Ndi masiari from Aubrey and Alice in Thohoyandou, South Africa!

1It was our last day at Marseilles Clinic in the small village of Majosi, where we had spent many days of our summer conducting focus groups on the management of hypertension and diabetes with the community health workers (CHWs) there. Only half of our original team remained in Limpopo at this point in the summer (the rest had returned home), and we were expecting this last day at the clinic to be a short one. All we needed to do was to conduct one last focus group and say our goodbyes and thanks to the dear friends we had made there.

Once our focus group was complete, we stood up to gather our things and begin to say goodbye, but we were cut short. One of our CHW friends, who we knew to be the boisterous leader of the group, jumped up and asked where we were going. She insisted that we stay for lunch and that we even help prepare the food.

2We had eaten lunch at the clinic on several occasions, but it had always been prepared while we were conducting focus groups. On this particular day, we had finished our focus group early, before lunch was ready, and so naturally, we were invited to learn how to cook the traditional South African dishes we had enjoyed all summer. We were in for a treat…

The two of us, and our dear partner and friend from the University of Venda, Mphonyane (pronounced Um-pun-ya-na), were led around to the back of the clinic, a modest, brick building, and we stopped in our tracks. Before us were two large cauldrons sitting over some sticks and hot coals, one filled to the brim with boiling cabbage and one filled with a thick, white meal called pap. Each cauldron was manned by a CHW who stirred its contents vigorously with a wooden spoon the length of a small child. Next to the two cauldrons sat four CHWs with a chicken each. Each CHW was in the process of slaughtering, plucking, washing, or gutting her chicken. The two of us stood with our mouths agape, while Mphonyane and our other friends laughed and ushered over to help with lunch. We managed to compose ourselves and began to help.

3Each of us took a stab at stirring the heavy pap in its cauldron, which only left us panting and with sore arms. Even Mphonyane, who had grown up regularly making pap, had never made a portion this large and struggled to stir such a huge pot! As we helped prepare each of the dishes for lunch, we were patiently guided by the CHWs who gave us cooking tips which ranged from how to scoop hot pap from the cauldron, to which parts of a chicken’s guts you save and which parts you toss.

As we continued to learn, the CHWs laughed, “We are teaching you how to cook South African food so that you can cook for your American friends when you go home. You cannot go home without knowing how to cook our food!”

4Three hours later, lunch was finally prepared. We eagerly ate our pap, chicken, and cabbage with our hands (which is customary in SA), starving after a long day. After lunch, we tearfully said goodbye and parted ways, not knowing when we would see our friends at Marseilles Clinic next.

Now that we have returned to the United States, we have yet to cook a full South African meal, but we have been able to reflect on how thankful we are for the people we met and the experiences we had this summer. We will always remember the lessons we have learned from South Africa – be it lessons on cuisine or lessons on this country’s long history. Ro livhuwa, South Africa

Elise Huppert: HIV in Thohoyandou, South Africa

I spent the plane ride from Washington, D.C. to Johannesburg, South Africa trying to convince myself that it was really happening. I’ve since spent 8 weeks working toward that realization which I can say with confidence I did not fully achieve until boarding the return plane.

1I’ve been lucky enough to visit Thohoyandou, South Africa and work at the University of Venda on identifying dual infection in HIV samples from Cameroon. HIV, which is a major problem all over the African continent, can be divided into 2 major groups: HIV-1 and HIV-2. The former is vastly more common, and can be further divided, eventually distinguished by subtypes A – K. Subtype B predominates in the western world, and C in South Africa, but Cameroon experiences circulation of almost all the subtypes and their circulating recombinant forms (CRFs) making it the ideal location for an analysis of dual infection, or infection by more than one subtype. High recombinant presence indicates high rates of dual infection because dual infection provides the necessary environment for genetic recombination. Though very few statistics regarding the rates of dual infection exist, Cameroon and other regions observing significant recombination are promising scenes to explore.

