August 10, 2013

Where and how many Filariasis patients are there?

Visit a house, search patient, and mark the date.

In some northern prefectures, where are pandemic areas of Filariasis, a patient searching program was conducted last month. Last searching program was conducted in 2005 so it was the time to update the list to grasp current morbid situation. The main purpose of the searching program was to figure out number and location of patients for providing patient care through Community Clinic in the near future.

Health worker asks villagers if there are Filariasis sufferers near around by showing pictures.
Followed by pre training sessions for supervisors in the district, training sessions on the patient searching program as well as on Filariasis patient care were held at each upazila. There are six upazilas in Nilphamari and the training was conducted for three days, two upazilas per day.
 I attended at upazila sessions and then went out to field to see how the searching was conducted during and after the searching period. The searching period was 10 days in late June.

At a training session. The instructor explain symptoms of patient.
So how the searching program was conducted? Health workers developed a searching plan, in which they list number of houses they would visit daily in their working areas. This time, they went to around 40 to 80 households a day. The workers visit house to house to ask if there is any Filariasis affected patient by showing some pictures. Villagers in the area are mostly aware of symptoms of Filariasis so finding patients wouldn't be that difficult. The important part is to identify and record patients' morbid status and contact information so that health workers can access to them whenever needed.

Health workers visit houses on foot. Not all houses are accessible from main roads.
Here is the chalk check.
Look up, it's not a picture of corns.

When health workers visit houses, they mark "F" for filariasis and date on walls or pillars by chalk. Supervisors would visit areas a day after when searching is done and check with the help of the chalk check and ask a few words with villagers if they have received searching.  

A chalk check on the wall.
I was more curious to see a jaw bone and a sho hanging over the door. 
It would be easier to see chalk check as large as this.
Chalk check on a glossary shop.
Chalk check on a glossary shop. Double!
For me, it was almost first work out in the field at that time, so I went together with health workers working in the targeted area to see the situation and they showed me around houses where they did the searching and also sometimes patients. During the period, health workers conducted the searching during and after their routine duties such as attending Community Clinic and conducting immunization program. I was able to visit searching site in all upazila within a week. And it was rather good chance to get familiar with my field, health workers and local lifestyles by visiting a number of houses.

Health Inspector asks villagers if they received Filariasis searching.

In front of a village, Kishoreganj, Nilphamari.

July 19, 2013

Visit to Primary Trining Institute (PTI) - Everyone has something to learn

We found our way to PTI with help of google map and a local Rickshaw driver.
One example of 
recent trend of Digital Bangladesh? (Adopting modern technology with somewhat localized taste.) 

On July 7th, I received my first guests to my place, two JOCVs working on the education sector. Their aim was to visit Primary Trining Institute (PTI) here. PTI is the governmental institute to train teachers of public schools. Some trainees are already experienced teachers and the others are new graduates. After 2 years' training at the PTI, they receive a certificate. A primary school is usually attached to PTI and is often located within the same campus.

At a trainee's class, talking about the national anthem of Bangladesh.
There is a projector facility, check. I might be able to show some awareness movies.

A small construction is being held but the building on the back is a primary school.

PTI is located in each prefecture and JOCVs are deployed at some of PTIs in Bangladesh to support instructors (trainees' trainers) as well as improve the training program. These JOCVs have education and/or experiences to work as a school teacher in Japan. There is no JOCV member at Nilphamari PTI.

I'm curious as much as you about what's happening in your class.

Even though we visited without any appointment, we came through to instructors quickly. To my surprise, instructors recognized two of my fellow volunteers as they had met at training sessions at PTI in some other districts. We discussed on overview of the Nilphamari PTI and instructors mentioned current shortage of human resources, and also asked how to get JOCV deployed at one's PTI (a request from the institute). I was also impressed the name value of JICA here. I rarely come across people who are aware of the organization in my area, except for health workers who have worked with JOCVs in the past decade and a few international NGO staffs.

