NEWSLETTER HARAMBEE 2006

HARAMBEE newsletter, 2006.

I’ve delayed chronicling all we’ve done in 2007 because a good update for 2006 wasn’t yet completed.  I hope this isn’t a character flaw—just the result of a sinking feeling of too many tasks & little time, so a newsletter slipped down on the priority list.

To briefly address 2006:  Our carefully planned medical student volunteer program went very well, with gratifying support from many donors & these results:(1) further exposure & help for those in the world who are most in need;  (2) a scholarly publication & two presentations at an international health meeting;  (3) participation in a university student leadership conference;  (4) several radio & newspaper interviews.

The months spent planning a solid itinerary for the May, 2006 mission proved a good investment.  At times, idealistic medical students working in Africa are charged with “medical tourism.”  We ensured that our work was substantial & productive--especially because it serves as a model for future academically-based service programs. 

There were three components:  Education, service, research. 

Education:  Seven students & I met periodically during the winter to plan & learn about Kenya, including cross-cultural observation & communication.  We did teambuilding exercises & came to know each other well. During the first days of our travel in Kenya, our own education continued as we visited HIV service organizations, toured the University of Nairobi medical school & research labs, the Catholic University of East Africa, & Nairobi hospitals, including Mbagathi—an infectious disease hospital with at least two patients in every bed.   

We had planned next to teach basic hygiene and HIV prevention:  education/service in various Kenyan clinics & villages. However, it quickly became clear HIV prevention education was not the fundamental problem; rather, HIV & accompanying health concerns are the manifestation of pervasive economic &

cultural issues. These are complex, but with a simple answer:  when people have control of their own destiny & can provide for their families, a healthy culture thrives.  Poverty is the real pandemic;  HIV is merely its flower.

Students quickly understood this & abandoned HIV education modules in favor of community-building efforts.  They focused on one village, EmBulBul.  We identified local resources for health care & education & attempted to foster a relationship & commitment on both sides; we began a soccer team for the children & investigated how the local church might be more fully engaged.  We tried to identify a market for crafts made by a youth workshop group.  These are small efforts to solve a big problem, but the motto of HARAMBEE is “One drop in the bucket is better than no drop in the bucket.”  Students who returned to EmBulBul in February of 2007 reported a slow, modest success. 

A central task of our trip was the health care needs assessment study—both for the valuable information it gave us and because it provided for dialogue and a unique window into the lives of those we wished to help.  We were trustingly invited into Kenyans’ homes and into their hearts as we queried them about their lives and health.  These encounters engaged us in a way we did not anticipate; information disclosed to us invariably led to strong emotions, tears, and increased resolve to work for social justice. 

Once again, economics stood out as a primary determinant of healthcare.  In a country where unemployment stands at 70%, how could it be otherwise?

Students reported the questionnaire as a transformative feature of their medical education.  Below is a piece written by Justin List and published in Virtual Mentor, an online ethics journal of the American Medical Association.  If you read nothing further in this lengthy newsletter, I urge you to read Justin’s article.

Virtual Mentor. 2006; 8:818-825.

Learning to listen in a resource-poor international setting: a medical student’s encounter with the power of narrative in Kenya
by Justin M. List, MAR

After talking with a woman who was living with HIV and caring for an HIV-positive child in the resource-poor community of Kawangware in Nairobi and completing a public health needs assessment for her, one of my medical school colleagues posed the following question to our volunteer group as we were working at the clinic: “What do I say to her at the end of the needs assessment when she asks me if I have hope that she’ll live?” I remained silent. How can I as a healthy, educated, middle-class medical student from the United States answer a question so outside the context of my daily life? Given my position of relative global power as an American citizen and consumer, can I offer her more than words of solidarity or a prayer? What new moral claims do I feel placed upon me by these global neighbors as they let me into some of the most intimate parts of their lives? These questions were just the beginning of a larger personal reflection that grew from dozens of interviews with members of various resource-poor communities in Kenya and from discussions among seven of my fellow volunteers [1].

Most members of the group had just completed their first year of medical school only days before we arrived in Nairobi. As we laid the framework for our trip, we had decided that we wanted to experience an international service learning trip through the lens of public health by using a needs assessment to understand how social determinants of health impacted the lives of those we interviewed. We also designed health education modules covering hand sanitation and HIV transmission prevention. Compared to the modules, however, the needs assessments spoke volumes to us as illustrated by the eagerness to cooperate on the part of many of our participants.

For some of those interviewed, it was the first time they had ever felt listened to, as we found out from them or their translators. And hearing about the power of having a voice and feeling heard illustrated for me a learning point that I might have missed had I come to Kenya primarily to study the science of medicine. I could have easily done just that given the disproportionate infectious disease burden there. As a person who feels “heard” more often than not, I realized that these survey participants were teaching me more about the art of medicine than I might have expected at first glance. I quickly realized how valuable it was to ask comprehensive questions about their lives and experiences, the answers to which informed my understanding of how their health was shaped beyond the ailments of HIV or malaria they might have had at that moment.

