The Results Are In

The randomly selected villages
surveyed.

Nearly eight months since its initial inception, the project to evaluate last October’s bed net distribution has finally come to a close. We have trained five trainers, 53 Peace Corps Volunteers, and 141 Togolese counterparts, 198 villages were surveyed, 6,015 households visited, 36,471 people counted, and two papers written—one in French and one in English.

It was way back in February that the partnership between Peace Corps Togo and a number of organizations working in Togo was initially suggested.  With months of back and forth communication, but little progress towards actually cementing the relationship and beginning the project it felt like it would never come to fruition.  But alas, it is finally done!

Working with a number of large organizations and the government to establish a project was at times very trying.  While working with large international organizations can lead to a wide-reaching and successful project, sometimes getting everything going takes much patience. Four months past of back and forth e-mails before all parties involved could agree on a meeting. After the first meeting each partner had different comments on how things should be executed and some of those suggestions came as contradictions to each other.

Representatives from our partners who worked
with us on the piloting committee.

As we hoped to get moving on the project before the a large group of volunteers started to complete their service and leave the country, even after our second meeting things felt to be moving very slowly as we waited for the agreed funds to arrive.  As soon as our funding came in though, we were a flurry of activity with hardly two weeks passing before we began training for the survey.  Giving volunteers and their teams time to survey and submit their data it was a month and a half before we got started on our analysis.

While we found that the campaign did not quite succeed in its endeavor achieve “universal coverage” which is defined as one Long Lasting Insecticide-Treated Net (LLIN) for every 1.8 people, ending with one LLIN for every 2.22 people, we found other interesting results that showed the success of the campaign and where some improvement could be needed. The campaign did help to achieve the Plan National de Développement Sanitaire (National Health Development Plan) of 2012-2015’s goals of having 71.4% of pregnant women and 75.4% of children under-5 sleeping in Togo under a bed net, however, in my own region, Maritime, the goal was not achieved for pregnant women as net usage was lower in Maritime than the other regions.

Before the campaign only 40% of households owned even one net, but after the distribution over 93% of households had received at least one net.  Close to 75% of bed nets were hung up for use and a little over 71% of people surveyed reported that they slept under a net the night before, though in Maritime only 63% of people slept under a net..  Pregnant women and children under five years of age were more likely to sleep under a net than the general population.  As they are a target population because of their susceptibility to malaria, it is a positive sign to see that they are sleeping under bed nets—likely indicating that previous efforts directed at them have had some success.

People’s knowledge of malaria seemed to be pretty high and the majority of people were able to identify the correct cause of malaria, though even for some who gave the right answer they also gave an incorrect response, including drinking dirty water and working too hard in the sun, thus showing that there is room for improvement in education and that there may be a lack of understanding to as to how to differentiate between malaria and other fever causing illnesses.  Besides an insufficient quantity of nets, one of the main reasons for not sleeping under a net was that it wasn’t hung at the time, including that it was being wash, there wasn’t space in the house and that people did not know how to hang a net, further indicating the need for more education as to proper care and use of a bed net.

All of our results went into two papers that were presented to our partners.  We also gave a presentation of our results to Peace Corps administrators and attended a meeting with the Minister of Health, the Director of WHO Togo, and a representative of UNICEF. The last meeting that was on Monday rounded up the conclusion of our work. 

Now that we are done I feel very put-out.  We spent so many hours planning and executing the project that these few weeks before my next project begins have seemed very empty, though, I am exceedingly happy to be back in Vogan for a while.  My partners here have been very understanding of my work outside of Vogan, but now we are very excited to refocus on our projects here at home.

Yep, That’s Happening

I was recently reading an article that discussed some of the negative implications of the Sex Offender Registry Act, one being that there end up being a number of individuals who are placed on the list due to crimes such as public urination.  As I was reading this I laughed out loud, not because I find sex offenders funny, but because I thought of the absurdity of trying to implement a similar policy where I live now.  If the Sex Offender Registry existed in Togo and had the same side effects of the act in the U.S., roughly every single man in Togo would be on the registry.

Public urination is entirely common here in Togo.  It is mostly men who frequently urinate in public, though when on long voyages women will as well.  Women tend to be a bit more discrete, but men will just whip it out wherever they are and whoever is around. On some walls you find signs spray painted on saying “deffense d’uriner,” but everyone continues to urinate publicly.  To my American sensibilities it can be sometimes shocking as I am walking down the street and a man shouts my name to say hello and start a conversation only to see that at the time he is holding his penis and urinating. All I can really do to cope is acknowledge to myself that, “yep, that’s happening” and I just shout “hello,” look the other way and hurry on.