One of the two classes for trainees.

Then we moved to a primary school attached to the PTI and observed some of classes. It was almost the first time for me to have a look at school properly in Bangladesh. Probably as it is PTI school, the number of student in a class is not so large and students listened to teachers and JOCVs carefully. A JOCV advised kids to put their bags away from desk and only put what they need for the current schema on the desk, so that they can visually see and concentrate on the subject they are studying right now.

I also found it adorable to hear from one of the teachers that her students were complaining at the teacher that why those Japanese only looked in other classes but didn't enter our class. Then they welcomed us with big smiles and cheerful greetings. We were just a bit careful not to disturb lessons so much. 

Relatively small class size, isn't it? 

During visiting one of the classes, I saw a JOCV talked to a girl who didn't take note. The girl said she forgot to bring a pen when asked why she wasn't writing. If I were her, I would have given my pen without much thought, just to help her at that moment. However, the JOCV did the opposite. She didn't give the school girl a pen but just gave a few words to encourage her. She let the girl be responsible for the matter instead of offering a helping hand easily. If the girl had received a pen from me, she wouldn't have reflected on her small mistake well. Then I realized that we cannot deprive children of chances to learn from their mistakes. I was reminded of the meaning of education by the time.

Learning from learners. Thanks for having us.

Yet, my main purpose to visit here was to get familiar with the Super Madame (the representative in charge) and seek an opportunity to speak about Filariasis as a part of awareness activity. Since trainees are going to spread to hundreds of local schools after the training and they will teach thousands of students, what if 20 percent of trainees would pass on to students about my message? Face to face communication is the most reliable way to deliver message but meeting 1.8 million people in the prefecture by myself is not possible. Then contacting influential persons in the community would be one solution. So, I plan to resume PTI and school program after the Eid holiday.

In the red basket, there are nutrition biscuits. He was distributing it to classmates. 

July 18, 2013

The first Health Education Program

Writing on the blackboard from the class. "environment, ..." 
I've been silent for almost 2 months unexpectedly due to hectic days and other priorities. Over the time, farmers finished harvesting rice and have already started planting for next round in paddies. Except for that, things are alright and I've settled down in my town Nilphamari. 

My office, Nilphamari Civil Surgeon Office.
Time series would be random, but remembering my last months I'd like to give update on how I live and work here. First comes about Health Education Program.


200 students attended at our program.
On Saturday morning on July 13, I went to a girls' private high school in Nilphamari to give a talk on Filariasis, accompanied with a Sanitary Inspector (SI), who is in charge of not only food sanitation at restaurants but also health education. I had a small chat with him in the previous week when I visited Sadar Health Complex and had told him that I wanted to go with him to a school program one day. Therefore he called me on a Saturday morning when he was planning to visit a school. By the way, since high schools went into holiday from July 14, based on a sudden notice by the government in related to Ramadan, this day was the last school day before one-month holiday.  

In prefectures of Bangladesh, the health education program is conducted by health workers in each Upazila. Health workers such as Health Inspector and Sanitary Inspector, visit schools in their areas targeted times per month to give lectures on health education. Weekly topics for the program are given at health worker’s monthly meeting and mainly about primary health, personal hygiene and common disease such as diarrhea and TB. At this month’s Upazila Health Complex’ meeting, I overheard that one of the monthly topics would be Filariasis. Therefore I made my mind to go there to see the program by myself to learn for my own awareness activity. I hadn't seen any school program so far in the last two months, so I wanted to see possibility to utilize the health education program to expand knowledge of Filariasis.

He wanted me to develop his picture and bring it to him.

The impression of my first school program experience was very satisfying. I saw a good opportunity to collaborate with the health education program. On the way back to the town sitting on a bangari, SI also mentioned one of the benefits of the school program, that students can bring knowledge to their homes and neighborhood in various villages around the school. It is very effective and efficient. 

