You know you are in Uganda and not in Seattle when.....

Truck going to the market

1.  Your driver throws all his trash directly out the window, including 1 Liter plastic water bottles (every time!).

2. The truck carrying people to the market looks like the photo instead of the Seattle city bus.

3.  Large 4WDs are not only popular, but absolutely necessary.

4.  You spent most of your time the last two weeks on unpaved dirt roads that are TERRIBLE.

5.  There are grass huts throughout the neighborhoods as opposed to Craftsman Bungalows.

6.  You have suddenly gone vegetarian the past two weeks because you don't like the taste of boiled meat.


7. The bigger the vehicle the more right-a-way you have on the road.  Bicycles...look out!

Current banana surplus

8.  You are expected to eat at least 4 or 5 mini-bananas a day and if you do or don't, people will keep buying them for you and you will have a banana surplus.

9.  Big IS beautiful for women.  If you are thin, something is wrong with you or you must be sick.

10.  There large beautiful mango trees everywhere.

Mango Tree

Sayana Press

Maternal mortality rates are alarmingly high in sub-Saharan Africa with over 800 women dying a day from preventable causes related to pregnancy and childbirth.  Almost all these women are among the rural poor in developing countries.  A landmark announcement was made at the 2012 London Summit on Family Planning where donors and leaders around the world pledged their commitment to ensure that 120 million women gain access to voluntary family planning services by 2020.  Read more in the press release here: http://www.londonfamilyplanningsummit.co.uk/1530%20FINAL%20press%20release.pdf

At this summit the Ugandan President, H.E Yoweri Kaguta Museveni, said “In developing countries like Uganda, women continue to die so needlessly during pregnancy and childbirth. Yet the causes of these deaths are well known and so are the solutions. The causes are largely preventable. Use of relatively cheap technologies, including family planning can lead to rapid improvements in conditions of women.”

Sayana Press

At this meeting a donor consortium made up of The Bill and Melinda Gates Foundation, DIFD, USAID, UNFPA, and Pfizer, Inc. agreed upon the purchase of 12 million doses of Sayana® Press to help reach some of the 120 million women pledged by the Family Planning 2020 goal.  Sayana Press is a form of the injectable birth control, very similar to the method Depo Provera.  Depo, as many of you know, is a shot that women get to prevent pregnancy protecting them for 3 months.  In its current form, Depo Provera must be administered in a clinic by a trained practitioner intramuscularly with a one inch long needle.  The new product, Sayana Press, is the same medicine (Depo) but in a different injection system.  This system, called Uniject, is a technology that was developed by PATH, and is an all in one injection device, with a small needle that can be injected subcutaneously.  The Uniject system allows for the same drug, Depo Provera, to be delivered to women outside the clinic setting.  Therefore unskilled community health workers can take the injection to women in the most rural of areas and administer it without them having to come to a clinic.  The donor consortium and PATH have a strong hunch that this will greatly increase access to family planning for the women who need it most. 

PATH won a grant to coordinate the introduction and evaluation effort for Sayana Press.  Within our grant we will be introducing the product in four to six countries and conducting a large outcome evaluation in 3 countries between 2013-2016.  I was hired on the Reproductive Health, Sayana Press team, to provide technical support of the evaluation. 

Plans are well underway to introduce in Senegal, Uganda, Burkina Faso, and Niger.  We will be evaluating in Senegal, Uganda, and a third country yet to be determined.  I am currently in Uganda conducting district visits in 22 selected districts that the Ministry of Health would like to introduce. The purpose of my trip is to visit with government district health teams and discuss the project and get some information from them that will help with introduction.  In addition, I am visiting a health care center in each district where women receive family planning services.

Community health worker in Uganda with Sayana Press

More about our project here:  http://www.path.org/projects/uniject-dmpa.php

I feel honored to be a part of this team and excited about the next 3 years.

Update - New Beginnings

In February, I made the difficult decision to switch teams at PATH from the WASH team to the Reproductive Health team.  The decision was precipitated by a number of uncertainties and difficulties within the WASH team, not the least of which was the lack of funding.  With the help of my super supportive supervisor, I was able to identify two promising options for teams at PATH which could potentially benefit from my skill set and expertise.  After carefully considering both options and consulting a number of old colleagues and friends, I decided to pursue the opportunity with the Reproductive Health team.   The Reproductive Health Global Program at PATH is solid and well-established.  The work ranges from the cervical cancer prevention, to breast cancer research, to the development of new, more acceptable methods of family planning, to advocacy for safe abortion.  After working 100% with team for the last 6 months I am happy to report it was a really good switch for me. 