Some men are more discrete and find a spot in the bushes, but there are some more brazen, and in Lomé I have passed one man literally standing in the middle street urinating.  There are those Togolese that oppose this common behavior and recognize its dirtiness, but there are no facilities really to give people an option not to do so.  There are very few public restrooms to be found here.  A few villages have constructed public latrines, but not many.  Bars often only have a “urinoir” or basically a walled in piece of ground to pee on. With cultural habits it is also unlikely that someone would ever ask to use another person’s restroom, especially if it is inside their house.

I know I’ve battled with the lack of public restrooms, particularly if I am ever out of my house for the whole day or traveling.  I find myself avoiding drinking water to limit the chances I’ll have need of a restroom and have found myself with a dehydration headache at the end of long work days.  The gender difference with this issue is quite evident and male volunteers end up having a much easier time as it is appropriate socially for them to urinate in public, but for women the general rule is to hold it until you get home.  You know, you don’t want to get put on that registry for showing your bum in public or anything!

Je Vois la Vie en Savanes

A couple of weeks ago I ventured up to what may well be one of the most beautiful places in Togo.  I took a couple of days off to travel north to the Savannah “Savanes” region to see a good friend.  It was, and unfortunately probably will be, my only time that I have visited the most northern region of Togo.  After spending over a year living in the relatively flat and often seeming characterless southern region of Maritime, Savanes was wonderful to see. 

Now, my deeming Savanes as being the most beautiful in Togo is a bit colored by the fact that I saw the region during the rainy season, when it is its most lush, and that I haven’t yet seen some of the most noted beautiful places like the waterfalls in Badou. But seeing it still made me wish I had been placed up there so that, even for part of the year, I could be surrounded by so much beauty.

At the time I went there happened to be a group of volunteers visiting Savanes and we rented a car to go see one of the few official tourist sites in Togo, the Nano caves.  We were dropped off at the bottom of a rocky crag of a mountain and took ourselves on a self-guided hike, which led us through a number of rice patties and cornfields, to the top.  The hike took about two hours, but by the time we were three quarters of the way up we had to stop for a break, at which point some women from the village below carrying large containers of a local beverage on their heads and not wearing shoes overtook us, even though we started out a good time before them.  We may have felt a little ashamed, but we quickly settled into that reality as we took our second rest.  I could have easily predicted such a thing, I currently live in a very flat life where I go months at a time without even mounting two stairs at a time, I ride my bike and walk around town, but beyond some rolling hills there isn’t really anything to climb, and the hike’s ascent was pretty steep and I just wasn't prepared (flip flops and all) for the hike.

At the top an expert from the local village showed us down a rickety ladder of welded rebar to the caves that are found in the mountainside.  These low ceilinged caves were inhabited in the 14^th century when warring ethnic groups drove people to flee to safe hiding places.  The caves still have the clay granaries used at the time, and our guide so thoughtfully pointed out the flat rock which was definitely used for milling grain, and the other flat rock where the elders sat and had their war council. The caves really are quite interesting and a clever hiding spot, but I couldn't imagine living there and not being able to stand up straight for months at a time.

Our driver was kind enough to drive up to the top of the mountain to bring us back down to the regional capital of Dapaong, where my friend is posted and the other volunteers were staying, so that we could wage a losing battle with a bar’s TV to watch the Olympics.  A day later I found myself back in good ol’ Maritime. I rarely get out of my post to do anything besides work and visiting the north, though it was very short, was a wonderful little vacation where I got to see a great person, eat some good food and demonstrate my complete lack vertical climbing endurance.  Je Vois la Vie en Savanes.

Not Here, Not Now

I’m usually a pretty big zombie movie fan.  It can be an interesting subject to think about and I enjoy imagining how I’d fare if this unlikely scenario was to occur.  Besides an old sports injury that would keep me from sprinting away too quickly, I figure I could hold it together and could survive maybe a little above average-ly well. 

But this afternoon I found myself thinking, “Please don’t let there be a zombie apocalypse while I am here in Africa. Not here, not now.” –OK, yes maybe thinking about zombie apocalypses may not always be categorized under normal activities, but I have a lot of time alone, so work with me here—Why did I find myself saying this? Because, I am almost 95% certain that I would not survive a zombie attack while I am here in Togo.

First of all I have no weapons.  If I was forced to defend myself from a zombie I would be out of luck.  Taking stock of what I would be able to find in my house: a frying pan, which I’m pretty sure the handle is going to fall off soon, so just a few whacks and I’m done for; and a hammer, a little too close range for my comfort; in a pinch I could probably grab my bench and use that but none of the options are optimal.  I have none of the typical sports or lawn equipment that represents the typical weapon choice and there is a zero percent chance I that will happen upon some avid hunter’s gun collection.  There are extremely few guns in Togo and hardly any private citizens own or possess a gun.  Some security guards and military personnel carry guns, but from what I understand bullets are often not included. So, in a fight to defend myself I’m basically handing myself over on a plate.

