The shiny metal cabinet in Sarah Helms’ sixth grade classroom is full of necessary supplies — not paper and pencils, but personal care products. (Credit: Sarah Helms)
The locked metal cabinet doesn’t look amiss in Sarah Helms’ sixth grade classroom, with its bright yellow walls and green plastic stationery caddies. But rather than pencils, pens or binder paper, its shelves hold bottles of shampoo and body wash, soap, deodorant, toothpaste, toothbrushes, cotton swabs, sanitary pads and tampons.
For the past three school years, Helms, an English teacher at Horace Maynard Middle School in Maynardville, Tennessee, has stocked a “hygiene closet” with personal care items donated for students from low-income families by fellow teachers, current and former Horace Maynard parents, and members of the community. Helms uses cash donations to buy supplies at the dollar store. Her parents gave her the cabinet.
“I noticed certain kids being picked on for not being well groomed, and I felt that many children were just too shy to go to an adult and ask for help with the items they needed,” Helms told HuffPost. She could see how it eroded their self-esteem when their classmates commented on their appearance or body odor.
Once a month, Helms pulls toothpaste, tampons and other toiletries — including “random donations,” such as hairbrushes, combs, body spray and lip balm — from the hygiene cabinet and packs them into plastic grocery bags for 14 girls and 17 boys.
“A huge blessing” is how one Horace Maynard parent I contacted described the hygiene closet at her son’s school. Helms reached out to this single mom (she asked to remain anonymous) at the start of the school year to see whether her son would be interested in receiving a hygiene pack. She said yes. Her son’s monthly bag includes shampoo, deodorant, toothpaste, razors and cologne.
Closet program increase highlights poverty gap
Horace Maynard’s hygiene closet is just one of the thousands of similar programs in public elementary, middle and high schools across the U.S., according to data from DonorsChoose.org, an online giving platform where public school teachers can ask for funds for their classroom needs. The site has seen requests for hygiene and personal care products mushroom, from just one in 2002 to 1,789 last year. Nearly two-thirds of requests come from schools in urban areas, and they are particularly common among schools where three-quarters of students or more are from low-income households.
Over a third of pupils at Horace Maynard are eligible to receive a free or reduced-priced lunch, and some benefit from the school district’s donation-supplied food program, which provides students a weekly bag of groceries to take home to their families.
Helms sends her students home with hygiene bags the Friday before the end of the month. “This is usually when items are needed most because those families who are on food stamps are low on money for other things like hygiene items,” she explained.
The government’s Supplemental Nutrition Assistance Program (SNAP) and Women, Infants and Children program (WIC) provide state-level monthly help to low-income households in the form of a pre-loaded card to purchase vegetables, fruit, dairy and pantry items. Recipients cannot, however, use the cards to purchase non-food items, including toiletries and sanitary products.
Lisa Greenig, a teacher at Fairfield Middle School in southeast Iowa, said the idea for her school’s hygiene closet came about after a discussion with fellow teachers about SNAP restrictions. “Hygiene items can be expensive. Considering 50% of our students live under federal poverty guidelines, I decided to go public with the idea,” she said. “The community embraced the idea and has been very generous to help stock the closet,” which the school started in January.
The hygiene closet at Iowa’s Fairfield Middle School, where half of the students live below the poverty line. (Credit: Lisa Greenig)
So far, about 24 families have signed up ― parents and guardians of students just have to complete a registration form to receive items from the hygiene closet. “We did not want to risk offending anyone by offering a bag of products without them submitting a request,” Greenig said. “At no time do we want families to feel embarrassed about using the closet.”
Greenig hopes more families, often reluctant to ask for help, will access the program once they realize how private distribution is. “Re-orders typically come through email directly to me. I pack a bag and quietly place the items in the student’s locker. Refills fit in student backpacks so they can be carried home.” With support from local businesses, such at the Hy-Vee grocery store, and backing from school Superintendent Laurie Noll and school board member Jennifer Anderson, Greenig says the district has plans to expand the program to the high school and two elementary schools.
School attendance and self esteem at risk
Other programs are a direct response to changing family circumstances, such as homelessness. “We’ve had an increase in families losing their housing, doubled or even tripled up in a household,” said Stephanie Martinez, program director of student services for the Jefferson Elementary School District in California’s Bay Area. “It’s been pretty drastic and very challenging [for students] if they’ve lost their housing or have a long commute into school.” Martinez is planning a hygiene pack program for the new school year to help students from the 100-plus families in the district living in transitional housing or shelters.
