Almost every restaurant, bar, and hotel in Bamako currently has a professional greeter, responsible for distributing squirts of hand sanitizer, ensuring any entrant washes their hands from a newly installed tap, and checking the temperature of every person through the doors with an infrared no-touch thermometer, held an inch away from one’s temple. On the streets, billboards, fliers, and a loudspeaker-mounted vehicle announce Ebola education and prevention messaging, while fact and rumor twist through communities and whispers.
In late October, Mali recorded its first recorded Ebola cases. First, a young girl carried the virus across borders from Guinea. Despite her having been in contact with hundreds during her voyage, initially there were no other cases. Then, an imam from Guinea sought treatment in one of Bamako’s best clinics, frequented by expatriates, UN soldiers, and Mali’s upper class. The imam died, as did a nurse and doctor who treated him, a mosque worker who cleansed his body, a friend who visited the imam in hospital, and a child of the deceased nurse. The second outbreak resulted in hundreds of additional contacts throughout the city, and has inspired deep concern around the preparedness of the public health system in Ebola’s newest breeding ground.
Its geographic and political state contribute to the precariousness of Mali’s situation, a large, landlocked country that borders seven other nations, including a vast, mostly ungoverned swath of earth – the Sahara Desert – that runs across Mali, Mauritania, Algeria, and Niger. An uncontrolled outbreak here could easily spread beyond the grasp of NGOs and governments, crossing borders unchecked and sharing territory with the likes of banditry and terrorism, both causes and effects of Mali’s 2012 coup d’état. Adding to this geopolitical quagmire are refugees in Niger and Mauritania and seasonal food insecurity. A low rate of doctors per capita and a longstanding user fee healthcare system further compound Mali’s current fragility.
International actors recognize this gravity. The CDC and WHO softened their predictive forecasting recently, should Mali become the fourth country overrun by Ebola. WHO Director Margaret Chan recently visited to motivate health workers and international actors to respond aggressively. The New York Times editorial board has , appealing for fast, international action, while the and have both opened emergency operations offices in Bamako over the last week.
Yet right now, it’s fast action and small efforts that can go a long way. A small dedicated CDC team seemingly managed to track most or all of the contacts across the city. has been working since September to educate, inform, and prepare, as our community-based efforts to improve maternal and child health dovetail seamlessly into effective Ebola response. And most recently, our redeployed Community Health Workers have worked as Contact Monitors to check in with every contact twice daily, taking temperatures and monitoring any symptom development. Their gridded pages have been slowly filled as contacts reach their 21 days.
Active case finding – sending local teams into communities to screen for the sick and educate families and parents about prevention and healthy habits – is one of the many roles a Community Health Worker can play, and if effective, can make enormous difference. Another is developing trust. While Ebola is spread by the contact with fluids, rumors are airborne, often complicating prevention or treatment efforts. The new Ebola Treatment Unit in Bamako, staffed by MSF, is where people are killed. Ebola is a white man’s conspiracy. Even, Ebola isn’t real. These sentiments highlight the very common breakdown of trust and understanding between communities and the health system, both local and international. In Sierra Leone, despite heroic efforts, this resulted in the forced quarantine of all residents in its capital city. In Mali, it’s clear how easy this would be. Already there are whispers of cases being hidden by their families.
But there is also a dose of heavily guarded optimism. Mali has had two Ebola survivors walk out the doors of its treatment center over the last weeks. If Mali reaches January 18thwithout another case, it can be declared Ebola free. But with more cases closer to the border in Guinea and the very real ongoing risk of complacency, there remains a strong likelihood that cases could return. Trust must be built and nurtured between the health and local communities through a national response of coordinated Community Health Workers. Early treatment must be promoted and adhered to in order to limit contacts and increase survival, and the system to support such practices put into place. If an early warning system can be implemented, trainers trained, clinics prepared with proper screening and protocols, and enough equipment and medical personnel in place to quickly trace, place and face each case, Mali could avoid the breakdowns incurred by Guinea, Sierra Leone, and Liberia, and would provide a blueprint for hope and effective execution.
