HOPE works in more than 35 countries worldwide. Please enjoy our blog as we document the successes and challenges of our work to provide Health Opportunities for People Everywhere.
Sierra Leone has the highest maternal mortality ratio in the world and is also plagued with an unacceptably high newborn mortality rate at 35 per 1,000 births. 80% of all newborn deaths in Sierra Leone are caused by preterm birth, intra-partum related causes such as asphyxia and newborn sepsis. This frightening health crisis for women and babies was exacerbated by the recent Ebola outbreak. Fear of contracting the virus resulted in a decrease in the utilization of maternal and child health services. The outbreak also led to the death of 221 health care workers, further complicating access to services.
Project HOPE is working to solve this tragedy of preventable newborn deaths by establishing and building the capacity of the Ola During Children’s and Bo District Hospitals in Sierra Leone following a continuum of care approach. Project HOPE helped establish the first two Kangaroo Mother Care Units for care of preterm and low birth weight infants in the country at Ola During Children’s and Bo District Hospitals providing renovations, equipment, supplies, staff training and continued mentorship through expert volunteers and consultants, and currently through the engagement of a technical coordinator and mentor midwife previously trained by Project HOPE. Project HOPE also trained national master trainers in essential newborn care, and supervising the cascade of training to district level trainers who in support of the Ministry of Health and Sanitation efforts to primary care level maternal, neonatal and child health providers in 2017.
Kangaroo Mother Care Brings HOPE to Mothers in Sierra Leone
Posted By Banneh Daramy, a Sierra Leonean midwife working for Project HOPE
Bo city is the second largest city in Sierra Leone after the capital of Freetown and the second location chosen for Project HOPE’s Kangaroo Mother Care (KMC) initiative, a low-technology intervention for care of small babies for early, prolonged and continuous skin-to-skin contact between the mother and her baby for thermal care with support for positioning, feeding and prevention and management of infections and breathing difficulties by trained health workers to ensure premature and low weight babies thrive instead of perish. Twin brothers James and Joseph are a beautiful example of how this care works. Born premature in September, the babies were just 1.9kg (4.1 pounds) and 2.0kg (4.4 pounds) at birth. Ruth, a first time mother, delivered the babies by cesarean section after finding out just prior to their birth that she was carrying twins and that they both were in breech position.
“We had long wished to have children and it all happened like a miracle when I learned that my wife had conceived,” said Bockarie, Ruth’s husband. “Because of the inadequate medical facilities, we only learned right before the labor began that my wife was pregnant with twins and that both babies were in breech position. Due to the increased risks associated with twins, we decided to opt for a hospital birth.”
After Ruth recuperated from the surgery, I told her about the newly established Kangaroo Mother Care program, that allows mother and baby to stay in a facility connected with the hospital for several days after the birth to learn about the KMC technique which promotes keeping the baby in skin-to-skin contact with the mother to keep body temperatures stable, and also promotes frequent feedings.
Because of the cesarean section, Ruth was not ready to immediately practice Kangaroo Mother Care with the twins, so the grandmother stepped in to perform KMC after learning all the protocols in the newly established unit. During the first two days, Ruth was also unable to produce breastmilk and so the trained health care providers at the center arranged for the therapeutic feeding center to provide formula milk for the babies.
The babies were fed frequently as the grandmother performed the KMC. Soon Ruth started producing breast milk and was ready to take over KMC herself. The babies’ weight and vitals were constantly monitored and Ruth was supported with guided to learn the KMC method. With the constant monitoring and feeding and KMC care, the babies gained weight and grew stronger and were able to be discharged to home just six days after their birth.
Two days later, I made my first home visit to the new family. Ruth was still continuing the KMC and the newborn brothers, James and Joseph, continued to improve. I encouraged Ruth to continue the exclusive breastfeeding and the KMC procedure. I also advised her to adhere to the medical advice given to her in the hospital to bring the babies back to the hospital for monitoring on a regular schedule.
I visited the home again a few weeks later and observed the continuous improvement and Ruth adhering to all the advice given. While the babies continued to grow and thrive, on the third home visit I noticed Ruth had missed one of the scheduled hospital appointments, so I was able to take them to the hospital for examination and monitoring.
James and Joseph were now up to 2.55kg (5.6 pounds) and 2.94kg (6.5 pounds) respectively.
Monitoring will continue.
