August 27

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Going to GEMBA

My first few weeks have sometimes felt like an episode of a TV reality show.   One where  you are given  a mission and some training and resources, then suddenly you are just out there with all the newness and the challenge of figuring it out for yourself – the language, the housing, the food, the money, the organization, everything.  So you do.  Exhilarating?  Scary?  Mind bending?  You bet.  It is all of that and so much more.

For weeks, I’ve been a desk jockey, immersed in my first assignment – to develop a protocol with supporting references, surveys and consents for a new project area.   I was sorting thru global frameworks and technical references, behavioral change and positive deviance models, epidemiological studies of vector-borne diseases (aka mosquito-transmitted).  I acquired a whole new vocabulary and could rattle off all the stats and acronyms and references.   I even got to where I could distinguish between illustrations of mosquitoes – which ones are associated with Malaria, which with Dengue.   So I should have been in my element – it’s meaningful work, learning is my top “strength” by long shot, planning and process are second nature for me, and to be back in a scientifically oriented role was a comfortable kind of stretch.   But in truth, something was missing.  I understood going in that I was here to use my business skills, but part of me was really hoping for a more a hands-on experience.   Then out of the blue I got to connect in a personal way to the “patient” part of the equation.

It is monsoon season in Cambodia, which means months of tropical weather:  wicked-hot and wet, wet, wet.  Weather that means flooding, weather that breeds mosquitoes and the fevers they carry. Malaria season. Dengue season.

This week, we were invited to ride along with the Director and staff of the National Dengue Control Programme to observe a Dengue Outbreak Response – and I got to go along. There couldn’t have been better timing for a real life “go to GEMBA”.  What I’d learn would make the difference between a conceptual project and one grounded in reality ( I could just hear my BI colleagues cheering me on). We’re up at 5am, 9 of us crammed into a couple pickups, heading to Rantanakiri, a rural province in the north easternmost part of Cambodia, bordering on Laos and Vietnam.

It’s only 250 miles, but a bone jarring 10.5hour journey from Phnom Penh, much of it through rain.  We rattle and jounce over a muddy clay highway filled with potholes the size of a jeep.  I’m off the seat a few times, slammed into the door, head clanging on the roof… amazed that I didn’t crack any teeth. We spent the night in Banlung, the tiny provincial capital, home of the regional referral hospital, the Provincial Health Department and local officials who will need to approve the project.  Fortunately, my guest house roommates, 3 geckos, 1 grasshopper and an assortment of crickets, weren’t hungry.

In the morning, more rain as we traverse another 35 miles to get to the District Health Center.  Scale back, way way back from anything like you’d see back home – this was a walled compound containing 3 simple open air buildings that serve as clinic, outpatient and administrative function; some chickens and a local family camping out while the father is being treated for dengue.  I’m thinking about our journey, then what must have been their journey.  In this remote place, where there are so few vehicles, how many miles of those rough rough roads did they have to travel in the rain to bring this very sick man here?

The staff takes us on a tour – showing off the big whiteboards that track their metrics (there is NO escape from metrics) – the key patient indicators and aggregate data that are reported against the national goals for maternal health and endemic diseases.  Big smiles all around when I tell them (with a lot of  help and hand waving) that at GSK we use visual controls too.  Much of the data comes in via SMS – that is when the phones work and when the HC staff (volunteers) have enough money to pay for cell minutes.  We talk about the protocol, dengue and the village where we’re headed.  I take notes, pages of them – updates to the protocol, observations for implementation, and questions, lots of questions.

Back to the trucks, but we only manage 5 more miles of mud and potholes before the road becomes completely impassible.  After some discussion, Plan B is decided:   we’ll take the local ferry across the Tonle Sap River.  Excellent plan – right up and until the moment we saw the ferry.   The boat’s crew was completely confident, but our driver is a prudent man.  No way is he putting our pickup on that tiny boat on that big fast river.  More questions for later, is this how they transport diagnostic tests, medicines, insecticides, forms?

Time to regroup again – you just don’t come this far just to turn around.  After a lively exchange with the locals – who had lots of advice – we settle on Plan C.  For me, this was the awesome part.  We hire a couple of local fisherman to take us the 20miles up the Tonle Sap in their long low wooden boats; the men wait there for us while we work.  UN-BE-LIEVABLE.   One of the absolute coolest things I’ve ever done.  Making our way up the river, it felt like I was on a Nat Geo Adventure special.  The grin on my face could have lit up the sky.  We past miles of jungle, palm, banana and bamboo trees, and a vine that looked a lot like kudzu – no crocs, no snakes.   Good thing since we were riding only 8-10 inches above the water (we did have life jackets).

And then there were roofs thru the trees, we land and climb a steep bank of steps to the village.  Pakalan is a muddy lane with a small Buddhist Wat (temple), a handful of houses and a couple tiny store fronts, some with electricity. The people here are a mix of ethnicities including Laos – so everything we say, everything written must be translated at least twice – to Khmer and then to Loas.  Villagers work in the forests, rubber plantations, rice fields; most are illiterate.   Back in June, about 100 people here had fever (roughly 1/3 of the village)–– most likely dengue. The outbreak is over now, but the team needs to gather blood samples to confirm the diagnosis and serotypes, do some situation assessments and deliver prevention education.  Those villagers who aren’t working will meet with us.

You know, you think you’re prepared.  I mean I knew going in that Cambodia was a developing country.  But really, nothing prepares you, not all the reading, not the pictures, not even the weeks I’ve spent in Phnom Penh – with poverty that I still find so hard to write about.   And I was completely unprepared for the sheer magnitude of what I’d seen on the journey here. Mile after mile, for hours, of people living in conditions that defy all I know of reality in 2013.

There are houses, but really those are just wood walls and a roof on stilts – with pigs and chickens and cows tethered with strings below. When the rains come and the river floods, most houses are standing in water or next to rice fields. I find myself ticking off additional diseases in my head – typhoid, TB, cholera, measles, diarrhea, pneumonia… treatable, preventable, if only.

Most houses have no doors or windows, most have no toilets, no electricity – so no lights, or radios or refrigeration.  There is no piped in water, no wells.   Here, like all over Cambodia the people gather rainwater in enormous clay pots – and those pots serve as the primary breeding grounds for the mosquitoes that carry breakbone fever – the local name for dengue.

We’d come to verify and test, to teach about mosquito borne disease, to show people how to recognize breeding spots and eliminate them by covering their water, to use nets, to get children checked when they fall ill.  It sounds so simple. It sounds impossible.  And for more than a few moments I was overwhelmed by two opposing thoughts. By the enormity of all that I’d seen, of what we were trying to accomplish; doubting that mere mortals could make any difference here or  in the many places like this around the world. And at the same time, I was bowled over by the power and hope of the vision of people like Bill Gates, like Andrew Witty – those who have the audacity to believe and the will to make it possible.  Because it is right.  Because we can.

And so we did. We started where any implementation begins, one step at a time.  We walked through the mud and roadside trash to the first house, asked a young mother about her little boys and fever; we looked at her water jars, talked about covers and larvicides and nets… I took notes. On this roller coaster adventure I am grateful for this connection, this stronger vision of how my small effort is part of making the impossible work.  And that is even cooler than a boat ride.

/ssd