What I Learned About Public Health in the Eastern DRC

Dear Blog Followers,

I did not keep my promise to you and write timely posts about my trip to the DRC. Life got busy. I also decided to take a different approach in what I'm going to post, presenting what I learned during my trip. So today I'm starting with Public Health. Eventually I also hope to write to you about the DRC, my Doctoral Research AND myself. 

As a refresher I was in the DRC working on a review of humanitarian assistance between 2006 and 2016. If this post troubles you I invite you to consider donating to MSF (specifically to their hospital in Masisi) or to Heal Africa in Goma. 

http://www.msf.ca/en/donate-now

http://www.healafrica.org/donate_to

My initial role on the review team was as the Public Health Expert, although methodological lead was later added to the list of my responsibilities. I was invited to fill this role not because of my extensive education in Public Health but because of my general experience around public health policy including the social indicators of health and helping to run the health clinic at KW Reception House. Fortunately, the review didn’t require any knowledge of the biological and epidemiological components of public health because then we would have been in trouble.

As the Public Health Expert on the team it was my job to interview individuals engaged in public health work. This included local chief medical doctors, nurses, nutritionists, project coordinators for international NGO’s and sometimes their heads of missions. I also visited numerous health centres and hospitals, camps for internally displaced people and NGOs. It was extremely eye opening.

Over at least the last 15 years most of the health centres and hospitals have been run with the support of international health partners. They are often operated by local doctors and nurses but their programs and access to medicines are funded by international partners. As a result of this support, they have been able to offer free medical assistance and medications to the local population in part and in whole. However, recently because of donor fatigue and the redirection of funds to new crises such as South Sudan many international health organisations have reduced or completely cut their assistance to health sectors across Ituri, North and South Kivu where the local population is now being asked to pay for medical assistance. This worried many of the local health care practitioners who I spoke with who indicated that much of the local population could not afford to pay the nominal fees that they were now being charged by the health centres and hospitals. This is particularly concerning because the primary causes of death in the region (malaria, respiratory infections, cholera and TB) are highly contagious but treatable illnesses. Lack of access to treatment could easily lead to the spread and possibly epidemics of these diseases resulting in a significant increase in mortality, particularly among vulnerable people including children and IDPs.

I also observed the conditions at the medical centres and hospitals. There were two examples of best practices. The first was the hospital in Masisi which we visited at the beginning of the trip. The hospital is funded by MSF and has extensive wards for malnutrition, trauma, maternity and pediatric care, it also has a well stocked pharmacy. All treatment delivered at the Masisi hospital is free. Unfortunately, the week we visited the malnutrition ward in the hospital was over flowing because desperately needed food aid wasn’t reaching its recipients because of corruption in the supply chain. The other strong example was the Heal Africa hospital in Goma. Like, the Panzi hospital in South Kivu where I visited in 2016, the Heal Africa treats and supports victims of sexual and gender based violence. The hospital is extensive and offers both medical and social services to its patients.

These two hospitals were very much the exception to what I saw. The most troubling cases I visited were health centres in Ituri, both which had recently lost funding. When I asked for a tour of the first health centre near Komanda I was shocked to see that the birthing room consisted of an examination table with a hole cut into it and a basin underneath it to catch the baby. The room was so dark, damp and dirty, I couldn’t imagine how giving birth in such a place could reduce maternal or infant mortality (although it apparently does, at least according to the statistics on their wall). The second health centre I visited in Mangiva was in much better condition and seemed to have more services available. However, that health centre had been attacked and raided by militants three times in the past three years and during the last attack the head of the centre, a young father, was briefly taken hostage.

Mangiva Health Centre

I also learned quite a bit how different diseases and socio-economic conditions can interact with each other to exacerbate existing conditions and contribute to elevated mortality. For example, someone who is chronically malnourished is more likely to die as a result of a cholera infection. People living in under-supported long-term IDP camps, without proper sanitation structures such as the one in Kalite in the Masisi territory are very likely to be affected by both. Further, when people flee fighting and war in the Eastern DRC, they also spend days and weeks hiding in forests, or walking to seek safety, where they are at much higher risk of being exposed to Malaria. Sub-standard living conditions and nutrition can also increase susceptibility to respiratory infections, as can HIV infections which is spread by the scourge of sexual and gender-based violence.