“We thank God for the gift our babies,” Ruth told me. “We appreciate the encouragement, sense of commitment of the hospital staff, particularly Project HOPE in providing the much needed assistance and support in ensuring that our babies developed from the low birth weight to the healthy weight babies. The KMC Unit was a blessing and the initiative is quite commendable. I will give this as a testimony to other mothers who deliver small babies and I will endeavor to encourage them to visit the KMC unit at the Bo Government Hospital.”
Project HOPE has set up the two Kangaroo Mother Care centers in Sierra Leone. Just through June through October 2017, 135 babies have benefitted from the KMC unit in Ola During, Freetown and 39 babies have been helped by the KMC unit in Bo District.
Dr. Elisabeth Poorman (pictured above holding the green medical bag) is a physician in Everett, Massachusetts. She traveled to Puerto Rico in November to support Project HOPE’s emergency response to Hurricane Maria.
Over the past few months, I felt the worst kind of déjà vu: hearing reports about Puerto Rico and remembering the devastation to my father's home town, New Orleans, which was devastated 12 years ago by Hurricane Katrina, and still bears its own scars.
Tired of bad news, I found myself googling volunteer opportunities, and left for a ten day medical mission with Project HOPE in Puerto Rico.
Weeks after the hurricane, over 90 percent of the island did not have power. By the time I arrived, the situation had improved dramatically, but unevenly. In some places, it was like nothing had happened. The mall in Ponce was up and running, indistinguishable from any other mall in America with a large Christmas display. Then a block later all the lights would be out. Up in the mountains, many were still gathering water in buckets to drink.
Everywhere we went, there were humanitarian groups, civil servants, and ordinary Puerto Rican citizens keeping calm and carrying on. The physicians, nurses, and other health care workers were working valiantly, and family members were extending themselves to take care of the most vulnerable.
On my last day in Puerto Rico, I traveled with Orlinda, a nurse who has spent her retirement going on trips like these, to visit patients who were unable to leave their homes. We were accompanied by two men from a church down the road who had a list of the 120 neediest patients.
I knew I would only be able to see a few before it got dark, and I was already exhausted, having seen 90 people with another doctor at a health fair in a soccer stadium that morning.
When we first got out of the car, I thought it was a mistake. The house was beautiful. The hostess was well-dressed with every hair in place. She could be 80, but looked timeless thanks to her immaculate appearance, straight posture and easy smile. “Aquí está el paciente,” she said, as she wound her way through darkened rooms.
It was cool, even though they didn’t have power like the rest of the neighborhood. A storm earlier in the day had cut into the heat, but also made the roads harder to pass. I noticed mud on my shoes as we stepped across her scrupulously clean floors.
In one room there was an old man at the end of his life, lying flat in a hospital bed which did not have power to help lift him up. “My husband,” the woman said, “had cancer and is very sick.”
His limbs were contracted and covered with a fresh blanket. His cheeks were sunken and his eyes were far away. He seemed overwhelmed by the commotion but didn't say anything. He turned away and faced the wall.
His wife rattled off his accomplishments and ailments, weaving them together as if all episodes of his life were happening at once.
She showed me a picture of her husband, a veteran, from the days before he shipped to Korea. He was a handsome man. In the photo, he had a look of optimism that reminded me of my grandfather’s Navy photos when he was just a boy in a uniform, and didn’t know what awaited him on the other side of the world. My own grandfather had died peacefully, having served his country and his family, his pain eased tenderly by the most compassionate caregivers.
This man was in pain. He hadn’t moved his bowels in days. He was refusing most food. I asked if he had been out of bed recently. “The nurse is gone, we can’t get him out,” his wife said. “She left before the storm and she hasn’t been back. We’re waiting.”
She couldn’t lift him out, and her grandson who came to help had fractured his leg. Somehow she had managed to take care of her husband, but she was petite and elderly herself, sharp of mind, but incredibly vulnerable.
I got on my knees to try to talk to her husband. He responded very little. I took his hand.
“Are you in pain?” I asked. He shook his head no. “Can I examine you?” He nodded. I removed the blanket piece by piece, careful to keep him covered. He had been well-cared for in spite of everything, his skin clean and intact. His lungs were clear, his belly was flat and soft.
Finally, he met my eyes and I said, “Sir, it seems to me you are doing well, but being stuck in the bed, for an active man like you, is very hard. And you seem a little depressed?” He nodded, almost imperceptibly.
“Would you like to go outside more?”
As soon as I finished the question he grasped both my hands, pulled his shoulders off the bed, his face almost touching mine, and blew air hard to say “Sí!”