Lack of access to hygiene products can have a negative effect on the lives of children and teens, said Aleta Angelosante, a child psychologist at the Child Study Center at New York University’s Langone Health: “If you are outwardly having difficulties with hygiene, it can certainly lead to at best being more neglected or ignored, at worst being pointed out and bullied in some way.”
North Carolina nonprofit BackPack Beginnings set up a personal care pantry in its Greensboro headquarters about 18 months ago to help schools in Guilford County provide products to students.“We have heard stories concerning the way it impacts self-esteem and the fact that some are skipping school because they are embarrassed by their own hygiene,” said BPB Executive Director Parker White.
Nearly 1 in 5 girls in the U.S., for example, have either left school early or missed school entirely because they did not have access to sanitary products. “Many have heard of teachers buying food for their students, but fewer people hear about them buying hygiene products. Our teachers are underpaid as is, and we want to take this burden off their plate.”
According to a survey of teachers who use DonorsChoose.org to make funding requests, 84% in the highest poverty schools have purchased essentials such as hygiene products for their students. Of those, 63% report spending more than $100 per year on these items.
Parker said about two dozen schools currently access the BPB pantry program, helping hundreds of students across the district.
Fighting for hygiene equity in schools
While programs led and funded by nonprofits and teachers are to be celebrated, hygiene equity campaigners say this issue calls for state intervention. Most hygiene items are taxed under state laws; some, such as dandruff shampoo and chapstick, are not. Some progress has been made around access to sanitary products and several states, including Nevada and Florida, have removed the so-called “tampon tax.” California’s Gov. Gavin Newsom is unveiling a budget plan this week that would drop sales taxes on menstrual products.
But as long as government programs such as SNAP continue to put toothpaste and tampons on the same list of prohibited purchases as tobacco and beer, teachers, parents and local communities will likely still provide such items for low-income students.
Helms said the hygiene closet program had show her just how much of a lifeline this and other assistance schemes are for many students in her community. As the Horace Maynard mother I spoke to told me, “The closet at my son’s school has helped us tremendously. The products that are sent home are used by all my kids. It’s really a very thoughtful thing to do to help make sure the kids feel loved. I would tell everyone that has donated thank you. A million times over, thank you.”
When she was diagnosed with breast cancer, Fauzia Aboud (middle) moved closer to home for the support of her family (Credit: David Macharia)
Cancer is the third highest cause of morbidity in Kenya.
Breast cancer is the second most common type of cancer in the country, with women under 50 accounting for 50% of those presenting.
Of the estimated 5,000 people diagnosed with breast cancer each year, around 2,000 will die from this disease.
Many of these women are mothers or carers, employees or small business owners so the impact is felt on their families, the wider community and on Kenya’s economy.
Navigating the cancer journey
Fauzia Aboud had recently given birth to her fourth child and was breastfeeding when she noticed that something wasn’t quite right. At first the 42-year-old, who was living in Tanzania at the time, dismissed what she’d found as a cracked nipple. Nothing to worry about, her sister reassured her. But when the discomfort persisted, Fauzia’s sister knew it was time to seek advice. One doctor’s appointment led to another and finally to a specialist who recommended a scan and biopsy tests that confirmed her breast cancer.
Living away from the support network of her family in Kenya, and with three children and a young baby to care for, Fauzia admits that the diagnosis in May 2016 and subsequent mastectomy surgery was “overwhelming.” So when her doctor in Dar es Salaam recommended returning to Kenya for follow-up treatment, Fauzia knew that she needed to move home and let her family help her navigate the next stages of this confusing and difficult journey.
How would she pay for the cycles of chemotherapy and radiotherapy that she needed? Who could she turn to for support on managing the side effects? And how would she be able to make the eight hour bus trip from Mombasa to Nairobi every few weeks to receive her treatment?
Listening to Fauzia and her sisters talk about these concerns brings into sharp focus the myriad challenges that people with cancer in Kenya face every day—from recognising symptoms and getting an early diagnosis, to accessing appropriate treatment.
David Makumi, chairman of the Kenyan Network of Cancer Organisations (KENCO). (Credit: David Macharia)
David Makumi is chairman of the Kenyan Network of Cancer Organisations (KENCO), the national umbrella body for cancer support groups and patient groups. He reels off some of the many complexities along the patient journey. For instance, a woman may discover a lump but lack awareness of cancer symptoms and not feel pain so will do nothing. If she does follow up, her doctor might not suspect cancer because of a gap in professional knowledge. If referred for a biopsy, she might not have the money to pay for it because her children’s school fees are due. And, when she eventually has the biopsy, the results may get lost so she has to start the process again.
“Then, if the patient finds out it’s cancer, the feeling is that cancer equals death because they don’t have enough information,” explains Makumi. “If there’s a district or county surgeon, they may do a mastectomy. The patient is booked to go in four weeks—she has to go back home, figure out costs, break the news to the family.”