I was also exposed the complexity of sexual and gender based health in the DRC. While I was there I spoke with a counsellor at a counselling centre for victims of sexual and gender based violence who didn’t know that she could use condoms to prevent unwanted pregnancies. I also met a priest who was prepared to distribute condoms to his parishioners in order to prevent malnutrition cases being caused by women conceiving too soon after giving birth (I gave him $20 to buy condoms). Finally I learned that, an well-known international health NGO has started offering free abortions to women who need them, despite the fact that abortions are illegal in the DRC.

When I was in the first year of my Ph.D. I read an article by Marriage (2013) which argued that international health NGOs should stop providing free health care in the DRC because they were duplicating state services and preventing the government from taking full responsibility for the sector. The Congolese government is not taking responsibility for the health sector (or most other sectors) and the local population cannot afford to pay the fees associated with medical treatment in the East. Another example of this was an HIV/AIDS advocate who shared with me that while the government provides free Anti-retroviral treatment for AIDS patients they don’t cover the cost of medication for opportunistic infections which could kill them and be spread to other parts of the population. Many people in the East with HIV/AIDS are too sick or stigmatized to work and so obviously can’t afford these medications.

To conclude, a full pull-out by international medical organisations would result in an overwhelming health crisis, which is already reflected in recent cholera outbreaks which have occurred across the East. More money needs to be directed back into the DRC to ensure that the most vulnerable people continue to have access to urgently needed medical care. 

Sad Goodbyes at the Goma Airport

I've cried in a lot of airports around the world. Toronto, Ottawa, Montreal, Halifax, Amsterdam and especially Johannesburg, but nothing prepared me to be holding back tears at the Goma airport. If you had told me a week before I left that it was going to happen, I'm not sure that I would have believed you. 

I was in the DRC participating in a review of humanitarian assistance between 2006 and 2016. The review was undertaken at the request of a UN body and I was hired to work as a public health expert for the review. Methodological lead was later added as my second title later in the contract after the team leave left and I narrowly skirted becoming fully responsible for the project a week before we were set to arrive. Being the methodological lead often left me in the difficult role of the intermediary between the firm who wanted the project undertaken in a specific way, and the team on the ground who knew that it would never go exactly as planned. 

Interestingly, this is the exact intermediary role that I've documented among local civil society organisations and other actors who need to negotiate between the needs of the local population and the desires of international donors who want to address those specific needs. Let me tell you, this isn't an easy spot to be in. 

Yet, as I've been sharing stories with my friends and family since I've arrived back in Ottawa it has become clear to me that I realistically lived two stories during this trip. One where I was pushed to the brink, wondering whether I should stay or walk away from a poorly designed project with a lack of institutional support that was unlikely to yield robust academic results The second where I got to travel across a region that I've studied extensively working on an important, if ill-conceived project, making new friends and learning to disregard the hurt feelings and pangs of regret prompted by the first. 

In the end  I was holding back tears at the Goma airport because I was saying goodbye to even more friends than I arrived with. I was saying goodbye to a team who I fought with and for who, despite everything we had been through, genuinely cared for each other. I was also saying goodbye to new friends who I shared drinks, stories, runs and tears with in three provinces. Lastly, I was also saying goodbye to friends from Bukavu for a second time who I so relished having the opportunity to meet again. Indeed, there was something almost joyful about having something to cry about on my departure. 

So over the next few weeks I'm going to share four more blog posts: one about each of the three provinces I visited and a final post exploring some of the things I learned on this trip. These posts will be divided between the story of the firm and the story of what it actually meant for me to be there. 

Names will be changed to protect myself and the unwitting participants in these stories. 

