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Our replacement fellows arrive in Rwanda tomorrow night.

That simple fact feels overwhelming in some senses. Where did this year go? How can it seem like I have been here forever and that I arrived only yesterday? To suddenly face the prospect of letting go of all the projects I had a hand in, to say goodbye to my wonderful office and to leave this community, fills me with bittersweet feeling. In the simplest terms, this has been a good year. While I am beyond excited to see my family and to return to my fiance, a big part of my heart will stay buried here.

I used to tell students that the experience of living abroad would not be a roller-coaster ride of enlightenment–meaning that the true lessons and understanding of how you changed as a result of the experience would not become evident until long after you returned home. But how does one even begin to process an experience like this? Only reflection will yield the lessons to be learned or the changes wrought, but where to start?

Just the other day, one of the higher-ups asked me how things were going as we prepared for the new fellows’ arrival. I quickly rattled off everything on my to-do list, breathlessly piecing together all the tasks requiring attention so that my replacement can have a (hopefully) painless transition. At the end of the tirade list, he grinned at me and said, “Remember six months ago when you felt like you were under-utilized? This is what falling off the cliff of work feels like.” 

I sat stunned for a moment, then laughed. That conversation occurred at one of the lowest points during this year. To have reached this point–dashing around from office to office, putting all my ducks in a row–after experiencing that lassitude and uncertainty is indicative of how much can change within the scope of 12 months. It took a long time to find my feet and only recently did I begin to feel like I actually knew what I was doing. Transitioning out now feels like ending a race prematurely, just when you start getting your pace right. 

Two weeks remain before I say goodbye to the dust and sunsets of Rwinkwavu. Three weeks until I say goodbye to Rwanda for an indeterminate period of time. I do not claim to “be Rwandese” or even to truly understand this place after a year, but I do feel immense gratitude to my co-fellow, my friends, and my colleagues for challenging and supporting me over the course of this year. Searching out the changes in my soul and processing the lessons from all of the experiences we had together will take a long time. With any luck, we will have all crossed paths again before that process completed itself. 

A deliriously wonderful group of people

A deliriously wonderful group of people

Next year’s fellows have a lot to look forward to. 

One of our last nights together as housemates

One of our last nights together as housemates

 

Expat communities are funny things. The vast majority of us typically stay for a relatively short period of time and the turnover brings new faces and names at a blistering pace. I find that people tend to respond to that rapidity with one of two reactions: they either form quick, but strong bonds or they jadedly disregard the newcomers.  The longer someone stays, the more often the latter result occurs (or so I find). Much like attending a large university, people find their niches and stay there. With such a rapid turnover in names and faces, investing the energy to get to know new people (while simultaneously continuing to navigate local challenges like transport and living ethically as a privileged foreigner…..but more on that later) can be exhausting.

I know I am guilty of the mistake of ignoring newcomers from time to time, but I think it is worthwhile to try otherwise as much possible. The world of global health is a small place and that individual you spent two months working with in Uganda may later turn out to be a colleague (true story). Living and working overseas, particularly in contexts like Rwanda, can bond people like few other things I’ve encountered. I should know, I met my fiance in Mali.

The point of this post is a simple one: I am incredibly grateful for all the people that I have encountered over the course of this year, both Rwandan and expatriate. As we draw to the close of this fellowship, I look back with wonder at all the people whose friendship and presence has blessed my time in Rwanda. When the time comes, I will not say goodbye because while we may not know when next we will meet, I am certain it will happen again.

Friends and colleagues (and roommates!)

Friends and colleagues (and roommates!)

It’s been a while.

So much has happened in the last couple months it would be pointless to try and summarize it all here. Traipsing around Zanzibar, hiking a massive volcano, welcoming my family to Rwanda…. Suffice to say that my recent realization that we achieved an incredible amount of living (while working constantly, mind you) over the course of the past 10 months received abundant confirmation. At times I feel like I only arrived yesterday and at others, I feel like we have been here forever. I can scarcely believe that the final two months arrived with barely any fanfare.

But here we are. I remember telling my group of students in Ghana that the readjustment would be way harder than the original culture shock. In some ways I know what to expect, having experienced reverse culture shock before, but how does one anticipate the feelings that will occur after an entire year of living in one place? I would not go so far as to say that I have “put down roots” but I certainly see some of the trappings of having done so. I rent a room in a beautiful house, I encounter friends in random places, and I get twinges of homesickness when I have to work in another district for a week. The disorientation at packing it all up and saying goodbye for an indeterminate period of time will be intense to say the least.

When we sat at our GHC training, contemplating the year ahead of us, it felt like an incredibly long time. But, much like how the hill feels much less long after riding down it, a year passes by incredibly quickly. Rather than lament how little time is left, however, I hope to hurl myself into living out the remainder of my year in Rwanda with as much vim as I can.