After surgery, the patient may be referred for chemo and show up for two cycles then stop because she can’t afford to continue and doesn’t know how to access funding. Makumi explains: “These are primarily social issues, not medical issues; that’s where we come in. Information is an important piece that impacts on the way patients complete their treatment.”
The escalating burden of cancer
It’s 9am on Wednesday morning and the cancer centre at Kenyatta National Hospital (KNH) in Nairobi is already crowded. There are no empty spaces on the benches outside the chemo treatment room and its rows of hoods and chairs. Women and children stand where the seats don’t exist. Some people will have traveled hundreds of kilometers for treatment but may not even get seen today.
Upstairs in the cancer clinic, lines of men and women snake along the corridors, around corners and up the staircase as patients check in for open-door appointments at the public hospital, the largest referral facility in east and central Africa.
Non-communicable diseases (NCDs) such as cancer are a growing burden in Kenya, accounting for 31% of deaths in in 2015 and more than half of in-patient admissions.
The prevalence in Kenya of communicable diseases such as HIV, malaria and TB has led to the government channeling health spending towards these areas, with successful public health campaigns and outcomes. However NCDs have not been similarly prioritised until fairly recently, resulting in a cancer treatment and care infrastructure that struggles to meet the needs of Kenyans who develop cancer.
Robert Makori, assistant chief nurse at KNH’s cancer treatment center, sees 60 new cancer patients a week. (Credit: David Macharia)
According to Robert Makori, assistant chief nurse at KNH’s cancer treatment center, the scenes at the hospital are the new normal. Makori sees 15 new patients a day so around 60 per week. An average 60-70 people are seen on the centre’s chemo days (Monday, Wednesday and Friday) between clinic hours of 8am to 4:30pm. From Monday to Friday, around 120-130 patients come in every day for radiotherapy.
Staff and clinic hours struggle to cope with patient volume, admits Makori: “KNH is the only public hospital with both radiotherapy and chemotherapy, and many of our patients have to travel a long way for treatment,” he explains. “A person could be given an appointment but if they’re not feeling well, they can’t have their treatment and may not get seen that day.”
Cancer treatment and care infrastructure struggle to meet the needs of Kenyans who develop cancer. KNH is the only public hospital with both radiotherapy and chemotherapy, so patients often have to wait hours to be seen by a specialist. (Credit: David Macharia)
Plotting the road map for cancer control
To address this escalating burden, the Kenyan government last year published the 2017-2022 National Cancer Control Strategy (NCCS) which builds on the work of the government’s first cancer strategy launched in 2011. It aligns with the Kenya National Strategy for the Prevention and Control of Non-Communicable Diseases 2015-2020 and with the government’s Kenya Vision 2030 commitment to improve the quality of life of all Kenyans.
More broadly, the NCCS is a response to the Sustainable Development Goal (SDG) target for 2030 of reducing premature mortality from non-communicable diseases, such as cancer, by one third.
Designed as a road map to how Kenya addresses cancer control, the NCCS has five focus areas: prevention, early detection and screening; diagnosis, registration and surveillance; treatment, palliative care and survivorship; coordination, partnership and financing for cancer control; and monitoring, evaluation and research. The strategy recognises that public-private partnership and collaboration with the non-health sector is pivotal to this work.
Financial access to cancer treatment is one of the biggest barriers to successful outcomes. Kenya does not yet have universal health coverage (UHC) although affordable healthcare for all is one of the government’s ‘Big Four’ economic development priorities.
Most Kenyans live on just a few US dollars a day, based on figures from the government’s latest economic survey. With an estimated 75% of the population not covered by a public, private or community health insurance scheme, paying for basic healthcare is already a challenge and paying for treatment for a life-threatening disease is even more of a stretch. According to the World Bank, nearly one million Kenyans fall below the poverty line because of health care related expenditures.
The state-run National Hospital Insurance Fund (NHIF) offers insurance to anyone over 18, with monthly payments based on income and starting from 150 KS (USD 1.50). Coverage was recently extended to provide 25,000 KS (USD 250) per patient towards cancer care.
But with treatment more likely to run into millions of Kenyan shillings and private finance interest rates of 20%-30%, many people with cancer have to rely on the Kenyan concept of ‘harambee’–community-self-help—or crowd funding to cover their costs. Alternatively, they go without treatment.
Makori at KNH comments: “Most people we see don’t have coverage so they start treatment but then 40% don’t finish because of lack of finance. It’s a challenge for our patients.”
