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.

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.

On the field again

*August 13, 2011

Our bus from Dhaka to Gaibandha lasted about eight hours today. We tumbled north through the narrow, moldering highways that connect this part of the world to the rest of Bangladesh. As a fourth-timer on such buses, the constant honking and fierce rocking from side to side no longer bother me. As we wobble and sway past rice paddies, quaint villages and verdant countryside, I pretend it’s all some sort of sweet lullaby and this chimera eases me to and from sleep.

From the onset, I can already tell Gaibandha is better off than Chilmari, the region of my first field stay. In the city center of Chilmari, dirt-floored convenience stores, metal roofed cook shacks, one-story makeshift shops and kiosks with crumbling foundations and paint line the streets, whereas in Gaibandha, we strolled past numerous fabric shops, handicraft shops, and shops that even sold TVs and motorbikes, that look better-maintained, more diverse. Gaibandha just seems livelier, too. After iftar at the Friendship Gaibandha office, we joined all kinds of hawkers and pedestrians on the streets, joining a throng of locals going for their evening tea. Actually much of what I know of Gaibandha comes from constant news reports of extreme flooding in this area over the past several weeks.

The purpose of our field visit, scheduled to last for five days, is to validate the monitoring tools completed so far – more precisely, our service checklists for the FCM’s one-on-one family planning counseling, for the uthan boitak or the community health meetings that the FCMs conduct, the checklist for the physical set-up of the satellite clinics and finally, our antenatal and postnatal care counseling. Tomorrow, we’ll visit a couple of chars to validate the tools on-site, and assess whether we are indeed where we need to be (in the ball park). In two days, we have a scheduled meeting with the health program managers and paramedics to go through the tools. Then, we’ll return to the chars for another round of validating and feedback from the on-site health workers and paramedics.

As our group walked around the city center after evening tea, I couldn’t help but ponder how fast time has flown. I’m proud of what we’ve done with this project, despite its ups and downs. Hopefully, our conversations with the field staff will make the tools that much better, that much more relevant. At the same time, on a more personal note, the fact that this might be my last time in the field and among the chars is a heart-breaking kind of realization, and one that resonated within me unstoppably tonight. It certainly makes my final departure from Bangladesh in three weeks that much real-er.

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