I did learn some of the science of medicine, though, if not explicitly clinical. We used a needs assessment to acquire quantitative and qualitative data that—we hope—will serve the community through its analysis. But because we designed this trip from a public health perspective and left the stethoscope and Bates’ Guide to Physical Examination and History Taking behind, my education in the art of the medicine remained a key component of my experience in Kenya. Being invited for just a glimpse into some of the most unjust and difficult life stories imaginable demonstrated to me how powerful narrative (and the skill of listening) can be in the patient encounter.

I did not need to go to Kenya to understand this clinical pearl, but it was there that I most acutely did. I suspect other students also experience this abroad if not in resource-poor areas of the United States. Paul Farmer writes, “We need to listen to the sick and abused and to those most likely to have their rights violated. Whether they are nearby or far away, we know, often enough, who they are. The abused offer, to those willing to listen, critiques far sharper than our own” [2]. I experienced this “sharper critique” as stories of dying from tuberculosis and AIDS-related illness, stories of poverty and a lack of employment, of abuse and, yet, stories of hope, love and faith poured out from the mouths of Kenyan men and women and onto my feeble survey, a document I could bury myself in when the raw emotion of the situation hit me.

Medical students working abroad in resource-poor, low-income settings will encounter a host of experiences and confront a variety of feelings, perhaps including some I have described. Students bring a rich array of experiences and feelings with them that affect their ability to truly listen to the content of the patient’s words, and it is to our benefit to explore these feelings before, during and after our international immersion. Like me, students may find themselves seeking clarification about how to incorporate international health care into their future careers after short-term, life-changing work. And medical students traveling abroad for the first time in their burgeoning professional capacity should be prepared to expect the unexpected despite extensive planning and pre-trip education; to experience complementary or conflicting feelings of duty, ignorance, education, helplessness and purpose all in a matter of days or weeks; to anticipate an unfolding lifetime of further professional and vocational reflection and action.

Remaining truly present and attentive may be the most difficult aspect of learning the art of listening in medicine, especially where unfamiliar contexts, cross-cultural issues and language barriers coexist. As physicians-in-training, we have a potentially easy exit—turning our focus to the rigmarole of the chart, looking down at the survey with intent, deflecting a consideration of the often difficult-to-comprehend social determinants of health or concentrating on the biomedical components of the present illness. For me, listening to these difficult stories took more energy at times than I could have imagined listening could possibly require. And yet listening is a skill that we as medical students must continue to practice consciously as we discover our personal limits in relation to our pursuit of justice and caring for patients holistically.

Listening is an end unto itself, but it is also a means and a beginning to addressing aspects of patients’ lives that lie outside but impact the biomedical context. In seeking out patient narrative, especially in international resource-poor settings, we must ask questions (in a culturally sensitive manner) to which we may fear to know the answers, answers that expose injustice yet open a new world of possibility to the patient and physician.

Justin M. List, MAR, a former fellow at the American Medical Association’s Institute for Ethics, is a second-year medical student at Loyola University Chicago Stritch School of Medicine. He received his master’s degree with a concentration in ethics from Yale University Divinity School and worked at Yale’s Interdisciplinary Center for Bioethics

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A somewhat lighter part of our work came when we visited the Mukuru women’s group, organized in one of Nairobi’s worst slums to make and sell crafts.  I have been working with them for 2 1/2 years, and they are the furthest advanced of the HARAMBEE groups in their business efforts.  We shared lunch, purchased their craft items, and enjoyed holding and playing with the two new babies of group members. (Stay tuned:  one of those babies provided motivation & focus for our 2007 service trip.) We heard all good news:  the group incorporated as an official business co-op, helped by a sales & marketing plan devised by students from the Department of Marketing at Loyola School of Business in Chicago. (Thank you to Jill Graham, Mike Welch, & students!)  One of the women, Catherine, is a trained midwife, & all of the others have been trained as health workers to provide home care when HIV patients fall ill.  While we were there, the priest from St. Mary’s Church in Mukuru came to bless their goods and the new shop located on church grounds.  HARAMBEE continues to purchase and market good from the co-op and to support them with new projects.

We ended our  3 1/2 week sojourn totally exhausted but inflamed with desire to return and continue this important work.  We have a million memories, a million stories, only a few of which are related on the website (www.projectharambee.org). 

Good things were accomplished during our short stay in Kenya.  I know that lives were changed: students’, those we met, my own.  We hope we accomplished some good while there;  we want to work hard to raise awareness of the catastrophic conditions in sub-Saharan Africa, the job ahead, & the need to share our gifts with those who have so little, who die in great numbers from preventable diseases, who struggle daily to survive.  We want you to know how much we here can learn from the Kenyans we met, from their faith and courage and industry.

We want to thank those who contribute materially and spiritually to our mission.  We can only do what we do because of your help.

We thank our Kenyan friends for their inspiration in our quest to make life’s playing field more even.  From you we receive more than we give, and you help us to be God’s hands here on earth.

Bless us all...

Keen

Keen@projectharambee.org