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Photo Essay on Rural Health

David Strider, RN, CCRN, MSN, ACNP

Democratic Republic of Congo1

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4Kasai Oriental ProvinceKasai Oriental province is an underserved, undeveloped rural area in south central part of DRC. It has 8.7 million inhabitants, in land area of 168,126 kms(2)1.6 million are within child bearing ageThere are only 5 district hospitals, and 750 health care centers, with 10,900 individuals per health care centerEconomy- diamond mines, minerals, subsistence farming, exported crafts5Kasai Oriental StatisticsIn 2010, infant mortality for Kasai was 105 deaths within one year of infant live birth for RURAL families, compared to 71/ 1,000 live births for URBAN families in Kasai OrientalMaternal mortality rate is 1,100 per 100,000 deliveriesIn 2010, 4% of rural and 36% of Urban families had working sanitary toilets with acceptable disposal systems In 2010, only 31% in Rural had treated drinking water, with 83% in UrbanInfantile Diarrhea incidence (40% rural, 37% urban) & pneumonia (39% rural, 52% urban)

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The small cluster of houses were scattered about the side of a jagged cliff that seemed to have no bottom. Wild grasses and trees were abundant. There was no apparent access to the village from the valley below. No roads were visible. There were no visible telephone poles or electric lines. If there was a woman or child who needed emergency help, I do not know how long it would take to reach the village through the back jungle roads.7Rural Health

8Rural HealthAnd yes, here was a road. This was one of the major highways through the Kasai. And there is the man, yes, he has much grain and other wares. He may be coming home from the village to his house in the southern part of Kasai Oriental. * He has a cap, good shoes, and is fully clothed.His bicycle tires are not flat. He will not be cold, hungry, or without shelter.9Rural HealthThe truck has broken down. Until a new axle is obtained, the truck cannot go anywhere. What to do with all the vegetables?Oh , My!

The trains do not always run. Gas is very expensive. How to get the crops to market?This may be most of the annual income for several families, that will be lost.10Rural Health The children are carrying water from a pond, that will be used for drinking. The little boy has a pan of vegetables. There is a chicken in the yard, that is the source of good eggs. None of the windows have screens. The children have shoes, but the toddler is barefoot.The cooking is done on a grill. The children are adequately clothed. The toddler appears well nourished.11Rural Health The women are resting under a hand built room. They are proud of their fruits and vegetables, which are for sale at this open air market. The woman on the right carries a full pan of freshly harvested peanuts. Note how she is balancing the bowl on her head with one hand. 12Rural HealthHere is the village again. Notice the baskets for sale on the right, and hot food stand in the Center. There is salad, I think, underneath the Cart , and towels to keep sun and flies off. I do not know where the beach umbrella came from. All of the dresses are handmade. There is a radio tower in the background, but there Is no electricity or running water in this village. When it rains this yard is a sea of mud.13Rural HealthThis woman is carrying firewood from the forest. She is used to balancing a lot of wood.The day is very hot. The vehicle roads are used for foot paths as well. Wood is easy to find, and will make a nice fire on the hibache grill. Cooking is often done outside, so that the smoke is not inhaled as much. The woman may make 5 or 6 trips to get a good supply of wood. She is used to a lot of walking.14Rural HealthThe person in the center is grinding nuts on the side of the road. This is a good source of protein. She appears well nourished. Her hair is neatly braided. In the rear center is a person who is most likely a refugee, travelling from village to village with all his belongings in two plastic bags. 15Rural Health

The young lady has excellent balance, standing on uneven ground and holding a 10 kilogram water tin in one hand and a large bowl of grain in the other hand. She has a beautiful peacock design dress, and her red blouse matches her shoes. The ground appears loose and with a deep layer of topsoil. There looks to be a well kept straw bungalow in the background. 16Rural Health

She was pulling out water from a small pond in the ground that was so murky you could not see the bottom of the 2 foot deep pool. Algae were encrusted along one side of the pool. She was using the same pan to pull water out of pool that had been used to carry food to the animals that morning. She is smiling. She has a source of water, clothing, and a good year for the crops so far.17Rural HealthThe delivery room supplies may consist of a small, single set of instruments that are used over and over, with cleaning by soap and water between cases. Some clinics in the outreach clinics have only one pair of gloves, that are used over and over. Women need to bring their own mattresses for the beds. The babies may be placed on a rough piece of plyboard, with no sheets or cushion.18Delivery Room in Hospital in Rural Kasai OrientalOne of the hospitals in Kasai Oriental. There are no shelves or cabinets in the room. There is a baby scale. The walls have been recently painted .Note the metal bedpans. Some of the rural clinics have dirt floors.