Kenya does not yet have universal health coverage: An estimated 75% of the population are not covered by a health insurance scheme. Public-private partnerships are pivotal to improve this situation. (Credit: David Macharia)
A partnership approach to improving access
Rose Wambui was just 32 years old when she was diagnosed with breast cancer. The mother of two underwent a full mastectomy followed by eight cycles of chemo then 25 of radiotherapy. “It was quite a shock to get cancer at my age,” explains Rose, who had two children aged under eight when she was receiving her treatment.
Rose was overjoyed when she was referred to a special programme that KNH had set up to offer women free HER2-positive treatment. (Credit: David Macharia)
When Rose’s oncologist suggested she pursue hormone therapy for her HER2-positive cancer, there was more worry: “It was so expensive and I knew that I couldn’t afford it.” It was then that her oncologist referred her to a special programme that KNH had set up to offer women free HER2-positive treatment. “I was overjoyed. I had to wait just one week then I started the treatment,” says Rose. “To have access to that treatment for free means a lot to us cancer patients.”
In Mombasa, Fauzia had begun her HER2-positive treatment privately but had to stop when her NHIF funding ran out. Family and friends pitched in to help her continue treatment and she even had to take out loans, but all fell short of her treatment costs. Finally, Fauzia’s sister Warda heard about the KNH programme and encouraged Fauzia to participate.
“I had been doing research and I kept thinking, ‘How can I lose my sister because of the cost of a drug?’ We thought it was the end of the road but then we heard about the programme and our imaginations started running wild,” says Warda. Through the KNH programme, Fauzia was able to complete the remainder of her treatment.
Fauzia and Rose are among the 82 women to date who have been able to participate in this programme at KNH thanks to an innovative public-private partnership formed in 2016 between Kenya’s Ministry of Health and Roche Kenya. The partnership, launched by First Lady Margaret Kenyatta, is designed “to improve access to timely and precise diagnostic services and tailored cancer treatment to make cancer therapy much more effective”.
Most Kenyans live on just a few US dollars a day, and paying for treatment for a life-threatening disease is a huge stretch. Special programmes like the one from KNH offer a solution. (Credit: David Macharia)
As part of this partnership, Roche and the Kenyan government have a memorandum of understanding to jointly cover the costs of HER2-positive treatment at public institutions (designed to be a stop gap measure until further NHIF or other government funding is possible).
Andre Mendoza, country manager of Roche Kenya and East Africa says that the partners had to take a step back and develop a holistic approach to improving breast cancer treatment and care in Kenya. “Public-private partnership was part of the government of Kenya’s strategy but the infrastructure was not ready,” he says. “The puzzle in front of us was how can we solve affordability issues—and everything else—through partnership so in the end patients can have access.”
Improving treatment through early diagnosis
An estimated 80% of cancer cases in Kenya are diagnosed at late stages due to low awareness of symptoms, inadequate screening and poorly structured referral facilities.
Dr Andrew Gachii, head of laboratory medicine at KNH, says: “As institutions, we’ve been grappling with infectious diseases and now all of a sudden we have this huge cancer burden. The unfortunate thing is that many patients come in late—stage 3 or 4—so some are just coming in for palliative care.”
To help improve early diagnosis of cancer, and as part of the overall partnership programme, Roche funded the installation of an immunohistochemistry analyzer at KNH. The machine is capable of advanced testing for seven types of cancer. Roche is also funding reagents for breast cancer testing at the 2,200-person facility.
The diagnostic equipment enables KNH to test whether a patient’s tumour is hormone responsive or non hormone responsive, indicating suitability for standard of care treatment for HER2-positive breast cancer. This is standard of care testing, now available for the first time in a public facility in Kenya. It is enabling patients to have a faster and much more accurate diagnosis.
With national screening guidelines still some way off, Dr Gachii says the partnership is helping KNH to improve diagnostics by providing more precise results but without the 10,000 KS (USD 100) fee charged by private facilities offering screening. He adds the cost of testing has been reduced to around 6,000 KS (USD 60): “Before we had the machine, less than 20%—perhaps two or three out of 10 patients—could afford tests. So 80% couldn’t get proper diagnosis to continue treatment.” Building capacity for cancer treatment
The Beth Mugo Cancer Foundation (BMCF) was set up in 2016 to promote access to information, detection and treatment of breast, cervical and prostate cancer. The organisation was founded by politician Beth Mugo, who in 1997 became the first woman to be elected to the Kenyan Parliament. In 2011, Mugo was diagnosed with breast cancer. Her initial response was to keep her disease a secret because of the stigma associated with it; eventually she began to discuss her cancer openly, attracting media attention and encouraging women across Kenya to get check-ups.
