Book of the Month: Factfulness

by Rachel

It's actually probably been years, but we used to have a blog feature entitled "Book of the Month."  There are a number of books our team has read which have informed our views and thoughts.  You're welcome to check them out here.

So, a few months ago I was reading Melinda Gates's new book, The Moment of Lift.  Excellent book, by the way (even though it's not the focus of this post).  I loved getting to read about the amazing work the Gates Foundation is doing to promote the development and empowering of women around the world.  Each chapter focuses on a different aspect of difficulties that women face, and people/organizations around the world working to ensure that each woman is seen as a life that is valuable; in fact, a life that has equal value to those around her.  Apparently, when the Gateses were forming their organization, they leaned heavily on the advice and wisdom of a man named Hans Rosling, a medical doctor and professor of international health.  He too had written a book....so off I went to check it out.

Hans Rosling was a Swedish doctor who spent years working in Mozambique and the Congo.  He then moved into more public health roles and investigated a number of disease outbreaks (including the 2014 West Africa ebola epidemic).  He passed away in 2017, and the book Factfulness was his last work.  Dr. Rosling's premise is basically that the world is a much better place than we think it is.

He uses a number of actual statistics from the world--infant mortality, life expectancy, kids attending school, average household income, even number of endangered species--to demonstrate that while most people interviewed will guess that things are getting worse, statistics show the opposite: that things have actually been improving over the past several generations.  Not only does he use statistics to demonstrate this, but the book is divided into 10 chapters of WHY he thinks we view the world the way we do.

As an American, coming from one of the most affluent countries in the world, who has now moved to Burundi, one of the most impoverished countries in the world, reading the book was actually surprisingly eye opening.  I tend to think of the world as either the "American" camp or the "Burundian" camp, while in reality there are so many more middle countries than either extremely rich or extremely poor.  You can't put Burundi in the same category as South Africa, or Egypt, or Thailand, or India.  Life expectancy and income are much higher for the average citizen of one of those countries than Burundi or Malawi, for example.  Rosling demonstrates that many of us use an "us and them" mentality when we look at the world, instead of recognizing that there are many different levels of poverty and development, and that the difference between a salary of $1/day and $4/day can have exponential benefits for the individual and society.

One of the lines Rosling uses towards the end of the book is this: The world can be bad, but getting better at the same time.  He's not asking us to pretend that everything everywhere is ok.  It's clearly not, and there are many many problems to overcome and injustices to surmount.  But, we can also celebrate the work and developments that have occurred over the last 100 years, even 10 years, as well.  That knowledge can give us hope that our efforts and the efforts of so many are not in vain.

As an addendum, I'm including some of his data graphics below.  The book is full of them, and it's a book that's fun and easy to read.  You can also compare your knowledge of the world to various Nobel laureates, billionaires, scientists, and chimpanzees...and see how you stack up. ;)

Zigama Mama

Zigama Mama logo, designed by Carlan

by Rachel

I've always been interested in the idea of public health.  People have likened the idea of medicine in the developing world (or elsewhere) to pulling drowning people of of a raging river.  Public health is going upstream to figure out why so many people are falling into the river in the first place.  Of course, if all your time is spent saving the drowning, it's pretty hard to find the time to pull yourself away to take a walk upstream.  Important and necessary, but challenging to prioritize none the less.

After six years here, Eric and I decided to take that walk.  Ever since the first months here at Kibuye, I have been noticing a huge amount of uterine rupture (UR) cases.  They are very rare in the US, but we have about 20 cases per year here (Side note for the medical folks: I looked at cases of UR from 2015-2017 and found 55, which is over 1% of our deliveries. !!??  Only about 50% of there are on uteri with previous scar.  So we have a huge amount of UR on unscarred uteri, which is pretty rare in the medical literature.  Harder to prevent for sure...).  A big risk factor for UR is labor after a previous Cesarean section.  Everyone in the health community "knows" this, but given broken systems and difficulty in education, many women who are at risk for UR continue to labor at home, in their villages, way after their due dates, instead of receiving a scheduled C-section or coming in to the hospital to deliver under surveillance.  Some show up with three previous C-sections, in labor, and don't even know their due date.  If only we could find a way to get these ladies to come in sooner, to decide if a C-section is the best decision, and to choose a date for that C-section, maybe we could prevent some of these cases of UR.  At the very least, we can decrease complication rates of infection, hemorrhage, fetal distress, etc, which are all higher in women with emergent vs scheduled C-sections.

Enter, Zigama Mama.  This is technically Kirundi for "protect the mother."  Our Burundian friends say that's not exactly the way they would say it...but we decided to use the phrase anyway given its catchy nature! :)  Our hospital is the referral site for 17 health centers in our district.  Any woman needing a C/S or increased surveillance would get sent from them to us, which also explains why our C/S rate is about 30% of our deliveries each year (instead of the national average of 6%).  The idea of Zigama Mama was to look at all of our C/S data from the health centers for one year, then do a training session for the nurses at the health centers.  The intervention is simple:  every woman with a previous C/S, even one, gets identified by the nurses, written into a register, and then she gets a "coupon" for a free ultrasound at Kibuye.  While ultrasounds are recommended in pregnancy, they are cash pay ($5) and most women can't afford them.  So, the free ultrasound is the incentive to come to Kibuye, where I can confirm their due date and decide if a C/S is indicated or not.  If yes, I schedule it.  If no, I encourage the women to come to the hospital (not the health center) for monitoring as soon as labor starts.  That's it.  We'll look over the next year to see if our rates of emergent C/S and UR decrease.

Training on Postpartum Hemorrhage, using resources from Laerdal Global Health

We had the initial training session last week.  Honestly, I wasn't sure how it was going to go.  Eric made up a schedule that involved a start time of 8:30.  At 8:30 on Thursday morning, only one person (out of the possible 35) was there.  However, people trickled in over the next hour and in the end, 16/17 health centers were represented!  We presented the rationale for the program, the nuts and bolts, and then had several hours to do some training for the nurses on post-partum hemorrhage and neonatal resuscitation, as well as share a meal together in the canteen.  It was great to see our Burundian doctors coming in to help out with the hands-on training programs.

We divided up into groups to practice techniques on a uterine model for treating PPH

Dr Ladislas, one of the Burundian docs on my service, also did a great job leading one of the groups

On Monday morning, I actually already had four ladies show up with their Zigama Mama coupons!  I'm excited to see how this intervention can have a positive impact on the health of women in our district.  There remain so many barriers to access to care, but hopefully, little by little, we can chip away at them.

The Zigama Mama ultrasound coupon