2My weekdays were spent in the lab amplifying Cameroonian samples for two genes, gp41 and the V3 loop of gp120, to be sequenced and examined for evidence of dual infection. Sequencing is the process of determining the exact genetic code of a DNA sample, and provides information on the protein formulation and their variants. These variants may be indicators of dual infection, and through their analysis I hoped to reveal the prevalence of dual infection in my selected cohort. I successfully amplified 54 samples for V3 and 41 for gp41. Throughout the coming semester, I will sequence them in detail and analyze those results, and the few that I have sequenced already show promising evidence of dual infection. The University of Venda students and faculty were so welcoming and helpful, and I know I would never have made any progress without their consistent support, as well as that from my lab back at UVA.

3I stayed with a number of other American students, from UVA and otherwise, and we tried to maximize our weekends to see the most of South Africa in this short interval we can. The first weekend we visited Kruger National Park, which is one of the largest attractions in the Limpopo Region of South Africa and home to all the quintessential safari wildlife I never thought I would see outside of a zoo or picture book. The next weekend we visited the largest tree in Africa, the Big Baobab, which was over a thousand years old. We also explored Leshiba National Park, famous for its outstanding rhinoceros population, and Magoebaskloof, a small mountain town with gorgeous scenery and nature walks. Between my weeks in Thohoyandou and weekends exploring the Limpopo province I was able to feel very acquainted with my home away from home by the end of my 8 week stay. The opportunity to study the discipline that matters to me in a place where I could personally observe its effects while expanding my cultural horizons has been incredible. I know I couldn’t have had the same experience in the United States, or anywhere besides Thohoyandou.

Gender Empowerment in Rwanda

1Today marks the end of our third week in Rwanda. After two very long flights, we spent our first few days staying with Mary Lansden Rees-Jones (a recent UVA grad and former CGH scholar) in Kigali. We had an amazing time exploring the city, which is bustling and loud, but clean and easy to navigate. We enjoyed the free wifi and delicious at some of Kigali’s many expat cafés.

2Our project focuses on beekeeping in southern Rwanda, around Nyungwe rainforest, with two focuses: market research and gender empowerment. In this region, beekeeping is a traditional practice. We partnered with Vincent Hakizimana, who is in charge of overseeing beekeeping development in this region and the Nyungwe Beekeeping Union. He works closely with the Rwanda Development Board and the Wildlife Conservation Society. During the duration of our project, we have been staying in a house in Huye (formerly Butare). It’s the second largest city in the country, but only has a tenth of the number of residents (and not quite as many fantastic restaurants).

3There are thirteen beekeeping cooperatives around Nyungwe which are overseen by the Beekeepers’ Union. We would have loved to visit them all, but they span a huge distance (travelling to each one would have meant several expensive motorcycle rides). Instead, representatives from cooperatives met with us in Kitabi, the location of the Rwanda Development Board’s office in Nyungwe. We also visited two beekeeping cooperatives that were nearby. Particularly memorable was our visit to the Coaseki Beekeeper’s Union, which included a short trek into the rainforest and interviews that took place on the rainforest floor. For our hike back to the main road, some of the beekeepers used their machetes to fashion us walking sticks.

4Last weekend, we took two days off to travel to Akagera National Park. We spent the day cruising around in a safari car, keeping our eye out for the parks inhabitants: warthogs, impala, elephants, giraffes, hippos, and zebras. During the genocide twenty-one years ago, Akagera’s lions were poisoned to prevent them from eating the cows that were the only source of food for fleeing Rwandans. Just last month, Akagera reintroduced lions into the park that were given as a gift from a private park in South Africa, a great source of pride for Rwandans. We weren’t lucky enough to see the lions, who according to our guide were roaming in the distant hills.

Our trip is coming to an end, and we are excited to compile our report. Many of the beekeepers we have met with have asked us to communicate our recommendations to them once we’ve written them, as well as to the RDB. We have learned so much from being here, and hope to help facilitate more CGH scholars coming to this region in the future to continue working with the Beekeepers’ Union. We are spending our last three days hiking the trails of Nyungwe National Park.

Mary Russo

Claire Williams

Lauren Jackson

William Heganan

Update No. 2 from Team Maji Safi na Salama!

1As we described in our first post, the first phase of our project was completing individual interviews with the Carpenter’s Kids families in Nzali. These interviews helped us gather background information on water use and general demographic and economic info. The next phase in our project was a group lesson to teach the families about water safety.