On a way to school. The vehicle in front of the house is "bangari". 30TK (40JPY/0.4USD) for 20 minutes ride.
So how did it go the whole program? When we arrived the school around 11am, we were welcomed by the head master or principal of the school. After exchanging self-introductions, SI explained about health education program and asked for a time to talk in front of students. Attended by 200 students, SI and I conducted the program for about an hour. SI first talked about primary sanitation knowledge including food related sanitation and safe drinking water for 45 minutes. The way he brought up topics one after another was a good learning for me. Although he talked about several topics in his program, since his talk was direct to points, it was easy to understand and persuasive. Then I talked about Filariasis about 10 minutes, with a help of SI and the principal.

His talk was smooth and clear.
Through telling to people about Filariasis, observing audience's responses, interacting with them as well as receiving questions, I can improve myself how and what to talk about it. Questions I received on that day were such as:
- Would any kind of mosquito spread Filariasis?
- Do patients always carry Filariasis parasite in their body?
- How long the parasite would stay in a human body?
- What would it happen when patients take MDA drugs?
- Can you say something in Japanese? 
  (I said a few sentences they wanted to hear. Actually students seemed more excited to hear that than my disease talk.)

A classroom with natural light and tin walls. Defect is loud sound when it's raining. 

Different atmosphere but the health education program day reminded me of a few things in the past, including my volunteer time at New Hope Cambodia. School has been my favorite field for a long time and hope it will continue to be here in Bangladesh.

After one good experience, I came across SI at my office today again and briefly talked about program plans. While I pick up necessary Bengali words one by one every day, I look forward to the next session soon. I thank the students who listened to my poor and too simple presentation and also the head master and SI who provided support. 

I promised to revisit the school before the MDA campaign in fall

May 17, 2013

Reaching patients through Community Clinic

My first project here will be Filariasis patient care through Community Clinic. Since elimination of Filariasis has been the priority mission, many of Filariasis patients are tend to be left without proper care to date. Efforts for eliminating Filariasis are bearing fruit and the Bangladesh government aims to conquer the disease by 2015. Thus JOCV members on Filariasis program will eventually launch a patient care project in each prefecture to support patients with relief of suffering, in addition to current awareness activities.

Tools for patient care. Also good learning materials for my Bengali study.
Main symptoms of Filariasis include high fever and pain as well as swelling of the arms or legs. Not everyone who is infected to Filariasis will develop symptoms. However, once developing these symptoms, there is no medical treatment to cure the disease. Instead, keeping legs clean and doing exercise are important to prevent progress of symptom and secondary infection.

Patient's legs with left leg swelling.
Even the lady lives outside of the clinic coverage area, she walked an hour to see us. 
In order to start up the patient care project, I and a senior volunteer visited one Community Clinic near central of Nilphamari, which is meant to be a model clinic to provide patient care for Filariasis patients around the clinic. A health worker assigned the area had listed 15 patients and gathered them to the clinic on the day we visited the clinic. We interviewed and registered them and explained briefly on the disease and treatment. Our plan is to hold a patient group gathering on a regular basis to support continuous self-care. To my surprise, roughly half of the patients we met on the day didn’t know well about how the infection occurred as well as ways to calm their symptoms, even they actually suffer from pain and swelling.

One of the big challenges is how to motivate patients to continue self-care as well as to come to the clinic. I feel that just lectures and exercise is not enough reason for them to come regularly and something benefiting is necessary. It can be peer-to-peer kind of discussion, life skill lessons, or tea time according to Bangladesh culture. If you have some more ideas, please suggest them anytime to help me J

A room in the Community Clinic

Community Clinic in Bangladesh

According to the Bangladesh government’s website, Community Clinic is a tiny clinic at the grass root level including the remotest and hard to reach area. It is basically meant for health education, health promotion and treatment of minor ailments, first aid, and identification of emergency and complicated cases to establish an effective referral linkage with the higher facilities. One Community Clinic covers 6,000 people and 13,500 clinics are planed nationwide to provide basic health and family planning services.