Mali Health has seen its first major victory in the fight against Ebola! A woman who was confirmed to carry the disease has been completely cured. This is a victory not only for Mali Health, but for all of the members of our coalition who are working tirelessly to quash this outbreak. This victory required a tremendous coordination between our Community Health Workers, the staff at the clinic, and our community partners. We are doubly excited to share this news with our community because it proves what we have been advocating for months: Ebola is preventable and curable with the proper care.
While we hope that this is the last case of Ebola that our country sees, we can use this experience to inform our response to the rest of this outbreak. Two important lessons we can take away: 1) It is imperative to call emergency services as soon as a person shows symptoms; if the person must be moved to a health center, it should be done by professionals who have the training and equipment to do it safely. 2) We must educate as many people as possible to combat the stigma around this disease and allow those who are sick to come forward and get the care that they need. Together, we can end this outbreak before it affects any more families.
In September, the Dorothea Haus Ross Foundation generously donated lab equipment to the community health center in Sikoro-Sourakabougou (CSCOMSiSou). It was a request the staff at the clinic had long held; even the best-trained personnel could only provide basic primary care without the equipment necessary to diagnose and then treat many less common diseases. Patients who needed this higher level of care were faced with two choices: remain at CSCOMSiSou, the closest clinic to them, and receive whatever care doctors could provide; or venture much further away, incurring the cost of transportation and time spent, to a clinic that had the equipment necessary to provide full and appropriate care. Until now, patients have largely chosen the latter option, sometimes even bypassing CSCOMSiSou altogether to seek care at other clinics. As a result, CSCOMSiSou saw fewer and fewer patients, and its revenue began to fall dramatically. Those patients who elected to stay and receive treatment at their home clinic often paid a higher price for medication that didn’t always address their condition.
This lab equipment, provided by the DHR Foundation, has already served to better diagnose and more effectively treat patients at CSCOMSiSou. With quicker and more accurate diagnoses, patients receive treatment faster, and doctors are able to prescribe appropriate medications, often resulting in reduced costs at the pharmacy. With the improved ability to provide more advanced care, the center retains more patients, increasing its revenue and therefore the resources to further invest in stocking diverse medications and training its staff in new and more effective consultation and treatment techniques. Mr. N’fally, the president of the ASACO community health committee, and Dr. Diarra of CSCOMSiSou, had this to say about the new equipment and the clinic’s renewed ability to provide more advanced care to its patients:
Written by Danielle Hull, Monitoring & Evaluation Coordinator
Earlier this year, Mali Health proudly announced we’d been awarded our largest grant yet: $100,000 from the Bill & Melinda Gates Foundation to implement a health system strengthening project at four community health clinics on the outskirts of Bamako. The grant, which aims to support bold ideas in global health and development, represents a momentous opportunity for Mali Health to address a problem we’ve confronted time and again through our work: major advances in maternal and child health require strong, resilient health systems, which are lacking in our communities.
Our project aims to support local clinics to better care for their populations though quality improvement and better management strategies. Within the clinic, itself, our approach will focus on the entire patient experience, from the check-in process to follow-up care. We will ensure that every patient receives the highest possible quality of care by working with medical staff to follow a standardized consultation process and to provide all appropriate tests. We will also work to ensure that clinic staff have access to all necessary materials for care provision and that they follow basic hygienic practices. Outside of the consultation room, we will work with medical and administrative staff to reduce patient wait times, improve doctor-patient communication, and identify and eliminate bottlenecks and inefficiencies.
The project – known as “Projet Amélioration de Qualité,” or PAQ (pronounced like “pack,” meaning Quality Improvement Project) – will stretch across four communities and clinics: Boulkassoumbougou, Lafiabougou, Sotuba, and Sikoro-Sourakabougou. In August, we held a three-day training with community health association members, clinic staff, and patient representatives from each of the four communities to cover tools and strategies for continuous quality improvement.
The first day of the training, I must admit I was cautious, even skeptical. Quality improvement and monitoring really aren’t a part of the work culture in Mali’s under-resourced community health clinics. I wondered if participants would be willing to openly discuss problems that exist at clinics. Would they react defensively? Would we be able to meaningfully engage clinic staff and community members, who are often under- or unpaid?”