I think my biggest concern/hesitation of making a topical switch was wondering if I would be as passionate about Reproductive Health issues as I am about water and sanitation.  After spending nearly a decade in WASH and pouring a good amount of my heart and soul into that work, would I be as excited within this new position?!  As I debated this, I thought about how lucky I am to have spent nearly the last 20 years of my life avoiding unintended pregnancy by having easy and cost-effective access to a variety of family planning options at more or less the drop of a hat AND in the near absence of oppressive stigma.  And then I thought about women in developing countries that I have worked in and I thought about how their choice, options, and means of obtaining contraception must be severely constrained.  Not to mention access to preventative cancer screening such as the ye ol’ dreaded pap smear that I now feel we TOTALLY take for granted.  Needless, to say the new team has opened up my eyes to a wide-array of public health issues in global reproductive health.  I feel happy and reinvigorated in the new position and am happy to report the team dynamics have also improved dramatically.  Suffice it to say, Liz Blanton is much happier in the RH group and you know when I say it in the 3^rd person I really mean it.    More about the current trip soon...

Starbucks Community Needs Assessment

Jai and Mtemi (the Starbucks Agronomist)

PATH recently received funding from Starbucks Foundation for the purpose of strengthening safe water and sanitation in coffee growing communities they buy from as part of their cooperate responsibility.  Jai and I are here to start this project by conducting a rapid community needs assessment in their areas of interest.  The premise of our proposal to Starbucks was to work with communities to identify the needs and gaps that need to be filled in water and sanitation and then work with them to design the appropriate intervention and then implement that intervention.  That may sound like a logical chain of events to people reading this blog, but actually, in my opinion, it is rarely done in global health.  Sadly, more often than not, we decide on an intervention and then go into a community without first consulting the community to see if they think the intervention is appropriate.  Personally, I have been a part of a number of these interventions in the past 10 years and I think this is a bit of a backwards approach.  All that aside, let’s faces it, who doesn’t want to work with coffee growing communities in Southeastern Tanzania?!   Jai and I are pumped to be here.  ; )

Closeup coffee plant

So, how do you conduct a community needs assessment?  Good question!  I had no clue before consulting a few people at PATH much more experienced in these assessments than I am.  They offered a plethora of suggestions and then we came up with our own design of participatory learning approaches (PLAs) to make up our assessment.  While here, we will be conducting 4 different data exercises in 6 communities that the local Starbucks Farmer Support Center (SFSC) selected. 

 Those data collection activities are:

·         Focus group discussions among farmers and non-farmers from each community

·         In-depth interviews with community stakeholders

·         Water testing

·         Asset mapping (visually verifying a checklist of assets while walking through a community)

Water sampling from a spring used for drinking water

We started water testing and asset mapping today while waiting for local ethical approval to start the community discussions and interviews.

As an aside, Starbucks has been buying coffee from the Arusha (Northern) area of Tanzania for quite a while but they are only now starting programs in this Southeaster region.  Personally, I think it is pretty cool that they are already starting a water and sanitation intervention in communities they are only yet thinking of buying from.   Don’t get me wrong, I still enjoy the hell out of a Seattle independent coffee shop but good for Starbucks for doing something worthwhile in areas of the less developed world that they purchase coffee beans from.


Southern Highlands

Mambo from the Southern Highlands of Tanzania!  After 34 hours of travel time sans layovers we have arrived in Mbeya, Tanzania.  I am traveling with my coworker extraordinaire, Jai Sutherland.  I am lucky to have such an awesome, bright, and fun traveling companion.

Travel time breakdown:

• Seattle --->Amsterdam = 10 hour flight
• Amsterdam ----> Kilimanjaro = 8 hour flight
• Kilimanjaro ----> Dar = 1 hour flight
• Dar ---> Mbeya = 15 hour drive

I think these US to Africa travels seem much longer to me than they used to.  Well they are longer from Seattle.  Haha!  I can say it was totally worth it.  It is absolutely beautiful here.  As in...I LOVE IT!!!  No big surprises there.  This is Tanzania. 

