Lesotho's Dreamers

I can’t believe I only have one week left in Lesotho! The past 4 weeks have flown by, and I honestly don’t think I am quite ready to leave.  There is just so much more to learn here, and so much more to talk about on my blog.  Recently, a fellow Notre Dame student and his friend arrived at TTL to do their own research.  This boy, Jason, is the only Basotho at ND.  He found our school through an African scholars program, he’s a physics major, and let me tell you he is one smart dude!  His friend Maseeng (Mah-see-ang) is in the process of applying to colleges in North America.  It’s fun living with Basotho here at TTL because they can give us the inside scoop on cultural practices in Lesotho.  It’s also cool to see two people who come from well off families in the capital, Maseru, adjust to life in the rural area of Mokhotlong.  They are doing research on traditional medicine and it’s interplay with HIV/AIDS…I bet by the time they leave they will have some interesting findings!

On my first day of outreach, we actually saw a traditional healer walking along the road beating a drum.  I thought nothing of the woman at first, until T yelled to me from the front seat, “Annie, take a picture of this woman!”  (T really says my name like “Ahn-knee,” he thought I spelled it Anny).  I try to be sensitive about taking pictures of people and I usually ask permission first (I don’t want people to think I am gawking at them!), but this was just too cool to miss!  I promptly rolled down my window and snapped a picture of this very interesting woman.

Sticking my camera out of the window for a good shot!

The le thuela beating her drum.

T soon told me that she was an “ngaka” (nah-ka) or a doctor.  She wasn’t just an ordinary doctor, however, she was a “le thuela” (lay tway-la)…a traditional healer!  So of course in Western fashion, I just had to ask questions about her.  T told me that the Basotho traditional healers prophesize in order to determine diagnosis, prognosis, and treatment plans.  Their prophecies actually come from the dead.  This healer was beating her drum in order to call the ancestors, who give her the power to heal and the wisdom to perform miracles.  Usually, the ancestors come to traditional healers in their dreams, giving them messages about each patient’s condition and how they should be healed.  Sometimes, they get premonitions in their sleep about where to find a certain plant to be used as medication.  Often times, one will go to a traditional doctor and will be told to come back the next day (and we complain about wait-times in America!).  If the healer didn’t know you were coming, he or she might be unprepared for your visit and need the night to hear from your ancestors.  Apparently traditional doctors are not present in every village, so many people have to travel to them.  I was told that you can invite them to your home, but this is a more expensive method of seeing the healers.

An up-close picture!

While learning about the role of the traditional doctor, I couldn’t help but wonder how people justify seeing both traditional healers and doctors who practice Western medicine.  Obviously, I asked T about this.  The answer I got was interesting, and actually pretty similar to what people who see homeopathic doctors at home would say.  The traditional healers are good for some diseases, but not for others.  For a long time, when facts about HIV were merely rumors and myths in Lesotho, a lot of people would see the traditional healers to be cured.  After a while, though, people began to realize that AIDS patients of traditional healers weren’t surviving.  Eventually, as stigma decreased and HIV education initiatives reached the villages in Mokhotlong, Basotho learned to accept Western medicine as a better treatment for HIV/AIDS.  So, even though one may see a traditional healer to get rid of the common cold, they recognize that certain diseases require real medical attention.  T told me that the two diseases traditional healers could not cure or treat are HIV/AIDS and “sugar” diabetes.  Diabetes is referred to as “sugar” diabetes here because Type II diabetes, the one associated with obesity, is more prevalent than Type I, the genetic form.

I did a little bit of research online and found out that there is definitely some tension in Lesotho between the medical doctors and the traditional healers.  To be an MD or a healer, you must be registered with Lesotho’s government.  Unlike at home, however, you do not need an MD to actually prescribe medicines.  Medical doctor’s do not want traditional healers prescribing chemically-based medicines to their patients because they are not trained in Western medicine, but there is nothing stopping traditional healers form doing so.  This is where the tension lies.  I am curious to know how many traditional healers actually “prescribe” pills, considering their main forms are healing are through herbal and natural substances.