I turned to his wife and we tried to brainstorm. She only had a few family members near. Her church hadn’t visited. They are waiting for the nurse, but there was no telling if the nurse would ever come back. Outside I asked the men from the church to try to visit and help him get out of bed at least once a week.
When patients are at the end of their life, it is an opportunity to step back from the day-to-day accounting, to take stock of their lives, to try to let them know that they are loved, and attend to their most pressing needs. In disasters, too, we have a chance to step back, to think about what happened and how we can do better next time, to consider what would make an effective meaningful response to future tragedies.
I told the man's wife over and over how remarkable she was, what a beautiful job she had done taking care of her husband.
We looked at the bottles by the bed. I clarified which medicines she could give more of, and which she should cut back on. We also talked about how he could eat what he wanted and refuse what he didn’t at this stage.
I thanked her for her hospitality. I wrapped my hands around the patient again. I thanked him for his service. He mouths “gracias.” I’m grateful to have been let in.
Their resilience pushed me forward to the next house.
The Project HOPE team was out in the cattle paddocks and mountain homes above Villalba in southwest Puerto Rico. Building on previous collaboration with the Villalba municipality the day was well coordinated and efficient. The municipality guided our medical, pharmaceutical, and mental health team in to the elevated barrios of Caonilla Arriba, Cubones, and Los Chivos. Psychiatrist Dr. Lisa Fortuna was engaged in many productive sessions, especially so was her conversation with a group of children as they returned home from their first week back at school.
“What was your first reaction after the storm, what do you remember?” Dr. Lisa asked the six neighborhood children.
“The trees were all broken and bare” came a reply. “We were surprised and bothered. Normally when we walked outside everything was green and full. Then every day we would wake up to a foreign landscape.”
Dr. Lisa continued the discussion in the thin shade of a breadfruit tree stripped of its bounty. She reminded them that the sudden loss of possessions, work, and routine such as in the case of a natural disaster is hard on adults and children alike. She coached them in self-care and anxiety relief exercises. As a group they imagined a delicious hot pizza pie in their hands, together they took a deep breath in … and a steady breath out. Anytime they feel overwhelmed this is one exercise they can do to reestablish control of the situation.
“Think of the trees that are still standing, what did they do during the storm to survive?” asked Dr. Lisa.
“They flexed and bent, but didn’t break,” replied the pupils.
“Right! And like a strong tree that is what we should do when we feel a lot of stress” Dr. Lisa affirmed, then introduced a light yoga exercise where everybody raised their arms in the air and stretched from side to side repeating the mantra, “Soy flexible, soy flexible, soy fuerte.”
People we meet are evidently disheartened if not devastated by the mudslides and 160 mph winds that ripped through their homes, the professional support that Project HOPE offers in the outstretched country roads of Villalbas is impressive. It is a confirmation that in this time of isolation, of no running water, of no power they can get through it and a reminder that they are not alone. The children beautifully concluded their unintentional metaphor of any post-disaster community:
“We are happy to see the green leaves growing back.”
When Hurricanes Irma and Maria hit in September, they ravaged the medical systems that aid those who face challenges seeking medical care. Project HOPE is reaching out with remote medical units in coordination with municipalities and the Department of Health, to target and assist the isolated, indigent and vulnerable populations.
Homebound, bedridden and terminal patients have gone months without professional medical assistance and in this aspect, the pre-Maria system is behind in recovery. Families we visited have proven resilient. However, without electricity, access to prescriptions, or needed medical interventions, even the most diligent family caretakers will become overwhelmed. The remote medical units bring hope and a reminder that family caretakers and patients are not alone.
The daughter and primary caretaker of a patient we saw summed it up well when she said, “She will die in time, but I want to make sure she is comfortable and lives with dignity. She is my mom, I have to take care of her like she did (for her parents), but without the nurse I don't know if what I do is right.”
The remote medical units are an impressive collaboration of inter-agency action.
In order to get to homebound patients, HOPE collaborates with local agencies to identify those in need and how to reach them.
- At FEMA events, local leaders collect the names of homebound patients.
- Local hospitals and the Department of Health coordinate with Project HOPE to plan house calls.
- Local municipality representatives help provide transportation to get HOPE volunteers to the people in need of medical care.
Visiting homebound patients is a logistical challenge because patients are spread out over miles of treacherous mountain roads, but the value is irreplaceable. One patient the team met was cared for by her daughter and neighbor. “They have done a great job since the storm” HOPE nurse Olinda Spitzer said. “Without running water or electricity they kept everything clean and the patient without bedsores.”
