if she had any pain or trouble swallowing. She had none.  But if it had grown to this size in 3 years, there was no telling when it would reach the point of obstructing her esophagus or larynx. The health manager intervened, telling the patient that we had a hospital where a simple surgery could fix her problem.

She was insistent, shaking her head from side to side. She also said she didn’t have the money to access the boat anyway. As she said this, the two or three young couples who had surrounded us to watch the situation unfold started laughing. I asked what was so funny, and the health manager answered, with a frown, that people were telling the patient she shouldn’t seek treatment because they’ll cut her open and she’ll die on the table. She’s old anyway, there’s no need to spend resources to fix her. Besides, it’s a curse from Allah. There’s nothing we can do to fix it.

I felt my cheeks get red. The discouragement from her fellow community members made her flee the scene as soon as she got her medicine for headaches. She had two sons who kept their distance, I was told. Additionally, I was informed that if she had daughters instead, they would be oppressed and ousted by the community, just like their mother.

Two things were at play here: 1) the fear and social taboo surrounding getting medical treatment in the form of an operation, and 2) cultural beliefs that the sickness was Allah’s will, and that’s it. Both are things that can be addressed with medical treatment coupled with educational outreach. It’s hard for communities to disprove the legitimacy of such operations and treatments once they see their neighbors healed. The hard part is getting those neighbors to get treated in the first place.

What a last visit. I don’t remember feeling this sad, disappointed, and hopeless in a long time. But one thing is for sure – this brought home for me the vitality of having services in communities in addition to our hospital boats. We can create all the hospitals we want – in planes, boats, buses – but if these health facilities are not used by those that they are geared to heal, then our work is wasted. Uthan boitak, our community health meetings, can be used for adding the roots needed to get these patients to view their health in an empowering way. The capacity is there, we just need to scale up, focus, and fortify.

I head home tomorrow morning. The bus will be a good time to process some of these thoughts and transform them into something positive – namely, a rant on the importance of community outreach in my internship report. I should have plenty of time, as bus strikes have gripped the nation by storm right before Eid.

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Char Visits

**Retroactive posts because of low internet again, 2 more to come tomorrow!

*August 14, 2011

Today marked our first day of validation among the chars. We are very lucky that the director of community health services from the Head Office is accompanying us these next few days as well. He brings a wealth of experience and knowledge, about Friendship and about our health services on the field, that neither Sareeta Apa nor I possibly match. His ownership is a pivotal part of this project – without him, we don’t have leverage or the investment needed to finalize and distribute the tools, and advocate for monitoring and evaluation culture, in general.

We were also accompanied by my translator today, a kind-faced young fellow who ended up not only translating for me, but also eagerly took on the role of cultural ambassador, pointing to fish farms and different crops, to villages “where victims of river erosion live,” to bridges destroyed by floods and newly rebuilt. As we drove down to the riverside and hunkered down on the boat (it would take us 3.5 hours on the water each way today, excluding FCM pick-up time from different islands), he leaned over to tell me this was his first time on a boat like this. I smiled, asking: “Why? You live so close to water!” His answer, delivered with a nervous smile: “I’m so, so afraid of the water!” A part of me felt for him, especially when his mother called to ask if he was wearing a life jacket. In that instant, I realized a newfound appreciation for how far I’ve come with my own parents. They still worry, but I also think I’ve set the bar high enough that I can picture my dad being a bit disappointed if I didn’t take on some of the adventures that have come my way. My translator rose above, though, even coming with us to the roof of the boat from time to time.

A gray sky, with periodic bouts of rain, accompanied us on our long journey through the river. We visited two chars today, Mollarchar and Shonnashir Char, where satellite clinics were taking place. Both are stable chars that have had a lifetime of 15 to 20 years.

Because I had a translator, we were able to effectively delegate validation of the tools as the satellite clinic took place. The health meetings (uthan boitak) were delegated to me. On our first char, the FCM had just given birth, so instead the assistant health manager gave the meeting on fever and diarrhea. I pulled out the tool, made up of about fifteen benchmarks, and listened to my translator as he transliterated the lesson. I observed the audience, participation level, and the relationship between the manager and the attendees. One by one, I could see the components of the checklist coming to life! It was an amazing feeling and happy warmth rushed through my body.

The same happened on the second char, where this time the FCM gave the uthan boitak to some attendees. The tool also incorporates a check-in with one of the meeting attendees, a short interview to assess quality conducted on a private basis away from the satellite clinic. On both chars, my translator helped me to ask questions to women beneficiaries regarding the topics discussed, such as if the beneficiary is planning to, or has already used advice that she’s learned at the health meetings, and if she feels comfortable asking questions during the meeting. This went smoothly, as well, with one of the women even saying that because of the health meetings, she now knows how to make oral saline solution at home for her children whenever they have diarrhea. Perfect. That’s what we want!