With the help of Pastor Emanuel, the parish priest and our main partner in Nzali, we spread the word among the seventy Carpenter’s Kids families to come to the church for a lesson on safe water. It was a great feeling to walk into Nzali’s church, a small concrete building with a rusty metal roof, and see dozens of people crowded onto the church’s wooden benches, all there to learn about clean water. More people continued to walk in as we were preparing for the lesson, and by the time we began it was standing (or more accurately, floor-sitting) room only!

2Before we started the lesson, we handed out sheets outlining the water safety lesson in Swahili (Tanzania’s official language) and MadiDrop instructions in Swahili and Gogo (the local language in central Tanzania). We began our water education with a discussion of the general benefits of drinking water. We were encouraged to find that many of the parents were eager to state their thoughts and ask questions from the very beginning of our lesson.
Next we discussed sources of drinking water, emphasizing that tap water and collected rainwater are the cleanest sources, and that shallow/unprotected wells and the river are the least clean sources and require more filtering and treatment to be safe to drink. As we learned in our interviews, most families in Nzali use water from the taps in the dry season, and water from the river and shallow wells in the rainy season. Water treatment thus becomes especially important in the rainy season.

For our third topic of education we discussed waterborne and water-related illnesses. This is particularly important for young children, the elderly, and people infected with HIV/AIDS, the three most vulnerable groups to waterborne and water-related illnesses.

Fourth, we taught different methods of water treatment: different kinds of filters, boiling, solar disinfection, chemical treatment, and MadiDrops. The parents were especially curious about ceramic filters like those PureMadi manufactures in South Africa. Peter, one of the two undergraduates from the Institute of Rural Development Planning (IRDP) who was helping us with our project, stepped in to give a lesson on these types of filters. In watching Peter teach by drawing illustrations on the blackboard, we learned the importance of using visual aids and demonstrations when teaching in rural villages like Nzali. Many of the adults in Nzali are illiterate, so even after we had translated our water education handouts into Swahili and Gogo, this information was still incomprehensible to a number of the parents. This realization helped to spark the idea to create a MadiDrop instructional video with a Swahili voiceover, which we made in the following days with help from the IRDP students and left on a flash drive with Pastor Emanuel.

Our fifth and final topic was water storage. Even water from the cleanest sources can become contaminated if stored improperly in a container without a top, a container kept outside, an unwashed container, or a container into which people dip their hands or a dirty cup to get the water. When selling MadiDrops, we provided containers with a top and a spigot to dispense the water.

Over the next several days, we let the Carpenter’s Kids parents and guardians know that we would be available throughout each day at Pastor Emanuel’s house, next door to the church in Nzali, to answer any questions they might have. A number of parents came by, each with a long list of insightful questions. These questions ranged from whether or not the silver in MadiDrops could cause an allergic reaction to the logistics of how they would be able to purchase MadiDrops in future months and years after our departure from Nzali. We realized that with all of these questions and the high level of interest in MadiDrops, we would need someone that could continue to teach about MadiDrops after we left. We organized a group of half a dozen volunteers, our “MadiDrop Ambassadors,” to whom we gave more in-depth instruction on MadiDrops. We also provided them with access to educational resources, such as the Swahili MadiDrop instructional video we made, and the ability to email us questions through Pastor Emanuel. When Professor Jim Smith came to visit, our faculty advisor for the project and the inventor of the MadiDrop, he also spoke with the MadiDrop Ambassadors.

3The last phase of our project was selling the MadiDrops. To determine the best price for selling MadiDrops, we used economic data we collected in our initial interviews as well as information on price and payment method preferences from willingness-to-pay cards that the parents filled out. We determined that 6,000 Tanzanian Shillings ($3) would be a good price point for one MadiDrop, lasting 6 months. For two MadiDrops, we lowered the total price to 10,000 Tanzanian Shillings to incentivize purchasing a one-year supply. We also offered a volunteer option in which parents could help with the latrine project at the Nzali Primary School. A group from St. Paul’s, Ivy, the Episcopal church near Charlottesville that sponsors Nzali through the Carpenter’s Kids program, was constructing new self-composting toilets at the school and needed volunteer labor. We offered one MadiDrop in exchange for 3 hours of work, and two MadiDrops in exchange for 6 hours of work. To thank the Carpenter’s Kids parents for helping us with our project, and to ensure each family would have a safe water storage container, we also used our research funding to provide a new 20 liter bucket with a top and spigot to each household that purchased a MadiDrop.