As part of Roche’s commitment to improving access to healthcare in Kenya, the company signed a memorandum of understanding with the BMCF in October 2016. Aimed at supporting people with breast, cervical and prostate cancer in Kenya, the agreement involves Roche providing training for BMCF employees on the subject of cancer and helping the foundation establish international links with similar organisations.
Building healthcare professional (HCPs) capacity is another priority. Kenya has a population of 45 million people, yet it only has nine medical oncologists across its four cancer treatment facilities. Makori at KNH comments: “We still have inadequate personnel… it’s not enough to manage the entire population.”
If the right structures, equipment and doctors could be deployed to every county, we could address the [cancer care] problems squarely.
Under the partnership with the Kenyan government, Roche is funding training scholarships for five medical oncologists and six oncology nurses, almost doubling the capacity of HCPs for cancer in the country. The training also includes support for two two-week surgical preceptorship programmes in biopsy techniques. The Ministry of Health has agreed to support and retain HCPs from scholarships and expand oncology treatment by increasing number of treatment centers and units.
Dr Angela Waweru, clinical oncologist at The Nairobi Hospital. (Credit: David Macharia)
Dr Angela Waweru is a clinical oncologist at The Nairobi Hospital (TNH), a private hospital, but is also on a six-month specialist attachment at KNH’s cancer clinic. Before joining TNH, Dr Waweru was employed by the United Kingdom’s publicly-funded National Health Service. She believes there is scope for further partnership between public and private cancer care facilities in Kenya to strengthen capacity. “I think that there’s opportunity for more. We do NHIF applications for patients at KNH and we’ve been treating the brachytherapy patients because the machine at KNH is out of action. Patients are waiting months for what we could do tomorrow.
TNH houses the Cancer Treatment Center, which offers a comprehensive service from diagnosis and surgery to treatment and rehabilitation. The center’s radiation treatment unit opened in 2012 and includes radiation therapy machines and a high dose brachytherapy unit. In addition to offering pro bono support to KNH with radiation treatments, lead radiotherapist Fredrick Asige says the center also offers free chemotherapy treatment to KNH patients with leukemia on alternate Saturdays as part of the hospital’s CSR programme.
TNH has also partnered with the NGO, Partners in Health (PIH) to offer free treatment to cancer patients in Rwanda. Under the agreement made in 2016 and supported by the Rwanda High Commission in Nairobi, PIH is funding the discounted TNH treatment over two years. Around 100-150 people are expected to be received radiotherapy treatments at TNH.
According to Mendoza at Roche, this approach to strengthening infrastructure began by listening to stakeholders to identify and fully understand the access hurdles to cancer treatment. “When we first started, the patient journey to get any sort of treatment was around nine months. The patient might get to another stage of cancer over this time and it might be too late. But with all these interventions, it’s now four months and going down. It is an ecosystem approach; you have to address all of the elements, or the patient will never get to the point of treatment.”
Jackie Wambua, stakeholder relations and health policy manager, Roche Kenya. (Credit: David Macharia)
Having champions like the First Lady and Senator Beth Mugo were key to opening doors and keeping momentum going, says Jackie Wambua, stakeholder relations and health policy manager, Roche Kenya. Wambua reached out to a range of stakeholders over two and a half years from 2015 before the government agreed to partner with Roche on breast cancer treatment. From early morning meetings at the Ministry of Health to listening to patient group concerns via KENCO, she joined the dots to help make the programme a reality.
“We had committees with government, Roche and KNH on what protocols do we need, what guidelines do we follow,” she explains. “We had to look at processes that weren’t there and set up ways for the patient to navigate from casualty or from referrals outside city.”
Against a background of devolution of health services in Kenya, with counties being given a bigger responsibility in prioritising and allocating resources, Kenya’s cancer strategy provides a framework for planning and implementing cancer prevention and control interventions.
Makumi at KENCO advocates for screening to be done at county level via outreach clinics once or twice a month. Makori at KNH would like to see the government offer the private sector incentives to invest in healthcare and provide equipment so that people with cancer can have the same treatment without having to travel across the country.
Building healthcare professional capacity is a priority. Kenya has a population of 45 million people, yet it only has three radiation oncologists at its four cancer treatment facilities. (Credit: David Macharia)
Removing the stigma of cancer
Although breast cancer occurs in both men and women, more than 90% of cases present in women. Risk factors include gender (being female), family history, alcohol and tobacco use, being obese or overweight and exposure to estrogen hormones through contraceptives.
Makumi at KENCO also believes faith-based groups have a role to play as partners in spreading this message. “We looked at what worked with HIV and what changed the tide is when religious leaders got involved in talking about HIV in temples, in mosques, in churches, in the shrines, in the places of worship. When they started doing that then folks listened. So we want to craft specific cancer messages especially around prevention.”
