Pilot Project: Community-Level Contraception

There is a huge unmet need for contraception in Guinea. Pretty much everyone here loves babies, but women often aren't able to space out their pregnancies or to stop getting pregnant once they have the number of children that they want. Especially in rural areas, too many girls and women are injured or killed by complications from pregnancies that are too close, unwanted, or high-risk. Using contraceptives for birth-spacing and avoiding unwanted pregnancies means healthier babies and healthier mothers, and in a culture that really values having children that message is appealing to a lot of people. Unfortunately, actually getting contraceptives can be difficult, especially for women living in rural villages without health structures. There are efforts to increase access, including launching programs to recruit and train people who are literate, responsible, and respected in their communities to be Community Health Workers (CHWs). These CHWs are able to serve as a accessible resource for information, advice, condoms, contraceptive pills, and referrals to local health structures. 

Photo courtesy of Save the Children/Guinea.

Save the Children launched a pilot program to improve and expand access to contraceptives by working with the Ministry of Health to recruit successful CHWs and train them to administer DMPA, a contraceptive injection better known as Depo-Provera. (DMPA is safe, reversible, extremely effective and lasts for three months at a time - not having to take (or hide) packets of pills is really appealing for many women.) Aside from safely giving an injection it is really important to make sure that a women is eligible (not pregnant, no relevant health problems) and understands the risks and benefits of DMPA. The CHWs were trained about reproductive health issues, effective communication methods, reporting and evaluation, when to make referrals to medical professionals, and how to minimize the risk of infection. A lot of work also went into communicating with local authorities, community members, religious leaders, village chiefs, husbands, and health professionals, so that people understood what the project was all about and to raise awareness about maternal morbidity and mortality in Guinea.

By all accounts, the pilot project was successful: when it was added to the other contraceptive options available in their villages, many women opted to switch to DMPA, and other women who hadn't used contraceptives before opted to try it. Women who tried DMPA reported that they had been advised about common side effects and nearly all reported a high level of satisfaction, even when they had experienced minor side effects. The biggest problem was that supply chains are really unreliable in Guinea "and ruptures of stock" are really, really common. (Stock-outs are really disruptive, not just for contraceptives, but of all sorts of medications and supplies.) There were no reports of serious side effects or infections, and all the women surveyed at the end of the pilot phase reported that they were planning on going back for their next injection, which says a lot. 

Photo courtesy of
Save the Children/Guinea.

Photo courtesy of
Save the Children/Guinea.

The Save the Children team presented all of this (and much more!) in Conakry last week, and it was really interesting to watch the response to presentations and to listen to all the questions and feedback. Despite the mountain of evidence demonstrating the many benefits of reversible long-acting contraceptives like Depo-Provera and Intrauterine Devices (IUDs), it can still be a touchy subject – even in the U.S. we can’t seem to figure out a way to make them affordable and widely accessible.

There seemed to be a lot of interest in the project, and a lot of support for better access to reproductive health services in general, which was encouraging, and I'm hopeful that I'll be able to work on the project as it continues on the next phase. 

Roadtrip!

Last week I went to Conakry for some meetings and a workshop held by Save the Children (SC). It’s a long and bumpy ride, but I was in one of the SC/Ministry of Health cars, so it was a much faster and more comfortable ride than it would have been on public transport – I got my own seat and everything.

The drive out wasn’t so bad. Once we’d cleared the flats of Upper Guinea there were low mountains and rocky cliffs to admire. Everything is excessively verdant this time of year, rivers are full, waterfalls spill over rock-faces, and there’s flooding in some lower-lying areas. (Looking at all the water made me think of the view from the airplane when I landed in Guinea in June – the approach to the Conakry airport starts over the Atlantic and then comes in low over a delta covered in serpentine loops of water and what looked like mangroves and deep mud, and it just goes on and on until you start to wonder if there really is a city and an airport and a runway.)

