A day in Mali -The Northwestern Access to Health Project

By Osefame Ewaleifoh

Cover Photo: Access to Health group in Dogon Country

The Northwestern Access to Health Project (NAHP) was started three years ago by the pioneering efforts of Clinical Associate Professor of Law, Juliet Sorensen. The goal of the project was simple, to leverage and integrate legal, medical, and business skills of Northwestern students to research health issues in communities in dire need through her course, Health and Human Rights. Over the years the course has grown to become one of the most popular courses in the graduate school, attracting a cohort of students from the law school, medical school, business school and programs in public health. Beyond providing a comprehensive introductory legal framework for students interested in public health, the program has increasingly focused on providing practical opportunities to students to apply group-focused interdisciplinary research techniques in real time to help address access to health challenges around the world. Each year, the class focuses on a particular community in which they work with local partners to identify the causes and determine possible solutions to major health issues. This innovative learning strategy has not only been beneficial to the students; it has been invaluable to the communities from South America to Africa, who benefit from the personalized practical solutions that students develop during the course.

In 2012, several insurgent groups from northwestern Mali attacked the government, seeking independence. Douentza, a picturesque village North of the Mopti region of Mali, was among the villages occupied by the insurgents for nearly two years. On the 15^th of March this year, a group of five students and I, drawn from the Northwestern law school, business school and the program in public health, traveled to Douentza with Professor Sorensen and Dr. Karin Ulstrup, her medical school counterpart, to look for new ways to improve access to health in the region.

Our journey through Mali began with a 12 hour drive -from Bamako to Douentza with a brief stopover in Seguo. The road out of Bamako was in remarkably good shape—and continued to be so at least up until we approached Doeuntza where things got a little dusty and bumpy. Our first stop in Douentza was the Near East foundation (NEF) Local broadcasting studio. Although unadorned and low-tech by any western standards, the broadcast studio provides the essential services of education, entertainment, health information and connection between the community and the external world. Unlike most other local institutions the broadcasting station was able to survive the 2012 occupation by agreeing to read the Koran 40% of the time but insisting that the remaining 60% of the time was free, independent programming. On how the radio station survived the conflict, the head broadcaster Boucary proudly beamed “we are an independent voice!”

 

Radio Douentza

Our next step from the studio was the meeting with the community advisory board (CAB), a group of health experts and community leaders assembled by the Near East Foundation to tackle access to health in the community. This group consisted of the head of the central hospital, a community youth leader, a women’s union leader, school leaders, a leading midwife, the regional cultural leader, and our host and organizer the regional director of the Near East Foundation. During our conversation with the CAB it became quickly clear how truly multi-factorial the challenge of access to health in the region was. According to the Chief attending of the central clinic, the central problem to access to health in the region was poverty and illiteracy. The role of widespread poverty was particularly significant as it fueled other factors such as malnutrition which was a major driver of infant mortality in the region. The role of malnutrition and childhood mortality became more apparent during the tour of the facility as we ran into a starving child cradled by his father with severe malaria. Thus while malaria on its own might not necessarily be fatal, coupled with severe malnutrition, malaria in children could be fatal.

At the main clinic in Douentza, the nurse draws blood to test for malaria

Next, we toured the main health center for Douentza and the outlying villages. We saw the social service room, the surgery center for appendectomy and C-sections, the maternity ward, and dentist. To address the lack of a resident specialist, once every year, a visiting ophthalmologist would be sent from Bamako to perform cataract surgery, which happens to be a major health issue in the region. During our visit we met two kind doctors who had already done 45 surgeries that morning – and it was only 11.30 am. Looking back, it was truly impressive how much the hospital is able to achieve with so little resources. This attitude was perhaps best captured in the words of the Chief attending: “we have the knowledge of the health issues, we just don’t have the capacity”.

Following our time in the hospital we also visited the local microfinance center called the “Nayral NEF” created by the NEF. Unlike the radio station, the credit union wasn’t functional during conflict. One of the business models for the Nayral NEF was simple; get women to form small units of accountability, about 10 women per unit. With 5000 Malian Francs, this unit joins the credit union and each woman in the group receives a small loan contingent on the other women paying back their loan. This system has been remarkably effective in that there are now about 200 women’s groups participating in the program. Unfortunately during the war a lot of women lost their initial capital and had to be refinanced by NEF to resume the process. According to the Nayral representative, currently about 75% of the women make their interest payments each month, a slight dip from the pre-conflict repayment rates.

Outside the main clinic in Douentza

We spent the remainder of our time trying to understand the role of education in the region. To do this we visited both the local school superintendent, the local high schools, middle schools and nursing schools. A reoccurring theme was how much the recent conflict had destabilized an already fragile educational ecosystem. Even more dire was the low rate of female education in the community – driven by poverty and culture. Most families want their daughters married by age 14, which often involves pulling them out of school. While the government has begun putting effort into this problem, much remains to be done.

The goal of the trip to Mali was simple – with boots on the ground, try to understand the practical limitations to access to health in a community that has been severely disrupted by poverty and war. Our ultimate intent is to integrate theory and practice together with what our informants shared with us to look for creative new ways to solve health access problems in the region. Working with our partners as the project evolves, we hope the project will make a lasting and useful impact in Doutenza.

Want to hear more? read MBA student Annie Conderacci’s reflections on the NU Access to Health Project’s blog: http://northwesternaccesstohealth.blogspot.com/.