Dr Tom Menge, chief pharmacist and deputy director, pharmaceutical services at KNH, agrees that cancer needs to be a public health priority. “Look at how the country dealt with HIV/AIDS—it was a concerted effort, declared a disaster and addressed issues of access,” he explains. “I believe that’s the direction that cancer is going.” He adds that the National Cancer Institute, currently in a formative stage, will contribute to this vision. “We worked on an amazing model for HIV; I keep wondering whether we can do same for cancer.”
Diya Melanoi Mohamed, another patient on the Roche/KNH treatment programme, wants to see more information about cancer treatment options. The 58-year-old and her husband, Farooq, had the support of their grown-up children to navigate her treatment. Farooq, who had recently retired when Diya was diagnosed with breast cancer, researched options and kept careful notes about his wife’s surgery, chemo and radiotherapy appointments.
Retiree Farooq Mungai helped his wife, Diya, to navigate her breast cancer treatment. (Credit: David Macharia)
But Diya knows not every patient will be as fortunate: “A lot needs to be done around education. Whether rural or in town, when you hear cancer, you think it’s a death sentence, it’s scary. But when you meet friends and talk freely about cancer, they’re surprised and realize you don’t have to be scared of it.”
The Kenya agreement is part of Roche’s Africa Strategy which began in 2015 and is working with local partners on a range of initiatives including strengthening healthcare systems, professional training and private health insurance with local companies. Markus Gemeund, head of Roche in sub-Saharan Africa, says the next step in Kenya is to find creative funding solutions. “The biggest challenge is funding and reimbursement. Cancer is cancer—it doesn’t wait for the economy to do well.” To this end, Roche is looking at what other creative funding mechanisms can be put in place until countries like Kenya have universal health care.
Back in Mombasa, Fauzia talks about reopening a hairdressing and beauty salon like the one she worked at before her cancer treatment. What would she wish for others who are newly diagnosed with cancer? “No-one should be afraid to reach out,” she says. “You will get help if you’re willing to look for help.”
As a schoolgirl in rural Tanzania, Memusi Saibulu was determined that becoming someone’s wife at the age of 14 would not be part of her life plan.
Growing up in the predominantly Maasai region of northern Tanzania, Memusi knew that her family would expect their daughter to follow tradition and give up her education in her early teens for married life. But the stellar student had other dreams: to continue with her schooling and eventually train to become a doctor.
Memusi, a quietly spoken teenager dressed in her school uniform of red sweater, red tie and black over-the-knee pleated skirt, says her mother had always encouraged her to study hard and do well at school. But her father, driven by cultural convention, had other plans — arranging a marriage and dowry for his daughter while she was still in primary school.
When Memusi told her favorite teacher that family expectations and prohibitive school fees meant she probably wouldn’t be continuing her education to secondary school, the instructor was concerned that such a bright student wouldn’t be given the opportunity to pursue her studies. Perhaps she could apply for a scholarship?
Then, just two days later, the man who was to be Memusi’s husband visited her family home. “The drunk son of my father’s friend,” is how she contemptuously describes the man who forced himself upon her that evening then urged her to leave her parents’ home for a life with him.
On her suitor’s next visit, Memusi felt angry and more confrontational. “You’re not going to get your crooked little legs in my bed,” she told her unwanted intended.
Memusi admits to feeling proud of herself about her defiance but also very scared: “What if he tells my father? What if he tells others in my community?” she thought to herself.
Meanwhile, thanks to the encouragement of her primary teacher, Memusi had secured a place at Orkeeswa School, a community-based secondary school in northern Tanzania that provides holistic education to high performing students whose families don’t have the financial means to pay school fees.
When Memusi received the acceptance letter for secondary school, her mother “jumped up and down” with excitement. Then Memusi took the letter to her father, which forced him to set aside the traditional path he’d envisaged for his daughter in favor of a different journey.
Memusi explained to him that marriage would be the death of her dreams. Secondary school would unlock myriad opportunities, she argued. She won her battle. Because of these strong opinions, says Memusi, she gained herself a bit of a reputation: “I am considered to be a role model for my community.”
Fewer than one per cent of girls in rural Tanzania continue their education to form five and A-levels. Memusi is currently studying physics, chemistry and biology as a form six student. She’s also served as student body vice president, a peer counselor and a leader in community service projects and extra-curriculum activities. Her dream, she says, is to become a general practice doctor who can treat people — particularly women and girls — in her community.