Error: This is not the Protester That You're Looking For

On Saturday an estimated 1 to 4 million women marched globally for gender equality in the face of a new hegemonic world leader who has openly showed disdain for women in his statements. Yesterday one of Trump's first acts as president was to re-instate out-dated abortion laws which put women's lives at risk both in the U.S. and globally and that undermine women's agency and autonomy over their own bodies. This is no surprise coming from someone who is now synonymous with the phrase "grab her by the pussy". 

Staring in the face of uncertain political and economic exclusion, the organizers and participants of the women's march are now facing criticism from both sides of the political spectrum. Before the global marches were even over, articles proclaiming that if the women's marchers did define a clear agenda that it would falter in the same way that the occupy movement had https://www.theguardian.com/world/2017/jan/19/womens-march-washington-occupy-protest. By Monday even Canada's (least) favorite female political pundit felt she needed to weigh in. Yes, Margaret Wente happily proclaimed, that there is no solidarity in the women's movement and that American women at least are as divided as ever. http://www.theglobeandmail.com/opinion/womens-solidarity-is-a-mirage/article33704854/ Margret Wente's positions are so predictable that it would probably be more cost-effective for the Globe and Mail to replace her with a robot. 

On the other side of the political spectrum I found many comments on social media outlets lamenting the heavy presence of white women at these protests, questioning whether these same women would be at the next Black Lives Matter protests and even questioning the audacity of women to participate in an event when gender and racial equality require daily resistance. 

I went to the women's march in Ottawa on Saturday and I was delighted to see my facebook feed full of pictures of other strong, empowered women who had done the same around the world. I don't feel that either of these critiques adequately capture the reality of the women who went to these marches and I'm going to tell you why. 

This was not my first women's march. I've also marched alongside women in the Democratic Republic of the Congo on International Women's Day fighting for gender equal businesses and public offices by 2030, and with women in Kasese in rural Western Uganda demanding an end to child marriage as part of a peace expo. I think it's also important to note that I've been to a Black Live's Matter protest and that I've eagerly participated in indigenous solidarity events. 

Marching is also not my only act of resistance. In 2007 I made a wish to keep Canada pro-choice in the face of another wish to end abortion in Canada as part of the Great Canadian Wishlist in which the CBC invited Canadians to make a wish for Canada's 140th Birthday and had people vote for their favorite wish. I've also published a policy review outlining gaps in Canada's gender policy in Fragile and Conflict Affected States. I've also had the opportunity to support the engagement of white women and women of colour through my work and to be honest, gender equality and women's rights are my primary focus, so I feel even more strongly for the women who organize within the movement who are facing harsh critique.

More importantly almost all of the women who I knew at the march have been involved in similar ways. Friends I saw included employees from the NDP with long protest histories, colleagues from local and international Non-Governmental Organizations, friends who I met at the Coady Institute's skills for social change program and University professors. These are not women who went home after the march to return to being passive housewives, these are women who already work for gender and racial equality everyday. 

In response to the need to have a "well-defined and set agenda" without which the march and the movement will become meaningless in the eyes of some analysts, I couldn't disagree more. Any third or fourth wave feminist should be able to tell you that gender discrimination and inequality impacts women differently across race, class, sexuality and (dis)ability lines. That's why at the march you saw a divergence of signs ranging from questions of sexual assault and access to re-productive rights to race and political freedom. In order to remain meaningful to a whopping 53% of the World's population the movement needs to capture a large spectrum of women's needs, including from different country contexts. It will be far more effective to have women continue to work on issues that are most urgent for them and to collaborate together to bring attention to those causes that are most important to them. This will also capture some of the concerns related to representation of Women of Colour within the movement.  

For those women who engaged for the first time this weekend, what a wonderful inclusive environment to march in for the first time. Now's the time to start thinking about how to continue to engage with equality in a way that interests and is sustainable for you. It is up to the more experienced and committed activists in the movement to introduce and entrench the importance of intersectionality and the participation of women of colour within the movement in order to present a representative and collaborative voice for women's issues in North America and around the World.