Aside from the scenery, the most striking thing about the drive was the number of broken-down trucks and wrecked cars, frequent reminders that my borderline phobia about in-country travel is not really so unreasonable.  Thanks to the nice car and good luck we made it to Conakry in about 14 hours, and I was very glad to get dropped off at the Peace Corps office/transit house to stretch, take a hot shower, and get some sleep. The rest of the week was mostly filled with meetings at the NGO Jhpiego’s Conakry office and at the Ministry of Health. The main event was SC’s presentation of the results of the Community-Level Contraception Access pilot project that they’re hoping to expand over the next few years, and it went really well. 

The only thing we have to fear is fear itself. And also rabies.

I spend a not-insignificant amount of time thinking about all the many dangers of West Africa – various horrifying parasites, mango flies, car accidents, diarrhea, civil unrest, malaria, grotesque skin infections… and rabies.

I'm pretty sure that car accidents pose the most serious danger to Peace Corps Volunteers, and diarrhea is the only thing on that list that is pretty much guaranteed to make my life miserable (again) at some point. Still, each evening at dusk, as I watch a cloud of mid-sized bats that sweep out from wherever they shelter during the day, I wonder how many mosquitoes they eat and also if any of them are carrying rabies.

As luck would have it, yesterday RadioLab released a mini-episode about rabies, which was totally interesting: http://www.radiolab.org/blogs/radiolab-blog/2013/aug/13/rodney-versus-death/

Image courtesy of RadioLab & Wikimedia Commons

We have plenty of rabies in America, but if you are bitten by something that might be rabid in the U.S. (probably a bat) you can go to the hospital and get a series of (very expensive) preventative shots and you will almost certainly be completely fine. However, if you are infected and don’t get those shots before you start to feel symptoms, you will almost certainly die. Even if you're able to get (astronomically expensive and controversial) experimental treatments, the odds are very much against your survival. Basically, unless you have both world-class medical care and miraculous luck, rabies is a death sentence, and an excruciating one at that. 

According to Wikipedia, India has the world's highest rate of rabies in humans, followed by Vietnam and then Thailand. In Senegal (and also here in Guinea, I would guess) people periodically put out poisoned meat to kill off stray dogs, because they want to protect their chickens and sheep, because most people here don't have much affection for dogs, and because they know that dogs can carry rabies. Poisoning is neither humane nor pretty and I don't like that it happens, but people see that as their best option here. (I do like the tactics used to combat rabies in foxes in Western Europe, which involved baiting meat with an oral rabies vaccine and turned out to be quite successful, but that's a whole different context.) 

In any case, when it comes to rabies I am about as well-protected as a person can be. During my training in Senegal I received three rabies booster shots, and if I ever have the misfortune of being bitten by some spazzy, drooling animal, I will call Peace Corps, be rushed to a doctor, given a full round of preventative injections, and probably be just fine. 

I still wonder about the bats here, though. 

Rain boots & Rainbows

Last week Ramadan ended on the rainiest day I've seen so far in Guinea. The morning was overcast and calm until the wind kicked up, bringing in the kind of horizontal rain that makes you circle around the house double-checking that everything is closed and latched and that water is not streaming in under the doors. (Happily, my rooms stayed dry.) After awhile the wind tapered off but it rained steadily for most of the rest of the day, putting a damper on everyone's end-of-Ramadan festivities. 

The next day people were out and about and making up for lost time, all dressed up and carefully skirting the pond-like puddles on their greeting rounds. The theme of the day seemed to be Small Children in Sunglasses, and it was adorable. Just on the streets right by my place I saw at least a couple dozen little kids in brand-new frilly dresses, little brightly striped t-shirts, fancy new sandals and neon sunglasses. (I really wanted to take pictures, but feel weirdly about taking photos of people I don't know. One of the big drawbacks to not living with a host family is not having a constant supply of people around who're more than happy to pose for the camera.) 