My anxiety was quickly quelled. After we’d gathered in the meeting room, the patient representatives stood up, introduced themselves, and immediately began to engage their audience, acknowledging the hard work of the clinic staff, all the while respectfully advocating for the concerns of the patients who frequent the clinic. I could tell then that this meeting was a turning point, a significant step in the right direction, the start of an honest and open discussion of how to improve the care available to community members.
Where at first I had feared that clinic staff would be even more reluctant to engage — wishing not to acknowledge problems within their home clinics — I was astounded at their eagerness to speak up and offer their perspective. Our discussion progressed to quality improvement case studies, and doctors, nurses, and midwives from every clinic came forward to volunteer their own stories and acknowledge cases where they and their teams could benefit from a focus on quality improvement.
We are several weeks into this new and long-term project, and it is not without its challenges. Each clinic faces different deficits, whether in terms of supplies, personnel, or management experience. Each community will face individual struggles on the path to improving patient care and services and ensuring clinic self-sufficiency. But in the face of big problems, the key is to focus on small targets and small victories, such as this midwife’s reaction to a new supervision strategy to ensure a complete and standardized approach to prenatal consultations: “I’ve been doing [obstetrics work] for years, but in the past few weeks, I feel that I, myself, have learned so much! I know now that I’m doing quality work and every chance I get, I review the steps so I can improve.”
Written by Diana Vergis Vinh, Mali Health volunteer & champion. All photos courtesy of Diana Vergis Vinh.
Would people still eat pounded millet porridge? and Would they have the same teasing cousins? were some of the questions going through my head as I returned to Mali to work with an American health organization 30 years after serving as a Peace Corps health volunteer. Looking at the old Malian man sitting next to me in his traditional dress and beard I thought, Not much has probably changed. Then he took out two cell phones from his flowing brocade shirt and shook several SIM cards from a used pill bottle into his hand. “Because I am a merchant I travel a lot and have a different card for each country,” he said as he expertly switched out his phones. Hmm, maybe a lot has changed, I thought as the plane touched down in the Bamako airport.
Security measures are much tighter, I observed as a soldier in a glass booth carefully took my fingerprints and examined my passport. Then I walked through the airport doors onto the same tiled patio I had crossed before and the warmth of the sun and the smell of ripe mangos hit me. I saw a cab driver holding up a sign for Mali Health and made my way towards him. As I sunk down into the car, the Bambara language came flooding back and I asked him about his day, his family, his friends and finally his name. When he replied that he was a “Traore,” I informed him with great gusto that he was “not a serious person and that his preferred food was beans.” Surprised, he gleefully replied, “Oh no! Your last name is not Diarra, is it? Walai! You are the bean eater!” One question was answered: the joyful tradition of teasing cousins was still going strong.
I was completely lost as we made our way towards the office; Bamako is one of the fastest growing cities in the world and it is enormous. Happily, the driver knew exactly where to go, and soon I was meeting the skilled and friendly staff at Mali Health. The brightly painted cinder block structure looked familiar, but as I talked with staff I learned that many of the health conditions I had seen — such as guinea worm, cholera, measles, onchocerciasis and leprosy — were much reduced. Maternal and infant mortality were lower as well. Sadly, malaria is still going strong, and it is one of the main things Mali Health is now focused on fighting.
The next morning, I went out to a suburb of Bamako to take pictures and videos of staff and patients at the Mali Health partner clinics. A lesson on water sanitation for the community health workers was being presented via a Powerpoint projection on the plaster wall. Midway through the talk, everyone broke up into small groups to brainstorm and create posters on ways water could be contaminated. I asked the workers about whether people were resistant to treating their water or using the suggested 20-liter containers. “No, they have seen that their children are healthier when the water is cleaner and there are few problems getting people on board,” was their response. This heartening reply was a far cry from my failed efforts at getting people to screen their water to prevent guinea worm.