I noticed some points of dissonance with the checklists, though – for example, the culture of taking attendance had disappeared somewhat from the meetings and needs to be brought back so we can track community involvement.

Once we were back in Gaibandha later on, a check-in with my supervisors revealed that there’d been frustrations about the distance traveled versus the actual amount of time spent at the clinics validating (about an hour each). I didn’t have any control over this and though I agreed, the selfish part of me enjoyed each of the seven hours I got to gaze at the gurgling water of the river, the numerous chars new and old, green and amber.

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Filed under FCMs, Field, Satellite clinic, Supervision and Monitoring Tools, Travel

Allies on the Field

*July 5, 2011

I talk a lot about geographical barriers in the chars. My trip today to the Gaibandha field office is a perfect case in point of how arduous it can be to travel from Point A to Point B. Sareeta Apa and I left EFH early in the morning for a half-hour boat ride to the mainland. From there, another 20 minutes with a motorized rickshaw took us to the stop where we got on absolutely the most full public bus (a fun and funny experience all at the same time). We spent about an hour on the bus, and afterwards, took a motorcycle to the Gaibandha Field Office. Friendship was recently voted as the best-performing NGO in Gaibandha for 2011 (more information here).

We followed the same structure of the health meeting we had in Chilmari, with the main purpose of trying to identify the strengths and gaps in our current monitoring and supervision tools. Three paramedics, a health manager and the district supervisor attended the meeting – an impressive showing considering that today was the first day of a 48-hour hartal or national strike in Bangladesh. The strike is a result of recent political developments, namely a recent constitutional amendment which scrapped the provision for a pre-election caretaker government, making it so that elections will be held under an interim party government from now on.

Some of the best parts of these conversations is not only that we get valuable feedback from the level of the organization that deals directly with the community beneficiaries, but we also establish partnerships with the true program implementers. The significance of this cannot be understated. We leave these conversations with an overwhelming consensus that program monitoring and evaluation will help Friendship identify the problems in its programs and find ways to rectify them. The Friendship field staff are the most valuable allies we can have.

In addition to visiting the Gaibandha office, we also visited two NGOs to gain information about some of their own monitoring and progress-tracking tools. Namely, we visited GUK, which works in five districts in the North to strengthen coping capacity as climate change occurs. I was also impressed with the work of Akota, an NGO operating in Gaibandha that aims to establish sustainable livelihood with various interventions ranging from gender, justice and human rights to health, sanitation and environment.

Because of these various encounters and exchanges, I think a lot about the words that comprise my generally accepted epistome of development. It’s a constant tug-of-war in my head as I aim to answer my own questions of the macro vs. micro, quality vs. quality, collective vs. personal, what is actually possible with NGOs and what is not. I came to Bangladesh to seek clarity in some of these questions, but the obstacle of reconciling all of the parts of my experience will prove to be harder than I thought. One thing is for sure – for years, Friendship has prioritized the quantity over the quality to follow its philosophy of ensuring health access for all. My internship project is part of a strategic move on part of Friendship to review and fortify, to ensure quality access. This a daunting task given Friendship’s many arms and mere coverage, one that is made more onerous by some of the same barriers our beneficiaries face – geographic, economic, and even social obstacles that separate the Head Office from the field work.

On a simpler note, as we were leaving the mainland, we spotted a huge gathering of folks, singing in a narrow path next to a house. It’s impossible to observe anything here without attracting attention, so Sareeta Apa and I were ushered to the front to see a tradition that is a part of a Hindu wedding. It’s sights like this that make me feel like one of the luckiest people on Earth.

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A truly far-flung life

*July 4, 2011

They have moved seventeen times. Seventeen. While he tells his story, his eyes make contact with mine, even though we can’t directly communicate. This man, I’ll call him “Tom” has four children, two daughters and two sons, all married. His wife, his eldest daughter and her grandmother-in-law, and a relative fill the room. We all sit on beds.

Tom tells me how all the lands he had previously owned had been “eaten by the river” and now he is completely landless because of river erosion. His family moved to the char we’re on about three years ago.

Some river erosion pointed out to me on a walk around one of the chars. It wasn’t there a few days before the walk.

He tells me he is a day laborer, even though he is approximately seventy. Even with his family’s investment in a profit-sharing cow, they make about 100 to 150 taka per day, which comes out to about 3,000 -4,500 taka monthly. To give you a picture of what that means, 1 USD equals about 74 taka.

I asked Tom when he married his wife. He answered, “Before 1974.” My heart sank. I had read the specific importance of this date. The measurement of time is different here. No one can tell you exactly when they were born or when they married. Instead, at least on the chars, events will be classified as either taking place before or after 1974 – the year that marked a most devastating famine in Bangladesh, killing more than a million. The famine resulted from the deathly mix of several factors: flooding along the Brahmaputra, government mismanagement of grains, legislation restricting movement of food from one place to another, among other failures in distribution.