As Memusi shared her experience with others via The Moth storytelling project in Nairobi, Kenya, she was acutely aware of her choice to reject the role of child bride and rail against tradition. She concludes: “I don’t want to destroy culture but I want to change girls being married at a young age.”
Memusi Saibulu participated in ‘Stories of Women & Girls: The Moth in Nairobi’ in January 2018. https://www.themoth.org/
A fast-track learning program in India is being scaled up to help 3 million young girls across developing countries stay in school. Udaan, a residential school for students aged 11-14, helps girls study instead of work or marry.
Teacher Maheshwari Verma (back left) works with Maya, 11, during language class at the Udaan Accelerated Learning Camp for girls near Hardoi, India, on Sept. 9, 2014. Photo by Erin Lubin/CARE
As the oldest of five children, 15-year-old Laxmi Pal grew up caring for her siblings and doing household chores in the rural Indian village of Kodanna in Uttar Pradesh, while her mother was out cleaning houses and her father struggled to find seasonal work on farms. But three years ago, Laxmi became the first member of her immediate family to attend school. Nine months later, she graduated from fifth grade and enrolled in a government secondary school to continue her education.
Like many adolescent girls growing up in rural India who never start or finish primary school, Laxmi envisaged a future of domestic work and early marriage. But instead, she was given a second chance at education through a fast-track learning course run by nonprofit organization CARE.
CARE’s Udaan program (Udaan means “to soar” in Hindi) compresses several years of primary school curriculum into nine months of accelerated learning. Launched in India in 1999, the Udaan residential school offers girls aged 11-14 the chance to quickly complete their education. The program is highly interactive, featuring learning by doing, educational games and group projects to keep the students engaged.
In addition to teaching language, math and environmental science, Udaan teachers help girls learn to question discriminatory practices and beliefs within their villages. Teachers also integrate activities such as morning assembly, where girls gather before class to recite poems, sing songs and perform skits. In their free time, girls play sports and learn to ride bicycles. (The latter is a skill that’s especially important, since the distance to schools is a major hindrance to girls’ education in rural India.)
Students of the Udaan Girls School work on a group exercise. The curriculum includes language, math and environmental science. Udaan teachers also interweave activities such as morning assembly, sports (volleyball, soccer), bicycle riding and computer skills. (Allen Clinton/CARE)
Since CARE started Udaan with local partner Sarvodaya Ashram, more than 95 percent of the girls enrolled have passed the fifth-grade exam. Since 2011, the Udaan model has been rolled out to Odisha and Bihar states; in 2013, an Udaan school opened in theMewat district in Haryana state, approximately two hours from Delhi.
According to CARE, just one year of secondary education correlates to a 15 to 25 percent increase in future wages for young women.
At the United State of Women Summit in June, CARE announced a$15 million rollout of the Udaan Second Chances program as part of the U.S. government’s Let Girls Learn initiative. Launched by President Barack Obama and First Lady Michelle Obama in March 2015, the initiative is aimed at the estimated 62 million girls globally – half of them adolescents – who are not in school.
Over the next five years, the Udaan program will expand to reach 3 million girls across Afghanistan, Bangladesh, Malawi, Mali, Nepal, Pakistan and Somalia. The program is supported by the U.S. government, ministries of education in individual countries, corporations, foundations and local partner organizations.
CARE argues that when girls are educated, all of society benefits. “Girls who attend school tend to delay marriage and pregnancy, are less vulnerable to disease, and are more likely to increase their own earning power for life,” said Joyce Adolwa, CARE’s director of girls’ empowerment, at the United State of Women Summit.
Brian Feagans, director of communications at CARE, says the program seeks to address lack of access to a relevant education for adolescent girls who are out of school or at risk of dropping out. “It helps them catch up through accelerated learning models and then transitions them back into schools at higher primary or lower secondary levels,” he says. “This is a comprehensive package of interventions that converge around education to create an integrated approach to girls’ empowerment.”
Udaan schools have been deliberately placed in the most disadvantaged areas, where the educational status, particularly for girls, is extremely low. Using the successful results of this model, CARE has advocated for the Indian government to adapt the Udaan curriculum into its state-run schools. Government teachers have been trained on the Udaan approach. This scale-up has helped change the future trajectory of thousands of girls, says Feagans.
Having been through the program, Laxmi now dreams of becoming a teacher. “If I didn’t go to Udaan, I would have been cleaning houses with my mom and soon married off,” she says. “Being at Udaan allowed me to dream about my future for the first time.”
A mobile health project in Ethiopia gives any health worker with a smartphone access to the information they need to deal with emergencies during childbirth. Now it’s being scaled up to reach 10,000 health workers across Africa and Southeast Asia by 2017.