The travels have not been without their hiccups - thus far we have encountered a seemingly corrupt and hostile immigration situation, customs red tape to relinquish water testing equipment, nearly hitting a cow in the road, hitting and killing a LARGE African bird, stopping to pee at a brothel, and nearly getting killed by a bus.  All that being said, I couldn't be happier to be here.  I love me some Africa.

On the drive from Dar to Mbeya we were lucky enough to drive through Mikumi National Park where we saw elephants, giraffe, water buffalo, gazelles, warthogs, and monkeys.
                                            


We are now in Mbeya staying at the "Peace of Mind" rest house.  It is colorful and nice.  The ceiling inside is even painted in a turquoise giraffe pattern.  The bed is large and comfy and I would say I am about 90% recovered from jet lag.
                                                        

The Southern Highlands are considered the "food basket" of Tanzania.  This is the major agricultural center of the county.  The region is dominated by volcanic soil which is rich in nutrients ideal for producing bananas, maize, beans, tea, and coffee.


We have been in Mbeya for the last two nights and head to Mbozi tomorrow where we will be conducting our project.  The town of Mbeya is very close to the border of Zambia and Malawi and Lake Nyasa, which I recently learned is the same as Lake Malawi.  As you may have guess a lake spanning two countries comes into dispute often and could be called two names by each respective country.


Tomorrow we travel to Mbozi, the final destination on our tour of Southeastern Tanzania where we will be doing our project.  What project you say?!  Stay tuned for the next post!


Khmer Food Adventures

Pa-cock!

So....eating in Cambodia has been a bit rough for Anna and I.  Pretty much everyday presents a new challenge and we have come to admit the novelty of Khmer food is fading fast.  Especially as we enter week 3 of field work.  The good news is weight loss is likely kicking in at this point.

I do recognize a familiar pattern with myself while traveling that goes like this:

• Week 1:  Hey, this isn't so bad.
• Week 2:  Hmmm....I wonder what I am going to eat today.  I hope I like it.
• Week 3:  Damn, I really miss Mexican food (we are currently at this phase)

This is not always the patten, like say in Thailand or Vietnam, but lets just say I am feeling especially food challenged on this trip.



Said restaurant in question

 The first day of field testing (between week 1 and week 2) we were out in Kampong Speu with the study team and Anna and I had  a record bizarre foods challenge.  The study team suggested we go to a "resort" in the area for lunch that was by a nice pagoda with monkeys and a river.  Prior to lunch Anna and I decided we would be more adventurous with our food choices.

Initially, things were going well including ordering a fried chicken that arrived with its head and feet (above).  At this point, Anna and I were still hanging strong.  Sonita insisted on ordering a soup despite my numerous attempts to avert the situation (our previous two soup encounters had been sketchy).  Ultimately a soup arrived.  Below is a play by play:

IRL study managers insists that we try the soup

Anna:  (Acting interested) What kind of meat is in the soup?

IRL:  It is like a cow that you find in the wild but smaller and not a cow

Anna:  Oh.  Ok I haven’t heard of that animal
Liz begrudgingly takes a small ladle of soup on her rice

Liz:  But Sonita, there are bug in it (not just bugs but large insets that resemble trader jackets)
Anna hears “But Sonita, there are bones in it” and thinks to herself, come on Liz we are trying to be more adventurous

Sonita:  Yes, it is ok to eat it

Liz pushes the insects to the side and takes a bite of the broth + rice and almost voms
Liz looks over to Anna who is getting a large ladle of soup and wondering what the f%^k is she doing.
 Liz continues to watch Anna in horror taking large bites of the soup. 
Half way through Anna experience she looks over to Liz realizing there are large insects in her soup and wondering why Liz didn’t warn her.

Pork grizzle

In addition to the bug soup there was also this lovely pork dish that we were forced to try that was not half-bad aside from the large chunks of grizzle.

Did I mention that I am happy to be getting home right in time for Cinco de Mayo?!