So what did it feel like to be back after so long? In short, it was wonderful; so many of the things I loved about Mali — the warmth and energy of the people, the beauty of the country and the delicious food (I did have the porridge) — were still there, and now good health practices, such as regular vaccinations, water treatment, and prenatal care, seem to be taking hold as well. There is concern about the revolt in the north and worry about politics in general, but as I got on the plane to fly home, the Bambara proverb, “An orphan is not a person who has lost their parents, but someone who has lost hope,” still seemed to ring true.
(This proverb is a little more genteel than my favorite: “You can’t run and scratch your butt at the same time.”)
This week, Mali Health’s long-standing Health Radio program was named one of the Sustainia100. Sustainia, a Copenhagen-based NGO, recognizes development programs around the world that employ a sustainable approach to improving the well-being of communities.
Health Radio reaches thousands of listeners, broadcasting on Bamako’s most popular radio station. Radio remains the dominant form of media in Africa, and therefore has the potential to reach the highest number of local residents. Crowding, land use, and sanitation have all become increasingly important challenges in the slum communities of Bamako, and Health Radio mobilizes local residents to address these and many other health concerns together.
You can read more about this year’s Sustainia100 here (we appear on page 128). And you can read more about Health Radio and its role in our larger advocacy efforts here.
In early 2011, Djeneba, a resident of peri-urban Sikoro, became pregnant. Identified as eligible through a local survey, Djeneba was recruited and enrolled in Mali Health’s Action for Health program. Impoverished and isolated, Djeneba would not have had access to vital health services without the help of our program, but through it, she received counsel, education and monitoring by one of Mali Health’s Community Health Workers, Fanta.
That November, Djeneba gave birth to a healthy boy, Ali. Mali Health continued to monitor and aid Djeneba and Ali after birth – Fanta made frequent home visits and ensured Ali was immunized against the preventable diseases that all too often keep Malian children from reaching their fifth birthday.
Six months after Ali’s birth, Djeneba left Sikoro to spend several months in her family’s rural village. Immediately after she returned, Fanta made a visit to their house to check on mother and child and was met with an alarming sight: Ali had lost significant weight during his time away and exhibited signs of severe malnutrition. Fanta took action immediately, rushing Djeneba and Ali to the closest health center.
Through Action for Health, Ali received lifesaving medical care and access to qualified health workers. He remained in the hospital for 10 days, during which time he regained enough weight to be returned to his mother’s care. Though Ali was no longer in immediate danger, Mali Health’s work was far from over, knowing Ali would continue to require close monitoring to ensure his complete recovery.
Even after his release, Fanta observed that “Ali was so weak initially that he could no longer support the weight of his head.” Neither Djeneba nor her husband had jobs at the time, however, so Ali’s recuperation was in jeopardy. In response, Mali Health provided Djeneba with milk, grains enhanced with vitamins, fish, fruits, and legumes for Ali for the next two months. Fanta continued her close care, sometimes visiting Djeneba every day to check on Ali’s progress.
Today, Ali is 3 years old. He is no longer malnourished and lives a happy and healthy life with his mother in Sikoro. Djeneba is enrolled in our Health Savings program, where she can borrow pooled money for future health expenses or to earn a small income. Mali Health’s Action for Health program has helped 2,000 children like Ali, employing community-based solutions that not only provide for short-term health successes but also long-term improvements in education and care. Mali Health believes that everyone has the right to experience childhood without the looming threat of illness or death. Ali’s mother thanked Mali Health, stating, “I think God has sent Mali Health to help poor persons like us… May God accompany those who fund Mali Health’s activities.”
Written by Danielle Hull, Monitoring & Evaluation Coordinator
At age 28, Fatoumata Diarra is the mother of four young children. However, she only received pre- or postnatal care for one. “For my first three children, I never went to the CSCOM to see the doctor or midwife. I’d stay at home and not talk about my pregnancy” [a common practice in Mali as some women are worried that talking about a pregnancy will lead to bad luck with the pregnancy]. Fatoumata, like many women in Mali, used to give birth unassisted in her home high atop a hill, a difficult walk to the nearest clinic. This lack of geographic access to professional care is one of the reasons maternal mortality remains high in Mali. “It was always a little scary,” she said. “I never really knew what was going to happen, or even supposed to happen, during each birth.”