CHCP sees moms of sick babies.
A Community Clinic covers about 6,000 people in an area.
Vaccination is one of the functions of the clinic.
A trained worker called Community Health Care Provider (CHCP) is deployed at each clinic. At a monthly meeting of Dimla Upazila Health Complex in May 7, for instance, certificates of completing training were handed to new CHCPs by Civil Surgeon, the top of health administration in a prefecture. During the meeting, they also reported number of visitors, deliveries, cases of maternal care at their clinic in a month.

A certificate was handed over to a new CHCP. Well done.
Reporting and discussing health related matters at a monthly meeting, attended by around 50 health workers.
Further details can be found in the government’s Community Clinic Project website.

May 9, 2013

Night blood survey in Rangpur

Night blood survey was conducted in Rangpur.
This week, I went to observe Night blood survey conducted in Rangpur, the neighboring prefecture of Nilphamari.

Night blood survey is conducted to understand the epidemiological situation, particularly the prevalence of Lymphatic filariasis. Filariasis patients carry microfilaria, baby filaria parasite, in their body. Since microfilaria appears in blood only during the night time, blood sample needs to be collected at night. This is called a microfilaria (Mf) survey.

I and a senior volunteer arrived in Rangpur early in the evening followed by the dinner with another volunteer there. Then we moved to the survey site, which is about 10 minutes away from the city center by car. The site is a house usually used for the vaccination program. In a small room, with a desk and a bed, 2 health workers set up equipment for blood sampling. Mf survey was conducted at 5 sites in Rangpur for 4 days and 100 samples at each spot were supposed to be collected.

Rangpur railway station
Street performance was about to begin in front of the station.
Today's dinner, chicken biryani. A dish often eaten on holidays.
The signboard says "Here, all products are from 1TK to 99TK" (1.2JPY/0.01USD-126JPY/1.2USD).
Didn't really get the concept of the shop though.  
Attended by the hospital chief of Rangpur and a medical laboratory technologist from Filariasis Head Office in Dhaka, the survey started at 10pm. Residents in the targeted area voluntary participated the survey and dozens of people had already gathered as we arrived at the site. A health worker listed name, gender, age, and father’s/husband’s name of participants for the survey. Father’s/husband’s name are asked as many people have the same first name, and for married women husband’s name is used for identification.

Ever since I had arrived in Bangladesh, I sometimes received questions asking my father’s/mother’s names and had been wondering why. I thought it was just out of curiosity but by observing the survey at the night I finally figured out the reason. This is one of the general questions Bangladesh people are frequently asked in the daily life. 

A qualified health worker collect blood samples.
The survey proceeded smoothly except the power outage. In my area, blackout comes every night for about an hour but this evening the electricity never came back. Therefore, several battery lights were laid on the table and the blood sampling were collected one by one in the dark. In the beginning, people were packed in the small room both for the registration and the interest for the Japanese, then gradually left for home after a while. 

Two supervisors left at 11pm, when around 60 samples were collected. We didn't stay to the end either but I think targeted number of the samples were gathered in the evening. 

The procedure was similar to a blood glucose test.

By the way, my recent boom is to ask back “Where are you from?” to Bangladeshi. As always, I was asked about it by a number of villagers on that night. Most of them get a bit stumped when I ask them the question but then proudly reply “Bangladesh”. I love the way they say that and these days enjoy this conversation here and there with locals. Another variety of it is “made in?”, which also means the same. But can I actually say “I’m made in Japan”?

Kids in a school yard, Rangpur.