However, it wasn’t until Project HOPE’s team arrived that the caretakers were able to get needed refills on prescriptions and help relieving one of the patient’s issues. When Dr. Elisabeth Poorman arrived with the remote medical unit, she assessed that the strength of steroid cream being used to treat the patient’s pressure ulcers was too strong and actually burning her fragile skin. A simple, but needed correction brought relief and comfort to a mother and daughter.
As acute emergency medical needs wane in Puerto Rico, HOPE’s approach to providing care for chronic needs is helping bring a return to normalcy on the island. “Our hospitals and pharmacies are good again, but we do not have the resources to reach all of the communities in the mountains,” a Department of Health official said recently. “That is why we are very thankful to work with Project HOPE.”
WASH for Health
Two months after Hurricane Maria, many Puerto Ricans are still living without easy access to potable water and electricity. As Project HOPE medical volunteers continue to bring needed care to people living in still hard to reach locations, a newly implemented WASH program is helping to ensure long-term health for Puerto Ricans learning how to live in a changed environment after the massive storm.
A water, sanitation and hygiene (WASH) education team is now working alongside HOPE’s mobile medical unit team to help Puerto Ricans stay healthy by offering convenient education opportunities on treating drinking water, the importance of continuing to follow healthy hygiene habits, and preventing vector-borne diseases that are on the rise after Hurricane Maria.
“The incorporation of the WASH program into to the mobile medical units is ideal,” said Daniel Halpert, Project HOPE’s WASH expert in Puerto Rico. “People can seek medical care, visit our pharmacist for needed medicines but also learn how to make sure their water is safe to drink, learn the importance of continuing great hygiene habits, and reduce the risk of vector borne illnesses – all in one place.”
Halpert, who has coordinated WASH programs for the Peace Corps in Panama, said tailoring WASH programs to specific needs after disasters is very important.
“In Puerto Rico, most people already know the importance of accessing clean water and using preventative hygiene habits like handwashing, but because of the hurricane, they have lost all of their infrastructure, especially the access to clean water,” he explained. “All of a sudden, they can’t turn on the faucet and have potable water coming out of the tap.”
“Living with limited amounts of clean water is now forcing people to face unfamiliar decisions like, ‘Do I really need to use my scarce amount of water to wash my hands before cooking?’ But forgoing those important habits can lead to larger and devastating health issues.”
Without easy access to unlimited clean water, people are also dealing with other challenges, including proper water storage and how to use chlorination and purifying kits properly.
“Many people have been given water purification kits and chlorine tablets, but without experience using these treatments, many are not certain on what the proper usage is,” said Halpert. “Project HOPE is providing handouts that let people know how to properly purify a bucket of water, or even a milk jug of water, so that everyone can feel confident and safe in the water they are drinking and using.”
Flood damaged homes and piles of decaying vegetation after Hurricane Maria are also contributing to the increase of fly and rodent populations. “Rodents and flies have dramatically increased near and in people’s homes,” said Halpert. “Now anytime people put food out, it attracts rodents and flies that can greatly increase the risk of vector borne illnesses. Part of our WASH training is teaching people how to make home-made fly and rat traps with materials they have in their own home to help combat this problem.”
Hundreds of people have attended the WASH education workshops since they were added to the mobile medical units last week. “There is a real interest for this type of knowledge. People know they need help,” said Halpert. “Community members are very engaged in our trainings, and despite having already seen our medical staff and receiving their medications, they are eager to stay and listen to the hygiene promotion for 30 plus minutes, often lingering even after the training is over to ask follow-up questions and talk about their experiences since the storm. Many people also take flyers home to hand out to their neighbors.”
One participant, an older woman who is dealing with a fly and rodent issue for the first time in her life, was especially interested in learning how to make the homemade traps Halpert said.
Children are also getting in on the education.
“You have to start training young. If we can help kids adopt good hygiene habits, they carry these behaviors with them for the rest of their lives."
"We’re targeting a number of behaviors that all children must learn – handwashing, dental hygiene and trash management. Inviting parents to accompany their kids in these workshops is also great reinforcement for the adults.”
The Project HOPE team is working with volunteers and students from the University of Puerto Rico’s Graduate School of Public Health in Rio Piedras to grow the WASH education programs. In addition to the education courses being offered after each medical clinic, the WASH program is also providing participants with hygiene kits filled with soaps, towelettes, toothbrushes, and toothpaste, among other items. Project HOPE recently received a pallet of chlorine tablets through the Puerto Rico Department of Health, which will be distributed through the WASH program.
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