Lesotho's Ministry of Health in Maseru

Interestingly, the pharmacies here sell a lot of drugs over-the-counter that require prescriptions back in the US.  This is frightening because it means that the chemists (or pharmacists) here might sell medicines that can be harmful to a person rather than helpful.  Not only could a person be allergic to an antibiotic, but there is also a high risk of buying counterfeit or substandard drugs in Sub-Saharan Africa.  I did a project on counterfeit medicines in the fall semester and came to learn that they are a HUGE problem in developing countries.  Counterfeits result in a variety of risks: harm to a patient, development of drug resistance, and economic loss to a country.  In 2009, Lesotho police trained by INTERPOL seized a large amount of fake drugs in the capitol city, which included steroids, antibiotics, antifungals, and contraceptives.  If these were all found in the capitol, imagine what is found in Mokhotlong where regulation of chemist services is non-existent!  (Don’t worry, brought all of the meds I could possibly need from home.)

The local version of a CVS Pharmacy

I am hoping that I might encounter another le thuela before I leave, but they are not easy to come by.  I will just have to keep an eye out for someone wearing feathers as earrings, beads on their wrists and ankles, and carrying a drum…wish me luck!

Some of my favorite pictures as of late!

(Click on them to see the full-size image.)

A client and all her medicines.

A waving little boy.

Love this kid, and his spiderman shirt!

BFFs 

Standing in the middle of the Mokhotlong River.

If you only knew the number of pictures I snapped of this little girl...

Conducting an interview.

Looking out from inside a rondavel.

A TTL client and her children carrying their nutritional supplements back to their home.

A group of children who gathered to watch an outreach visit...3 hours away from TTL.

Lesotho's cowboy.

Carrying her day's work home from the field.

A decorated rondavel.

My translator and I!

View of Mokhotlong.

VHWs, CHWs, and Riders

(Be sure to scroll to the end of this one for a treat!)

In the course of my global health studies, we constantly learned about the importance of the village health worker.  In developing countries, since most people don’t have easy access to clinics or hospitals, members of the villages are trained to work as village or community health workers.  The responsibility of VHWs or CHWs is usually to educate other members of the community about basic hygiene and locally prevalent diseases, as well as screen children and adults in the community for malnourishment or sickness and refer them to clinics, hospitals, or local organizations as necessary.  Sometimes they even survey the community for baseline statistics on health in order to track trends in disease epidemics and transmit this information to governments and non-profits.  Essentially, their job is to promote health in areas where access to healthcare is limited.

Mahpolenang Health Clinic, run by the Red Cross.

The crowded clinic waiting room.

A few weeks ago, on a day I didn’t go on outreach, I got the opportunity to attend a VHW meeting at a clinic in Mahpolaneng, about one half hour outside of Mokhotlong.  The Red Cross of Lesotho is responsible for running this clinic.  I thought we were going to watch a training session, but it turns out they were actually waiting for us to give them information about TTL.  When we first entered the clinic, Jenn, Brad, and I were introduced to the nurses in charge of the clinic before being led through a crowd of waiting patients to a back room.  Sitting in the room was a group of mostly elderly women, wrapped in their Basotho blankets, staring intently at us.  The TTL outreach worker who planned this gathering and drove us to it introduced TTL and then made each of us stand up in front of everyone and introduce ourselves in Sesotho.  Needless to say, my heart was pounding as I stood up to say, “Lebitso la ka ke Annie.”  Luckily I didn’t butcher it, and all the women clapped and smiled as I sat down (I was quite embarrassed that they were clapping!).

M'e Mantja speaking to the VHWs

The next half hour was spent asking the women questions about their job responsibilities, their pay rate, and their roles in the community.  I found this really exciting because I was asking critical questions along with Jenn and Brad, finally applying what I learned in classes to a real-world situation.  We were trying to figure out exactly what the VHWs needed to do their job better, as TTL and PIH might work together soon to improve Lesotho’s government-run VHW program.  Eventually, after some prying, the VHWs in the room all agreed that they wanted more training, especially on HIV/AIDS, antiretroviral therapy, and tuberculosis treatment.  This prompted us to ask the last time they received any sort of formal training from a Ministry of Health official, which we soon found out was in 2009.  2009?!  For real?!  I know Mokhotlong is 5 hours from Maseru where the Ministry of Health is located, but not having someone come to train VHWs on the most recent advances in healthcare education in over 4 years is just simply unacceptable.  For a country where the HIV prevalence is through the roof, you would think that the VHWs would have the most up-to-date information to pass along in the villages.  Rather, you have a group of women who are supposed to be the most knowledgeable on health topics in each community wishing they knew more about the diseases affecting their families and friends.  I also have a hard time believing that these very elderly women are truly the best candidates for this job.  Lesotho has no age cap for their VHW program, so women like to keep the job for as long as possible since they receive a cash payment for their duties.  Yes, maybe older women get more respect from community members, but these women were frail and it didn’t look like walking from rondavel to rondavel would be an easy task.  As excited as I was to go to this VHW meeting at the beginning, I was equally disappointed in what I learned while I was there (I’m finding this to be a common theme in my experiences with healthcare in the developing world).