A midwife at Gimbi Health Center in West Wellega, Ethiopia, uses the Safe Delivery App to help her carry out an examination on a patient. Photo by Mulugeta Wolde
For Ethiopian mother Mitike Birhanu, the birth of her twins almost ended in tragedy. She was unconscious when the second of her babies was delivered, and the newborn seemed lifeless. But her midwife quickly consulted an app on her smartphone, diagnosed the problems, and used emergency procedures to save both Mitike’s life and that of her child.
Every year, over 300,000 women globally die from pregnancy-related causes, and over 5 million babies die during birth or within the first weeks of their lives. Yet the vast majority of maternal and newborn deaths could be prevented if health workers attending births had better emergency skills and knowledge.
Many health workers in low- or middle-income countries work in environments where there is no electricity or running water. But one thing they do have is smartphones.
The Safe Delivery App (SDA) was created as a simple tool for health workers such as midwives and nurses to access basic emergency obstetric and neonatal care skills. Developed by Danish NGO Maternity Foundation in collaboration with the University of Southern Denmark and the University of Copenhagen, the app aims to train and instruct birth attendants on how to manage potentially fatal complications during pregnancy and childbirth.
Based on global clinical guidelines, the SDA contains four basic features: animated instruction videos, action cards, a drug list and practical procedure instructions. The five- to seven-minute videos teach lifesaving skills such as how to stop a woman bleeding after birth or how to resuscitate a newborn. When there is no time to watch the full video, the action cards give clear, essential recommendations and immediate care information – such as how to mix an alcohol-based hand rub.
The SDA is free to download from Google Play and the App Store. And it can be preinstalled on phones, so once it’s downloaded, users don’t need a network connection or internet access to view the videos or other features.
Meaza Semaw, project coordinator at the Ethiopian Midwives Association, says the app is ideal for places like Ethiopia, where women’s access to quality maternal health services is challenging, especially if they experience complications in birth. “The Safe Delivery App is a great tool to improve maternal health in Ethiopia. Most midwives, if not all, have a mobile phone, so accessibility is very high,” she says. “The app is easy to use because it is supported by animations and videos. In addition, it uses local languages.”
With the support of the MSD for Mothers program, the first four of the app’s 10 videos were tested in a one-year, randomized controlled trial across 78 facilities in Ethiopia during 2014. Results show users’ skills in handling most common complications such as postpartum hemorrhage and newborn resuscitation more than doubled after 12 months of using the app.
The app was officially launched in April 2015, and a year later was chosen by the Women Deliver conference as an example of how a partnership-based innovation can help end maternal and newborn mortality. SDA is now currently in use in Kenya, with plans to roll out to Guinea, Sierra Leone, Myanmar, Laos and India in the coming months.
So far, the app has been funded with help from over $50,000 in donations through an Indiegogo crowdfunding campaign, and Maternity Foundation is working with partners in individual countries to fund the translation and rollout of the app. The hope is to be able to fulfill the commitment Maternity Foundation made to the U.N.’s Every Woman Every Child to reach 10,000 health workers with the app by the end of 2017, so ensuring a safer birth for 1 million women.
At Wollega University in Ethiopia, student midwives use the app during training. (Mulugeta Wolde)
Maternity Foundation CEO Anna Frellsen says the organization is working in partnership with governments, midwives’ associations and larger NGOs to achieve its goal. “We really want to see the app integrated as part of the existing health system in countries, and we are starting to engage with the [health] ministries and stakeholders in each country to find out how it can be used and adapted,” she says.
The Ethiopian Midwives Association is currently working on integrating the SDA into its ongoing training program. Frellsen hopes other health organizations in participating countries will do likewise.
There is also a new version of the app in the works, which will feature quizzes and a test (rewarded by a certificate) to “push” learning to the user and make the experience more interactive.
Frellsen says one of the key components of Maternity Foundation’s “backbone” support for its partners will be disseminating learning around the SDA and mobile health in general. “We are looking at how we can publish some of the learning for sharing with others who would like to use the app, but also more broadly as a case for how to scale up an mHealth [mobile health] tool,” she says.
In western Ethiopia’s Gimbi rural district, the midwife who saved Mitike’s life says the Safe Delivery App has already made her better at her job. “I am confident that from what I have learned from the app, I can stop [a mother] bleeding,” says Yane Ababaw. “I can save her life.”
A midwife at Gimbi Health Center in West Wellega, Ethiopia, uses the Safe Delivery App to help her carry out an examination on a patient. Photo by Mulugeta Wolde
At Wollega University in Ethiopia, student midwives use the app during training. (Mulugeta Wolde)
Liza Ramrayka 