4Over the course of just five days of sales, 67 of the 70 Carpenter’s Kids families in Nzali came by the church and Pastor Emanuel’s house to purchase MadiDrops. A dozen of these were cash sales, and the remaining transactions were in exchange for volunteer labor. The volunteer option was hard work, each person carrying an average of ten 20 liter buckets of sand, water, or gravel, or 10 25lb concrete blocks up to a mile to the school. As our real research question was on the people’s willingness to pay for MadiDrops rather than their ability to pay, this was a very positive result. The Carpenter’s Kids families in Nzali were very willing to pay for or work for the MadiDrop. Because our project took place in the dry season, when families’ incomes (mostly from farming) are the lowest, most families did not have cash on short notice, but nearly all families were willing to give their time and labor in place of cash. If a monthly installment plan were available in future years, we feel this might make purchasing the MadiDrop even more accessible. In our willingness-to-pay surveys, many families expressed interest in an installment plan, dividing the MadiDrop payments into smaller monthly amounts.

We couldn’t have asked for better results from the first introduction of MadiDrops in Nzali. Pastor Emanuel and the Carpenter’s Kids parents were eager to give us all the help and participation we needed throughout our project, and everyone we met expressed great interest in adopting MadiDrops as the solution for clean drinking water in Nzali households. We plan to send additional MadiDrops in six months’ time to replace those now in use, and we hope to expand the distribution of MadiDrops throughout the region next summer.

MadiDrops Take Tanzania

1Team Maji Safi Na Salama here to talk about our introduction of the MadiDrop in Central Tanzania!

A brief description of the MadiDrop: The MadiDrop is ceramic water purification device that is embedded with silver nanoparticles that purify household drinking water through the slow release of silver. To use the MadiDrop, one simply drops the MadiDrop into the household water storage container, fills the container with 10 to 15 liters of water and waits 6-8 hours. Then after 6-8 hours, the released silver effectively kills any pathogens in the water making it safe to drink. One of the best features of the MadiDrop is its durability. A MadiDrop can be used for up to 6 months before replacement. Sounds great, right? We wanted to see if it would be a good fit as a method of water purification in Central Tanzania.

2Our project focused on the village of Nzali just an hour outside of the capital city of Dodoma. Nzali is a good representation of a typical village in Central Tanzania, where the citizens are mostly subsistence farmers with very low incomes especially in the dry season. The project had two main objectives: the first was to determine if MadiDrops could be used effectively in a primary school setting, and the second objective was to determine the demand for MadiDrops in Nzali with a Willingness-to-Pay study. But before we could get started with the MadiDrop, we had to gather some baseline information on how water is used both in the school and in the household.

For the school study, we observed the levels Standard 4 and Standard 7. We noticed that none of the students drank any water during the day nor was drinking water regularly provided. One of the teachers mentioned that sometimes students will ask for water at one of the teacher’s houses on campus, but most go thirsty.

3To see how water is used in the household, we conducted 50 one-on-one interviews from a sample of 70 Carpenter’s Kids families (our partner organization that helps supports at least 50 of the most vulnerable kids in each village across the Dodoma region). We asked simple demographic questions such as “How many people are in your household?” and “Are the children in school?” as well as questions about general water practices such as “Where do you get your water?” and “Where/How do you store it?” In addition we asked questions about water beliefs such as “What is the primary reason a child has to miss school?”, “Do you think you can get sick from your water?” and “How would you rate the quality of your drinking water?” The answers gave us an in-depth look into the water situation in Nzali.