Some Basotho VHWs speaking out about their needs...

It wasn't all a let down, however.  When Brad, Jenn, and I got up to leave, we were quickly told to sit back down.  A bit confused, we followed orders and took our seats.  Before we knew it all the women were standing up swaying from side to side.  They were soon entertaining us with a song and dance (that was quite long!), led by one of the most talkative women in the group.  As she sang aloud, the other women echoed and followed her movements…somehow they were all singing in harmony!  After the first song was over, it was followed by another dance performed while kneeling (this one was shorter and kind of odd, but cool nonetheless).  I thought the first song might’ve been about health, since I saw some hand washing motions at one point, and this was confirmed by TTL’s outreach worker.  In fact, the song teaches mothers how to make homemade ORS (oral rehydration salts).  ORS can save a dehydrated child’s life, whether they are suffering from malnourishment or diarrheal disease, but can also kill a small child if made incorrectly.  Therefore, the dance moves that went along with the tune showed the exact amounts of water, salt, and sugar required to make ORS.  For example, they held up the thumb and pointer finger pinched together to demonstrate using only a “pinch” of one ingredient.  Having learned a lot about the importance of ORS in my grad program, I was elated to at least witness the promotion of making these salts with little to no cost in Lesotho’s villages.

The village health workers got moves! (Singing their ORS song.)

The knee dance.

We were finally ready to head back to TTL, but got distracted by a man on a red motorcycle outside of the clinic.  He was dressed in a jumpsuit, was wearing a silver helmet, and was carrying a backpack that read “Riders.org”.  Riders (also known as Riders for Health) is an organization that works in several countries of Sub-Saharan Africa.  They hire locals to work as nurses and community health workers who drive between many villages delivering healthcare services.  The cool part is that they teach the “riders” how to maintain and fix their vehicles because one of the greatest issues in developing countries is the delivery aspect of healthcare.  Here in Mokhotlong, the riders not only deliver ART medication to patients in the rural villages located far from the hospital, but they also draw blood from HIV positive patients to be brought back and tested at the hospital for CD4 counts (for the non-health folk, CD4 cells are white blood cells that fight disease, but are also the cells that HIV attacks and kills).  Sometimes they even get sputum samples from patients to test for TB and bring young children immunizations.  According to riders.org, their services have reduced the turnaround time for test results in rural Lesotho by 50%.  I think Riders for Health is an awesome organization that deserves more attention, support, and applause, and I was honored to be able to speak to one of their riders about his own work.  I saw this rider at a shop in town just the other day, and was pleased when he recognized me (although being one of the only white people here, I guess that shouldn’t have been so surprising).  He made me promise to stop by his laboratory at the hospital before I leave Mokhotlong for the summer with the picture that I took of him.  I get the feeling that the riders are very proud of their work!

Riders for Health!

I really hope that in the near future Lesotho’s VHW program is revamped and becomes more effective, hopefully as effective as Riders for Health has been (seriously you should check out their website…it’s riders.org if you haven’t already figured that out!).  It’s really amazing what some organizations do with business models that think a bit outside of the box.  I hope that one day as a physician I will be able to do the same as a physician and, in doing so, change the lives of thousands (maybe even millions!) of people around the world.

The Million-Dollar Question

Recently I was video chatting with my dad, telling him about how my day consisted of a 3-hour car ride just to get to the first rondavel receiving outreach services.  Just when I think there couldn’t possibly be another village tucked into the mountains so far from town, we always seem to come upon a new group of rondavels.  As I was explaining this to him, he stopped me to ask a very thoughtful question, “Where do these people go to the bathroom?”  Ahhh, the million-dollar question!  I realized that in all of my explanations of Basotho culture and village life, I never discussed the all-important hygiene and sanitation…well here goes!

Some village health workers singing about sanitation and hygiene.