But that changed with her last pregnancy; by then, she’d been enrolled in Mali Health’s Action for Health program. Her community health worker made regular visits to her hilltop home to monitor her pregnancy. With the help of Mali Health, Fatoumata made all four of the WHO-recommended prenatal visits, where she received counseling and advice from midwives. Also for the first time, she had access to medication to prevent malaria and a vaccine against neonatal tetanus, both life-saving medicines. And when she was ready, she gave birth at Mali Health’s newly-constructed maternity ward with the assistance of trained doctors and midwives.
“There is definitely a difference between my births. Before, it was very scary and my children were small and sickly. The last time, I knew that everything was going to be okay, because I’d gone to prenatal visits and was with doctors, and my baby was born bigger and has stayed healthier.” Too often in Mali, the day a baby is born is the most dangerous in the life of mother and child, and 1 in 28 mothers in Mali will die from pregnancy-related causes. But Fatoumata Diarra will not be one of them.
Today, May 1st, is Labour Day, and I wish each of you a good day of deserved rest.
I know that I am demanding and that I ask the very best of you in everything that you do for Mali Health. I also see that you not only meet, but exceed what I ask of you. You all work tirelessly to advance our mission and to help reduce maternal and child mortality in our communities. You help us to realize our vision of a more just world, one in which everyone has access to quality primary care at a lower cost, one in which everyone’s dignity is valued and preserved. You all should be proud of yourselves and your colleagues because you have chosen to take on this life-changing work each and every day.
The photo below shows the thrush, also known as the Lily of the Valley, a symbol of Labour Day. It is also a symbol of renewal, rejuvenation, which you help bring to the families in our communities every day. Many live in desperate conditions, lacking money, lacking information on how to stay healthy and avoid disease, how to access care when they need it, not knowing how to work in partnership with health professionals to get affordable and effective treatment. You are there to help them bridge those gaps. You are the lily in the valley of the poor.
Thank you, thank you, and thank you again for your work!
And together we thank our donors, without whom, we would not be able to do this important, life-changing work, improving the lives of thousands of mothers and children in Mali. Thank you to all who help to make this world a just place.
Mariam Fofana Diallo
Last year, Mali Health launched its health system strengthening program, Project Izumi (named after our partner, the Izumi Foundation, which provided funding for the program), to work across all levels of the system to improve access to and quality of care for all members of the community.
Improving a whole system is a daunting task if looked at as a whole. That’s why we have adopted the Kaizen Methodology, an approach that helps to simplify the improvement process. Through Kaizen, the ultimate goals for improvement are broken down into small, achievable tasks. Every member of the team is expected to work toward these small tasks every day, enabling continual progress toward the ultimate goals of a more effective and efficient system.
We recently put this method into practice at our partner clinic, CSCOMBoul1. Patients at the clinic had identified issues with communication between themselves and clinic staff. Specifically, patients noted that they had no prior knowledge of what services are available at the clinic and what the services cost, leading to some reluctance to seek treatment and confusion when they did seek help. Therefore, our team at the CSCOM worked with staff to create a sign listing available treatments and services, as well as their cost to patients.
This sign is now prominently posted near the entrance to the clinic so that patients will know what to expect when they meet with the health providers. Informed patients feel empowered and are more likely to seek treatment for their ailments quickly.
This is just the first step in what will be an ongoing process of achieving significant improvement across the health system, but it is indicative of the fact that real, meaningful change is possible. The Deputy Chief Medical Officer of CSCOMBoul1 recently expressed his enthusiasm for the new efforts: “Kaizen sessions have allowed us to be better organized, with a conscious awareness of our staff. We believe we can solve the various challenges the CSCOM faces with Kaizen sessions.”
Outside of the clinic, our Project Izumi team organized a community meeting to promote the importance of prenatal care. Recently, a woman experienced a stillbirth at the clinic. We strive through Project Izumi to reach zero child mortality, so our team worked together to organize this public forum reinforcing the importance of prenatal care for all pregnant women in order to ensure a healthy pregnancy and birth. The forum was well-attended, and it is just the first of many conversations and events that will help to provide better health for the families in our communities.← Older posts