Here are the results from a typical respondent:

  • They usually come from a large household (at least 4-6 people) with at least some of the children in school and the parents having completed schooling up to Standard 7.
  • The most common reason for missing school is stomachaches, most likely due to unsafe drinking water.
  • In terms of monthly income, most households do not have a steady source as money fluctuates with the season. Because it is mostly rainwater agriculture in the Dodoma area, there is no income in the dry season.
  • The most common purchases made by households are soap, sugar, salt, vegetables, and cooking oil.
  • Sources of water also fluctuate with the season. During the rainy season, the main sources are the hand-dug shallow wells in a seasonal riverbed. During the dry season, when the shallow wells are mostly dry, the main sources are the village taps, with water from the borehole (which most households recognize is a significantly cleaner source of water).
  • Water is stored in a bucket that is stored inside the home, covered with a top, and cleaned at least once a week. Water is taken out of the container using a cup.
  • Most people do not have to travel very far to get to the water, as they live within 500 m of a tap or a shallow well, although there are a few exceptions living far away by their farms outside of the village.
  • Many households know that they get sick from their water although few have heard of or have access to any methods of treatment. One method that was commonly mentioned was WaterGuard, a single-use chlorination purification method, which many of the villagers disliked because it changed the taste of their water.

4Based off the interviews, the MadiDrop was looking like a good fit as it is low-cost, highly durable, easy to use, and doesn’t change the taste, smell, or color of the water.

The next phase to come was an introduction of the MadiDrop in the school, which would be the first time safe drinking water would become available at the primary school. The following phase was to be water education both in the school and with the members of the households followed by the Willingness-to-Pay study.


Sam, Charlotte, Rosemary, and Mark

EMR Design and Implementation in Totonicipan National Hospital, Guatemala

1Hola! And Bienvenidos to the Electronic Medical Record project. My name is Zack Ballinger. I am a rising 4th year majoring in both Biology and Cognitive Science. This year, I’ve had the privilege to travel to Xela, Guatemala to work on the design and implementation of an Electronic Medical Record system in the National Hospital in Totonicipan, Guatemala. The project team consists of our mentor, Dr. David Burt of the UVA Medical System, Kevin Carlson (a UVA medial student), Jessica Gonzales (Guatemalan project coordinator), Ivan Castellanos (Guatemalan IT director), Roberto De’Leon (Guatemalan Computer Engineer), as well as several past years of research contributed by other teams of students both in the US and in Guatemala. We are also working closely with several doctors in the Toto hospital, namely Dr. Scarlet Lopez and Dr. Hector Medina, and their respective students to receive feedback on our system.

Well before any team member arrival in Guatemala, years of research were completed into Electronic Medical Records, Trauma Data Registries, and the Guatemalan Health System. It was concluded that individuals benefit from EMRs through the reduction of medication errors, increased disease prevention and the management of chronic diseases (as compared to systems with paper records, like those in Guatemala). EMRs allow for the improvement of patient safety through a system of automated warnings in the event of abnormal patient circumstances. Additionally, due to the fact that 90% of death due to traumatic injury occurs in developing nations, collection of data related to traumatic injury (as outlined by the Pan American Trauma Society) allows for more accurate management of pre-hospital treatments, in-hospital care, and post-discharge outcomes for individual patients to assure best outcomes for patients.

2Not only does electronic record keeping allow for the protection of data in the event of a natural disaster, data can also be easily retrieved by researchers, physicians, or other clinicians to survey and track communicable diseases, run diagnostic quality improvement measures in specific hospitals, and more accurately track public health data. EMR implementation in Haiti, Cameroon, Kenya, Peru, Uganda, Malawi, and Brazil have all demonstrated the benefits of EMRs in resource-limited communities.

Previous work by the Guatemala Initiative suggests that clinics within the Guatemalan Highland region may benefit from the implementation of an electronic medical records system. Initial work in the region has shown that multiple record keeping systems, both paper and electronic, are often used within a single clinics. This resulted in disorganized and even irretrievable data, many times forcing patients to be treated without any previous records. Our study, then, will build on the former and current UVA-GI in-country research of Huntington & Sherwood and French & Coes, the former of which examined proprietary and non- proprietary EMR models best applicable to resource-limited environments and the latter of which examined EMR system requirements. Work preformed by University of Virginia School of Medicine students, Taylor Huntington and Kyle Sherwood, on the ground in the region assessed numerous clinics as possible sites for the implementation of an EMR system.18 This and ongoing work by the Guatemala Initiative identified Hospital Nacional Jose Felipe Flores as an ideal candidate for implementation. As a teaching hospital, this clinic maintains a staff of computer literate medical students eager for the step to electronic records.