Actually escaping would be pretty much as impossible as defending myself. Particularly during the rainy season, roads can be impassible on a normal day, much less one with zombies. Roads are often barely wide enough for two cars and one overturned truck would block the only road to get where you are going.  There aren’t very many cars in good condition around either.

 With many windows that are cracked or don’t close, when your car inevitably stalls you are dinner in a take-out box.  There would be no stopping them from breaking the already weakened windows or clambering right into your lap as you reach for the window crank only to find it doesn’t exist.  And don’t bother trying to make a dash for it, the door you need to leave though probably doesn’t open or at the very least needs to be opened from the outside.  One positive note though is that you are unlikely to fumble with keys when trying to escape; many cars are old and the keys have been lost, so they are hotwired to run—just pinch the wires sticking out of the dashboard together and away you go!

In every zombie film the heroes are running to somewhere. They choose a spot they think may be safe and set that as their goal. I have no clue where I would try to run.  I am not familiar with the official or secure buildings in Togo or its surrounding countries and would be hopelessly lost.  I guess I may head for the U.S.  Embassy, they have marines and a building that is more soundly built than my own house.

If I wanted to hunker down and hope for it to blow over I’d be at great risk because my house itself is not an ideal zombie proof hideout.  You may think, “but Liz you have a walled in compound. Surely that will stop them!” My wall is maybe six and a half feet tall, and I have myself contemplated climbing over it when I have been locked out at night a couple of times. With a few zombie bodies piled up against it, it would be a cake walk to amble your zombie-self right over it.

My door would likely provide little to no extra protection, as I am quite sure a small child could break it down if they put a little effort into it.  The weight of a zombie horde would definitely be too much for my already splintered door to bear. I wouldn’t even be able to try the “be quiet and everything would be alright” tactic, because every sound in my compound is amplified ten times. I can hear my neighbors brush their teeth, one move and those flesh eaters would know I was in here.  On a positive note I do have bars on my windows, so at least they wouldn’t get in there.

Finally, I don’t know if I could mentally take a zombie apocalypse.  A while back I got my hands on the second half of the first season of the Walking Dead and I haven’t been able to bring myself to watch it; I get to the truck being turned over in the first scene and I’m done. I rather like the show,  and watched it alone and at night plenty back home, but I feel too uneasy to watch it by myself here. I think it’s from being so far from my friends and family and being in a country where I can’t talk to half the population, it has sapped a lot of my confidence and mental stability.   If I can’t hold it together enough for a TV show, how would I ever be able to survive a zombie attack?

I would never wish for a zombie apocalypse, but if there ever is going to be one, let it happen once I back home, where at the very least Matt could try to save me with his self-professed awesome zombie survival skills.

Being a Peeping Tom, I Mean Surveyor

Planning the survey and organizing the training for volunteers and host country nationals was only part of my work in the evaluation of the bed net distribution of last year.  Even as one of the organizers I still participated in the survey itself.  My team of four, myself and three counterparts, had four villages we had to go out and survey.

The first day we all went out together to one of the villages to make sure we all were on the same page with the instructions and to each practice interviewing a household.  While we got a later start than we had planned everything else went pretty smoothly.  Except for a drizzle here and there the rain held off while we did our survey and we were able to get finished in the early afternoon.

This first village was incredible; nearly everyone possessed a bed net, had them hung and reported the whole family sleeping under the nets.  Honestly I was sort of surprised (in a good way) I rarely get to see inside the bedroom of my community members and with everyone behind walls in my city I don’t even get to play role of Peeping Tom to peer through windows and see if there are nets. My only experience with malaria and bed nets had been prior to the campaign, and the campaign itself fell into that awkward period when I was just moving into my town and hadn’t really established any personal or work relationships.

Everyone also seemed to know why it was important to use a mosquito net and how malaria is transmitted. You often hear of people believing that eating too many mangoes, working in the sun, or drinking dirty water gave you malaria, but everyone seemed to know that it was caused by mosquitos.  One man let us know that he used to believe that it was something you ate that gave you malaria, but after the campaign he now understood that it was mosquitoes. Having him say that he had his mind changed about the cause of the disease was encouraging because surely there were others like him that were once mistaken but now understand malaria a little better.