We covered a plethora of topics during our conversation, from their healthcare-seeking decisions to their health care beliefs. For example, I learned that it’s widely believed that the cause of diarrhea is poison in the stomach and that barefooted-ness is a major part of maintaining health, because it maintains their connection with the earth. We also touched a bit on their fears of seeking healthcare from hospitals. The eldest daughter talked about the fear of “cutting her stomach” in a hospital to give birth to her baby. Socially, having a pregnancy that requires a hospital visit suggests that the baby is not normal or healthy. The maintenance of this normalcy is important in Bengali culture even as the baby becomes a child, as symbolized by a single rope or “tabis” tied around the stomach of the child, to prevent any sickness or disease. There are three healers or “daktars” that this char community has access to, who charge next to nothing for their services. All the women tell me they visit Friendship satellite clinics to get ANC care, but for the final birth, they utilize the “informal” community healers.

I found myself thinking about the importance of these beliefs for Friendship, because they give insight into the social embeddedness of the health-seeking actions of our beneficiaries. In a place where there are so many barriers lying between patients and services – social, economic, geographic, economic, and organizational – understanding and documenting this concurrently mixed method of seeking healthcare can only help Friendship operate more effectively in these communities.

After long, exhausting days visiting our chars (it’s exceedingly difficult to get people alone for interviews), we head back to EFH by boat at night, sometimes serenaded by the sweet voice of one of my older colleagues. Life at EFH is going very well. I’ve made some new friends!

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Chars, Collection and Communication

*July 3, 2011

I sit on a bed, observing the satellite clinic. A paramedic, donning a worn white coat, sits at one of the longer sides of a rectangular table. One edge of the table is filled with medicine – various small tablets, pills, packages and boxes. The patient records, notebooks, lie in front of her. To her direct right, there is a chair for the community members to sit and tell her their grievances. Listening, she measures their blood pressure or temperature, or talks to them, and prescribes medicine.

The FCMs surround the table. One sits directly behind the patient, helping voice her precise health condition. The house itself is one of the FCMs’. I can’t help but notice an empty white bag, not far from where I am, hung on a bamboo support for the dwelling. “World Food Programme” is printed on its side with huge blue letters, followed by a picture of the Japanese flag. The family had received a ration of rice, as a “gift from the people of Japan.” What a striking situation, to get to see the receiving side.

This is my second day observing the chars and first day of official data collection on this island called Shirajbeg. Sareeta Apa and I will conduct interviews with the FCM, the paramedic, and the paramedic assistant on this char. We’ll also hold a focus group discussion with community members who attend the health meeting, lead and given by the FCM.

Shirajbeg is one of the closer chars to the mainland. It took us about half an hour to get here by boat.

The boat that we take to travel from char to char!

Yesterday, we visited Bozradiarkhata, where we tested some of our survey tools before starting to collect data. It was also on this char that I paid a visit to one of Friendship’s vocational training centers, where women learn how to weave and earn a living doing so, creating beautiful cloth.

Friendship's Weaving Center

Shirajbeg is younger than Bozradiarkhata. It’s sandier and the vegetation is shorter across the island.

Houses in the distance!

Char bank

The house we’re in has all the components of what you would envision would come with a makeshift settlement: hard-pressed dirt floors, a thatched roof and sides of reeds. The hut is small, and it’s clearly leaky during monsoon. Sides of the house are wet from the rain, with buckets strewn about to catch drips of water.

There is a growing line of waiting patients circling the house, all women, facing the heat to visit the satellite clinic (which costs 5 taka, or less than 0.07 cents). The scene is incredibly colorful. Each woman wears bright, catching colors in their saris. (I’ll really miss this about Bangladesh.) I also notice that all of the women come with at least one baby, which they casually carry at the hip. The babies are mostly undressed, except for a rope that they wear at the belly to ward off evil or malign influences. One by one, they sit in front of the paramedic, some to talk about contraception and others to get medicine for their babies. I can tell some of the children have watery eyes from fever, but almost all of the kids around me are incredibly underweight. They seem delicate; I’ve never seen bone on bone like this before.

I have also never been in a place where I am so constantly aware of different components of my identity – white, Turkish, woman, unmarried, Muslim. I have limited communication with the char communities, but they ascertain my status on some of these things pretty well nevertheless. And I’m proud to say I have mastered several key Bangla phrases, so why not use them as much as I can, no matter how ridiculous I may sound? In addition to the Bangla, I communicate in other ways, like yesterday, when a pre-teen girl and I winked back and forth for about three hours. Later today, I met the young daughter of a doctor on EFH. I drew for her a smile on a napkin, and she returned the gesture. What can I say? Like many overly naïve and idealistic travelers have uttered before me, the language of winks and smiles proves universal.

Smiles, smiles

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