3Prior to my arrival in-country, Dr. Burt and UVA students Emory Buck and Sarah Perez developed a comprehensive list of information required of a basic EMR system. This list includes all the information required by the Pan American Trauma Society, the organization that decides the minimum data required for effective trauma patient data analytics. UVA medical student Kevin Carlson spent the previous 6 weeks working closely with Jessica Gonzales, Ivan Castellanos, and Roberto De’Leon to develop an EMR based on this list of information. Kevin and the team were able to generate a series of pictorial representations of what the final EMR will look like. These representations were critiqued by the team of doctors and students at the Toto National Hospital through several iterations.

I arrived in Guatemala 3 weeks ago. During this time, I have been taking rigorous Spanish classes at the Celas Maya Spanish School in Xela. I atteneded Spanish class Monday – Friday from 8 am to 1 pm. After lunch (the largest and most elaborate meal in Guatemala), I met with Kevin and the team to discuss updates to the project. As of last week, Kevin’s last week in country, we have completed the final version of the ‘pre-EMR’ representations. Now that the content and layout of the EMR are finalized, Roberto can begin to build an online version of the system with full functionality. Additionally, I will be creating fillable-PDF forms from the test images of the EMR as a rudimentary, placeholder system to test in the hospital while the full system is built by Roberto. Additionally, Dr. Burt is working stateside to recruit a software engineer to build an offline, proprietary EMR system akin to those used in US hospitals.

Though the combination of work and Spanish school has kept me extremely busy, I have been lucky enough to have the opportunity to explore this wonderful country. My first weekend here, a group of UVA students (and one new friend from Alabama) traveled to Monterrico, the most famous beach in Guatemala. This beach is one of the famous volcanic, black-sand beaches of Central America. The huge waves, good friends, cheap tequila, and sunrise trip through the nearby Mangrove Forest made it a weekend to remember forever. Amazingly, I had an equally fantastic trip with several students from Celas Maya the following weekend. We scaled Tajumulco, the tallest volcanic peak in Central America. Though the 7 hour hike to camp was difficult, to say the least, and the summit at 4 am was bitterly cold, I think the stunning images of the sunrise were well worth the duress.

As I am now halfway through my time here in Guatemala, I cannot wait to continue to explore the magnificent city of Xela. I hope the second half of my trip can be as productive and memorable as the first half.

Sustainable Technology Surveys – Guatemala

1Today we arrived in San Lucas, Lake Atitlan in Guatemala, where we will be carrying out our survey of local communities to find out about their sustainable technology needs. Before coming to the Lake, however, we spent three eventful weeks in Quetzaltenango (Xela), studying Spanish at Celas Maya Spanish School, exploring the city and its surroundings, and preparing for our project. With the warm welcome we received from our host families and teachers, we quickly adjusted, and began navigating the city, visiting open air markets to buy local fruits and vegetables, scaling the many hills to get a view of the cityscape, attending salsa lessons at a popular discotheque, and eating our fill of the delicious bread at Xelapan! We also had the opportunity to go on some adventures. Early one morning, we hiked to see the eruption of Santiagito, one of Guatemala’s active volcanoes, and we ended up having an impromptu salsa lesson on the mountainside while we waited for the eruption, courtesy of our guide! We ventured one weekend to Chichicastenango, the home of one of the largest markets in Guatemala, where we were surrounded by colorful fabrics, handmade crafts, and hundreds of people. For some relaxation, we visited Fuentes Georginas, a collection of hot springs originating from a nearby volcano; the waters were soothing and the atmosphere peaceful—Alena even went back for a second time, by bicycle! Of course, we were also working hard at studying and practicing Spanish for five hours each day for a total of 75 hours, which we put to use in translating our survey and delivering a presentation about our project to our teachers at the Spanish school.

2    3    4

5Immersed in the culture of Guatemala, we have seen the immense beauty and vibrancy of this place, as well as the heated political climate, lack of infrastructure, and severe poverty that a large portion of the population experiences. While we were enjoying the experience of exploring Xela, we also took time to reflect on our role in the country and its troubled history of violence, some of which was instigated by the United States. We have immense gratitude for the hospitality of the Guatemalans we have met, and we look forward to expressing our gratitude and appreciation for this country’s vast potential through our project at the lake. More updates to come.

Lauren Catlett, Clinical Nurse Leader Class of 2016

Alena Pugacheva, Clinical Nurse Leader Class of 2016