On the first day of outreach, I hadn’t thought much about the toilet situation because at TTL’s headquarters we have a pretty normal bathroom with a septic tank.  Not unusual considering many older homes in America still have septic tanks.  Out in the villages, however, septic tanks do not exist.  As a matter of fact, I’m willing to bet most people out there wouldn’t even know what a septic tank is.  Luckily, on my first trip into the villages I managed to not need the bathroom once.  On the second, third, fourth, etc. trips, I was not so lucky…

As you might’ve noticed, the rondavels have no toilet, so people must go to the bathroom outside the home.  But what happens when there isn’t a bathroom outside the home (which is the case in many rural settings of developing countries)?  You simply go where you please.  Convenient, yes…sanitary, no.  Back in 2000, countries of the UN agreed upon the Millenium Development Goals, which are a set of 8 goals aimed at reducing poverty by 2015.  One of these goals hoped to halve the proportion of the world’s population without access to basic sanitation.  One of the vital aspects of basic sanitation is having some means of a toilet, whether it be flushable or a pit latrine.  As of 2010, 40% of the world’s population have no means of personal sanitation and 1.1 billion people are still practicing open defecation (clearly, we are not on track to meet MDG #7 by 2015).  In the developing world, open defecation is a major contributor to disease transmission, especially for diarrheal diseases and intestinal parasitic worms.

Since my master’s defense project is on soil-transmitted helminths (STHs), which are transmitted through feces of animals and humans, I paid special attention to the defecation practices when I first arrived in Lesotho.  Most villages have at least one toilet for each group of rondavels (and by toilet I mean a horrible-smelling, tin-like porta-john).  Some villages actually appear to have had some organization come in and build one identical toilet for each rondavel.  Other villages have no toilet at all, or a toilet still in the process of being built.  Unlike a porta-john, though, these latrines are never cleaned out.  I am told that, instead, they must get a chemical substance to break down the materials inside the latrine over time.

Left: Tin toilet outside rondavel...Right: Stone toilet outside rondavel.

Okay, so they have some place to go to the bathroom here…but do they really use it?  That is actually the million-dollar question.  The more I think about it, the more I believe that open defecation is more common than not in the villages.  Most of the time, villagers and shepherds are working out in the fields far away from their homes.  And guess what they don’t have out in the fields?!  (If you said toilets, you’re right.)  This means that people are going to the bathroom among the crops they are growing.  Furthermore, there’s animal feces everywhere here.  It’s seriously like a minefield of sheep and cow dung everywhere you walk, including in the fields where animals graze and families grow crops.  These animals can actually pass human parasites in their feces, which poses a large threat to the villagers whom these parasites are looking to infect.  What’s more, Basotho use cow dung for fuel.  There would be no harm in this, except for the fact that they collect the cow dung with their bare hands (I haven’t seen a single pair of rubber gloves outside the hospital or TTL’s safe home).  I was in complete shock the first time I saw women walking down the road carrying buckets of feces on their heads.  I hope you are not reading this while eating!

Not a toilet in sight!

Yep, a woman carried this on her head and will work it with her hands into dried dung chips later.

A large pile of dung and dirt ready to be burned for heat.

Sanitation also involves washing hands after defecation or after working in the dirt in general.  Since people here do not have taps in their home and must carry water sparingly in buckets, the likelihood that they wash their hands often is not very high.  Just look at the kids!  I saw one little girl eating dirt the other day, and most of the children here look like they have dirt caked to their bodies at all times.  Most of them don't wear shoes either, so they are walking in and playing in (and even eating) a mixture of dirt and feces that could easily result in transmission of life-threatening disease to a child.  There is also garbage thrown around everywhere here, especially in the villages where there is no service to remove it.  The trash strewn in the grass outside some homes in pretty unsightly, especially in the town of Mokhotlong.  Moreover, even many of the people in town have to use a bucket of water and a washcloth to bathe.  These practices make Basotho and people living in developing countries sound gross, but it’s really just a matter of not having easy access to the items that keep us clean.  This became really apparent to me when my translator asked one women to use her toilet, and she came back into the rondavel with a bucket.  I was hoping to use the bathroom as well, but couldn’t build up the courage to go in a bucket that someone else would have to clean up.  I have used these “porta-johns” several times now, and let me tell you bringing t.p. and hand sanitizer in your backpack is a life-saver here!

Look at the dirt on these kiddos...

I know this post is kind of gross, but the reality is that having sanitary bathroom practices and making a habit of washing hands regularly has been proven to break disease transmission all over the world (and I just know some of you have been wondering the million-dollar question as well!).  Having access to simple things like soap, water, and a toilet are truly vital to hygiene and, in turn, improving global health.  So next time you go to the bathroom, be thankful for a toilet that flushes…and wash your hands!!

 Foundation of a toilet being built next to this rondavel.

A field of garbage behind this rondavel.

Garbage on the side of the road.  Sadly, a lot of the garbage here are packages of antiretroviral medications for HIV positive patients.