The second day of surveying our team split up into two letting us complete two villages in one day.  These villages were not nearly as encouraging as the first.  Those we surveyed still sighted mosquitos as the cause of malaria, so at least there was some understanding of the disease, but very few people were using mosquito nets.  There were people who didn’t receive enough nets for their entire family, or who were traveling on one of the days and missed getting nets all together, but the bigger issue was just people not using the nets they had.  Very few people had their nets hung at all and the majority said they didn’t sleep under the nets.  Some said they were just too tired to hang it, others said there were no mosquitos, and one woman said she refused to use the one she did receive because she was angry that she didn’t receive a second for the other members of her family.  Further still there seemed to be a lack of understanding about how to use the nets.  One woman said she wrapped herself in it like a sheet she’d go to sleep in.  The man I was with asked her to demonstrate and she through it over her head and laid down wrapped up head to foot like a mummy.  My surveying partner couldn’t help but be discouraged and kept sighing heavily every time we found another family not using their nets.

With our fourth village my surveying team decided that they all wanted to do the village together, but this time I sat out in order to save money on transportation costs.  This village seemed much like the second two, there were nets but people weren’t using them.  I had been excited for the first village and the apparent success of the campaign in all aspects, but out of my cluster of villages it seemed to be the exception instead of the rule.  I cannot know about the bigger picture in Togo until we do our final analysis, but it was interesting to see other villages besides my own and get to peer into a bunch of people’s bedrooms. 

Phase One (mostly) Complete

Just about two months ago it was confirmed that Peace Corps Togo would be the independent evaluator for the Global Fund funded mosquito net distribution that occurred last October in all regions of Togo (excluding one piece of the Maritime region).  Togo received roughly 70million dollars from the Global Fund to complete last year's bed net distribution and 20million dollars more has been promised if the first phase of the distribution goes well.  To determine if the distribution went well, and to give the organizations and the government who distributed the nets an idea of how close they came to reaching their goals, an independent evaluator is needed (A.K.A. us).

With funding from the WHO, UNICEF, and Plan Togo, two other volunteers and I were chosen to lead the study.   Our task was to perform a nation-wide survey of households to determine bed net usage, how many more nets are needed to achieve the goal of universal coverage, and of course the effectiveness of the bed net distribution itself.  To do this we have organized six trainings for Peace Corps volunteers and their Togolese counterparts to educate about the importance of the collection of good data and the protocol for performing the survey.  With five regional trainings (one for each region) and training for the trainers we will have trained over 220 people in everything from why this survey needs to be done, to what is bias, to how to ask a question.  The majority of these trainings occurred this Monday, except Savanes which is a week later, and the Training of Trainers which was a week earlier, all of which seem to have gone pretty well. 

I am glad Monday is over. Leading up to these trainings we have been working tirelessly booking hotels, writing manuals, negotiating budgets, creating computer programs, mapping villages to be surveyed, and so much more.  There were days that I would come into the office around 6:30am and not leave ‘til midnight, only to show up again the next morning at six.  I spent three straight days staring at a map on the med-unit wall, because it was the only map available that had on it (nearly) all the villages I needed.  It has been a tiring couple of months and it is nice to have a good portion of our work over with.

After these regional trainings, volunteers and their counterparts will go out to their assigned villages and perform a survey of household in those communities.  Once the surveys are completed volunteers will send us their data and we will compile our report analyzing the results.  Until we begin to get data back from the volunteers we have a little break where we will get to think about our report in a more relaxed setting, and I will finally get to return to my own bed and will no longer be sharing a cot the size of a twin bed with another volunteer or eating street food every night of the week.

For now we must wait to see if our survey goes well. I’m hoping for some good data and lots of bed net use!

A Machine that Does Your Laundry

Wow, a laundry machine, who would have thunk it?  I believe I have said that after hand washing my clothes for over a year I will never complain about doing the laundry again back home in the States.  Yesterday confirmed that.

A couple of weeks ago one of our Peace Corps Togo organizations Gender and Development (GAD) had an auction to raise money to support gender related projects and one of our medical staff donated five loads of laundry in her laundry machine, and I won.  I redeemed by first load yesterday morning. It was awesome.

I stuck my clothes into the machine, added a little soap, and pushed a button.  A couple hours later I moved my clothes to the dryer and BAM! my clothes were clean.  No blistered fingers, cracked skin, or aching back necessary.  I lounged around read my book and napped.

And can I talk further about that amazing out of the dryer feel?  That warmth that is so dry it is cozy? I was sweating as I folded my clothes, but I wanted to wrap myself in my freshly laundered clothes and I don’t know, just cuddle with them.  It was great.  If I had the plumbing hook up I might have gone right then and there and bought myself a laundry machine and dryer.

Heaven.