I want to write more. There are blog ideas that have bounced around my head for months that I need to get to paper. I want to travel around Rwanda some more and hopefully make it down to Burundi. I want to fill my heart with the love and warmth of my friends and colleagues so the long Minnesota winter won’t feel quite so cold when I get back.

A little over two months left. Let’s stay in the present, every step of the way.

“Global Health is an attitude. It is about the universal nature of our human predicament. It is a statement about our commitment to health as a fundamental quality of liberty and equity.” – Richard Horton, Editor of The Lancet

Whenever I mention my work overseas, I get met with skepticism nearly as often as curiosity. To say that I work in “global health” typically solicits blank stares from most audiences, requiring me to give a brief explanation of what exactly that means. More pernicious, perhaps, is the frequency with which my career choice is looked at as some sort of phase, a temporary bump in the path to a real job. The attitude is not always intentional or aggressive, but even so it remains deeply engrained in many people. Many of us in global health have heard lines like these before:

“Sounds fun, but when are you coming home?”

“Isn’t it dangerous?”

“Don’t you wish you made more money?”

We hear them before we leave on a plane. We hear them when we work for non-profits at home. We hear them when we return and start planning for the next rotation abroad. Underlying all of it is the assumption, whether consciously acknowledged or not, that “global health” does not count as a legitimate field of work and study.

To a certain degree, they might be right. To quote Dr. Paul Farmer and his colleagues in their book Reimagining Global Health, “global health remains a collection of problems rather than a discipline.” My colleagues are doctors, social workers, biostatisticians, economists, and engineers. How can global health stand as a discipline on its own when its practitioners come from such varied backgrounds?

As Global Health Corps Fellows we are helping to forge global health into a new discipline, one united not by the training required to participate in it, but by its goals and the philosophy behind its methods. We who work in this field believe fervently that health is a human right and that inequalities in health outcomes and access to healthcare are unjust and unsustainable. But we recognize that inequalities result from deeply embedded social, political, and economic factors. If global health limited itself to one training path, one set of knowledge, it would lose out on the immense potential impact of other fields.

Ours is thus the careful work of establishing connections within the collection of problems, of building bridges between the doctor and the economist, the biostatistician and the engineer. The complexity of health inequalities, both in the United States and overseas in developing countries, requires this collaboration. We cannot continue to myopically peer at each individual problem through the lens of a single discipline.

Global Health is the career I choose. It is not a phase or a speed bump on the road to something else. It will not pay well, and it may even send me to difficult or dangerous environments, but ultimately it is a career in service of a greater goal: health for all, no exceptions.

The health center perches at the apex of a ridge jutting into the lush green valley below. A couple dozen women sit on hard wooden benches as an annoyed-looking nurse walks up and down the line, thermometer and blood pressure cuff in hand. I, the odd man out, sit at the far end of the line and quietly wait for the door of the consultation room to open.

For once, I am not here for the illness of either myself or a student. One of our clinical programs asked me to tag along on a site visit in order to brainstorm ideas for measuring patient follow-up. Monitoring and evaluation starts like this. Before we figure out specifically what to measure and how to measure it, we have to get the 30,000 foot view of the whole process. From the moment a patient walks in the door to how their visit is recorded and to whom it gets reported. How the process reads on paper, however, may have no bearing on how the process plays out in practice.

This is where site visits like today come into play. I sit in the corner, neatly dressed to look official, and makes notes as a patient intake creeps along in a language I barely understand. Even small data errors at this stage can be deeply problematic if they compound across patients. What definitions does the nurse use for the patient’s status? Do they fill in the patient register as the visit progresses or do they wait until after to complete it from memory? Is their handwriting even legible?

When I worked in a jewelry store in college, my boss used to tell me, “Fix it in the wax”–address problems early on when they’re still small and manageable rather than waiting to deal with the consequences. Finding and fixing issues in data quality at this stage–the point of collection–saves a lot of time and headache later on. Nothing is worse than realizing that a large chunk of your data is useless because someone did not record answers properly.

Why does this matter? The word “data” conjures images of spreadsheets marching off to the horizon and understandably excites most people about as much as watching grass grow. Why do we care about numbers pooled together from hundreds and thousands of patient visits across health centers and hospitals? The individual patient disappears in the shuffle and rapidly loses all meaning.

We care because the data tell a story. The data tell us how our programs improve or decline, something which a single patient’s story could not reveal. The story influences decisions that have the potential to impact thousands of individuals, so it matters very much that the data tell a true story (or at least a very close approximation of it). What we measure and how we measure it are how we pull together the elements of that story, but we have to know where to look. 

That is why you find me in a distant health center, flipping through ancient paper registries and talking with the health center staff. I want to know how we can better tell the story of this program, how we can pull together the elements to convince our listeners of its merit. I look for the pieces that will spin a true tale of our program so that we know how to make it better. But first, we have to find them. 

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