It rained a lot yesterday, too, and I took some pictures of the street-turned-stream outside the Save the Children office, and also of the amazing complete double rainbow that followed. (It was a lot more impressive in real life, but you get the idea.)

This is why I brought rain boots to Guinea. 

After work I walked around the neighborhood, surveying the water levels and picking up things for this morning's breakfast. I tried to make it over to the Pulaar vendors who were so amused by my mediocre Pulaar the other day that they gave me a free loaf of fresh bread, but I didn't feel like wading so I settled for bread and eggs from the vendor lady just down the way.

The vendor lady is also nice, as are her kids, who very expectantly watched me leap over a decent-sized puddle and were impressed (and possibly disappointed) when I made it. She wears a black burqa-type veil, made of very thin fabric that she seems to be able to see through just fine. (I can't recall seeing any burqas in Senegal, but I see them here pretty frequently.) As someone who hasn't done much interacting with burqa-clad women, when I first went by her boutique I wasn't sure if I was supposed to look at her face-area while talking to her or what, but I think any awkwardness on my part probably blended in with the general awkwardness of being a foreigner who doesn't know where to find pasta or what that white powder is or how much anything costs. In any case, she seemed pretty relaxed about everything, and I go by there pretty regularly, partly because she's patient with my questions and partly because she always has fresh eggs. I've been by around prayer-time a few times and noticed that she just flips up her veil to do her ablutions there in front of her shop and doesn't seem to mind coming over to sell me some eggs and onions while bare-faced, which I found slightly surprising. I suppose I didn't expect her to be so laid-back about it, but then I'm the one who's not used to veils and washing up at prayer-time and running a little side-street boutique and all the rest.

Anyway, yesterday her shop was not totally surrounded by a rainwater moat, so I stopped and bought my bread and eggs and continued on my way. It's remarkable how quickly the earth soaks up the water - roads that are completely flooded can be partially clear after just a few hours, and dry up almost completely if the next day is a very sunny one. On the days when it isn't raining it's been really nice out, blue sky and extremely green grass and billowing clouds. Here's a recent sunny-day photo of the welcome sign on the main road not far from the Peace Corps office, the phone company Orange puts them up at the edges of cities and towns all over West Africa. 

Happy Birthday to Marielle, Arielle, Switzerland and Me!

The birthday box that I'd stowed in my suitcase.
I forgotten about some of this stuff, so opening it
turned out to be a pleasant surprise.

Happy birthday, indeed. I started this morning with coffee, and Birthday Cake Oreos, and a nice long yoga session, followed by scrambled eggs, the BBC World Service, and delightful text messages. (The filling in Birthday Cake Oreos smells and tastes exactly like Funfetti frosting, which is the sort of thing that I avoided in America but find absolutely delightful here.)  

(The thoughtful computers at Starbucks & the Red Cross also sent their regards.)

When the internet came on I was greeted with an opening salvo of birthday well-wishes, and also Radio Lab just added a new episode about Blood, so obviously the day is off to a pretty fantastic start.

Breakfast of (Birthday) Champions. Thanks, Heather! 

A few minutes ago there was a little commotion and one of the guards called out “Hey, les poulets! Les poulets!” and then came in to help me shoo a couple rogue chickens out of my bathroom. We got them out, but not before they both pooped on my floor.

Anyway. I have a few mundane office-type things to do here and then I’m going to head to the market to pick up vegetables and stuff for dinner. A few PCVs (and PCRVs) and I are going to get together to cook, bake a cake, and talk English.

UPDATE:
Dinner was excellent. I made salad and green beans and garlic bread, Stacey cooked up some fancy soup, Kenny contributed a box of Kankan's finest wine, Keila provided moral support, and Sarah made a delicious lemon cake (With frosting!! From America!!) that is sadly not pictured because my camera is falling apart and stopped taking pictures. Many thanks all around, it turned out to be a really nice birthday.

Peace Corps neighbors are the best neighbors.