Cambodia

Sua s'dei from SE Asia!  Coming to you from Cambodia where I have been for the past two weeks.  I am working on a final evaluation for our most successful Safe Water pilot.   I pushed hard to do this evaluation on our own without the assistance of an outside research firm like Abt Associates.  As mentioned in my performance review this year, "Liz would benefit from a return to direct research as this is truly her passion and interest."  Great.  Agreed.  This is one of such efforts. 

I am fortunate to be accompanied on this trip by Ms. Anna Larsen, program assistant extraordinaire at PATH.  Anna applied for an ONP grant (Opportunities for New Professionals) from PATH to come to Cambodia and learn some evaluation skills by working with me on this project.  Anna is amazingly good at her job, very bright, enthusiastic, and overall a really good time to travel with.  In addition, to the evaluation work, we have discovered we are well-matched shopping partners and have been throwing it down in the Russian market in Phnom Penh.  After day 1 in the field we realized we needed hats so we bought matching one at the market.  The top zips off and it doubles as a visor...totally ridiculous but yet so useful.

This is my second trip to Cambodia and once again I am reminded how much I really enjoy working in this area of the world.  It is the hottest time of year in Cambodia; at the tail end of the dry season, directly preceding the rainy season.  On a recent day in the field, temperatures soared over 40 degrees Celsius (approximately 104 Fahrenheit).  Needless to say it is very hot and humid and I basically have not stopped sweating since I got here...yuck. Lucky for me, both hotels we have stayed at thus far have swimming pools.  Life saver!!



Countryside in Kampong Speu



Our pilot was in Kampong Speu province (pronounced Kampong Spur) and ran from February to December of 2011.  The pilot tested the sale of a ceramic water filter, The Super Tunsai (Tunsai = rabbit in Khmer = lucky), through a micro finance institution (MFI) that issued small loans for the purchase of the water filter.  Interestingly, a version of a ceramic water filter (the Tunsai) has been on the market in Cambodia for well over a decade but never achieved appreciable levels of penetration on the Cambodia market.  In our previous evaluations we found that 4-6% of households in the study area were using a ceramic water filter.  During the pilot phase we tested the hypothesis that households may not like the filter that has been around for a decade and they may not be able to afford it without a financing mechanism.  The original product, the Tunsai, and the redesigned product, Super Tunsai can be seen and read about here:  http://www.hydrologichealth.com/category/social-marketing/.  If interested, please watch this You Tube video clip of the country-wide commercial released for the promotion of Super Tunsai.  While marginally patriarcical, in my opinion, the commercial appears to have blanketed awareness of the new product across our pilot area. 

As mentioned, this is the most successful of the nine pilots we launched through the Safe Water project.  On an endline evaluation in November we showed that uptake of a ceramic water pot increased from 6% at baesline to 43% among microfinance clients and 21% of the general populations in Kampong Speu.  We are very pleased with these results and feel that partnering with a microfinance institution allowed households to afford a $22 water filter that they normally could not afford without financing.  Interestingly, when the two filters were sold side by side the Super Tunsai outsold the regular Tunsai 3 to 1 despite is price that was nearly double the original Tunsai; $22 compared to $12.50.  I guess people in this area really did prefer the new and improved product option.  Perhaps the best news about this pilot is after it ended in December both partners signed an agreement to scale-up to other provinces in the country without PATH's assistance which is what you would hope for as the NGO assisting with implementation of the project. 



Interview of a MFI client with a Super Tunsai in her home

Because of the success of this pilot we decided to do an additional round of evaluation to take a closer look at why the pilot was so successful which brings us to the current purpose of the trip.  Anna and I are here conducting an assessment to take a closer look into the MFI pilot model.  Specifically we are conducting a quantitative and qualitative assessment to learn about client perceptions and quality of life improvements since households took the microfinance loan to purchase the Super Tunsai.  For the last two weeks we have been focused on launching the quantitative assessment among 1000 rural households in Kampong Speu province.  Tomorrow we start work with a different research firm to start the qualitative assessment.  From this assessment we are interested in learning more about what people like/dislike about the Super Tunsai and why they may not have wanted to take the loan when they attended a meeting to hear about it.

So, far things are going well and it is fun to be on a project learning about the successes (as opposed to the failures).  Both local research firms we are working with are well-qualified making our job a little easier.  I am a bit behind on blogging this trip but plan on a few more within the next week.  Stay tuned....