Filariasis control by JOCV

My assignment here is to support elimination of Lymphatic filariasis, which is an infectious disease transmitted by mosquitoes. It is listed as a neglected tropical disease (NTD) by WHO, and still prevailed in the Northern part of Bangladesh. For the elimination of the disease, currently JOCV members are dispatched in 5 prefectures including Nilphamari, and 2 more volunteers are to be dispatched in next month. In addition, 1 volunteer is assigned at the Filariasis Head Office in Dhaka, as a program officer, to liaise closely with volunteers in the fields. Although we are in charge of each prefecture, JOCVs on filariasis control often work together to exchange information and experiences, help with each other and discuss effective awareness campaigns.

It reminded me of days in Cambodia.
They used to say "Good luck for you and good luck for me" as greetings.

May 5, 2013

Nilphamari life kicks off

Fresh green paddy field from apartment's rooftop.

I've finally arrived at my assigned field Nilphamari for a week ago. First week has gone so fast as I sorted out basic living environment. There is a senior volunteer in Nilphamari for the moment and I’m his successor. He helps me a lot from work to daily-life related matters so that I can smoothly start a new life. We will work together until his duty period will end in next month. Our mission as JOCV (Japan Overseas Cooperation Volunteer) members here is to work on the infection control program, especially on elimination of filariasis.

My work place, Civil Surgeon Office, Nilphamari.
BULBUL Textile compny's bed covers and towels, made in Bangladesh.  

Nilphamari is located in north-west of Bangladesh and takes about 8 hours by bus from the capital city Dhaka. There is also an airport in Saidpur, half an hour from the center of Nilphamari and flights to Dhaka are available twice a week. Nilphamari has a border with India up north but it is not possible to cross the border to India on foot.

Origin of Nilphamari's name backs in British domain period, when the British brought chickens to the area for chicken farming. “Nil” stands for “blue” in Bengali, indicating the color of the UK and the latter part comes from “farm”.

We've arrived, and to prove it we're here.

Menu board at a local restaurant. Why not adding "Smile 0 yen" in the bottom?
Landmark in my neighborhood. 

As my counterpart, Civil Surgeon of Nilphamari describes, this is a peaceful, calm and quiet place. The paddy fields' green is quite eye-friendly as well as impressive. Also, I enjoy beautiful fireflies outside of the apartment's window at night. Less cars go by on the road compared to the heavy traffic in Dhaka. Instead, motorbike, bicycles and other sorts of local vehicle are often seen here. CNGs (a local natural gas- fueled car), run only up to Bogra and there are no CNGs in Nilphamari. Therefore, CNG could be an indicator of urbanization in cities of Bangladesh.

The largest stadium in Nilphamari prefecture with a stray cow in front.
Sheep move through middle of the street rather than a motorbike.
Locals look at me curiously while a local dog keeps his routine.
Artistic display of spicy snacks called chanatur. 
London market is a place to relax in the weekend. 

Luckily I've found a room to settle in with a help of JICA staffs and a Bangladeshi landlor d immediately. What needs to be bought on the first day to start a new life here is bed sheets,   curtain, mosquito net, fan and broom. Since it’s becoming hotter these days towards summer season, the number of mosquito is not huge but still mosquito net is must item. Actually I’m here to work on a mosquito-born disease, so protecting myself from it would have an important message.

The health complex in Dimla, Nilphamari. 
A stubborn and yummy lunch place in Dimla. Only one menu, chicken curry is available but was unready.

Clearly, I am the only Japanese besides my predecessor and still a stranger in the city. Most of the people just stare me and around one out of ten would talk to me. A small child looked at me on the street and burst into cry for fear. Yesterday, however, when I was taking a stroll in the neighborhood, a boy came up to me and suddenly handed over four green mangoes. This one happening somehow released my tension a little which I bore since I've newly come here, and gave a feeling that some parts of the city welcomed my arrival.

My punctual flatmates, Mr. & Mrs. pigeon.

When I first got here, I arrived in my room and looked at the slopes, and I had to take a minute to readjust, ... Now, I'm having a very good time.
        Christopher Reeve

Sunset glow in the very first evening in Nilphamari.