19Rural Health Here is a privately owned rural medical clinic.The owner and operator of the medical clinic may have no medical background. The community depends on this clinic for many of their immediate health care needs.20Rural HealthTwo Rural Heath clinics for our women and children of Kasai Oriental province.

Kasakaji and Wibiayi, in Luputu, 180 kms. From Mbujimayi

Esperance Medico Social Center, in Mweneditu. Notice the electricity and phone lines. Awnings over windows, fresh paint.21Rural Health

Here is one of our nicest health care centers in the rural Kasai. It is kept very clean. The stone walls and roof keep the water out most of the time. The mothers and infants come here. Many babies are born here. We do laboratory studies here. The vaccinations for the babies happen here. It is a busy place. 22Rural Health Measuring the pelvis in an 8 month pregnant woman. The exam beds are old, and the rooms are not always as clean as we would like. The beds are hard, but better than nothing. We have plenty of gloves, but in some of the smaller clinics there is just one pair of gloves, that is washed and used over and over again.

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A mother with twins. My, she is doing well. Two lovely little babies, a boy and a girl. She looks very tired. She has her two gallons of drinking water, and a plastic hamper for Some diapers, soap, and baby clothes. She was very happy yesterday to have two lovely babies. She will need lots of help when she goes home. 24Rural HealthThe mother is not well. She has severe malnutrition and anemia. She may have HIV.Many of our women have HIV. We see some with tuberculosis, and occasionally they have malaria. 25Rural Health Themes for Kasai OrientalThere is a significant lack of material and equipment resources for delivery room and post partum care, both for the mother and the neonate. This deficit is much greater in the rural maternal / pediatric clinics. Lack of running water and electricity, poor Waste disposal systems, lack of potable water, and absence of screens or mosquito netting post ongoing health care risks for the mothers and infants

26Rural Health Here we are in a post-partum ward. All the mothers have delivered. One of the mothersLost her baby. She is very sad. We go over the breastfeeding, bathing, diaper changes, and baby sleeping. We talk about the vaccinations.The man in the corner is a male nurse. The women have their drinking water underneath the beds. 27Rural HealthHealth in the rural Kasai Oriental is expressed In a positive sense by:- Closely knit extended families.- Validation of subsistence farming and open air markets as a way of life - Resiliency of the women, who often serve as single parents, operator of the farm, and maintenance of their own physical health. - Use of rural clinics for many minor health issues28Rural HealthThe National Health Ministry of the Congo demonstrates persistence efforts to achieve vaccination for all infant and toddlersThe records for vaccination demonstrate an improved level of adherence to vaccinations for infants and toddlers in the Kasai OrientalE.K and J.M. both note that their measurement Of community health is with reference to the Millenium Goals, with special attention ot MDG 4 and 5.29Rural HealthThe significant lack of roads and bridges in the Kasai Oriental make access to any central location very difficult. Most women who are seeking prenatal care may attend a clinic if it is within walking distance, but will not come to a clinic that is more than several miles from their residence. There does not seem to be an established home health nursing initiative in the Kasai Oriental.30Rural HealthVaccinations- Rural vaccination rate is poorer than that of URBAN, for DRC as a whole (Dec, 2010)

Analysis for > 6 doses, 4-6 , 1-3, and no doses of Trivalent or pentavalent vaccines* Of note, 21% of Kasai Oriental children 0 5 years Old received no vaccinations. This is the second to Lowest rate of vaccination adherence in the districts surveyed for DRC.

31ReferencesChopra, M., Daiviaud,E., Pattinson, R., Fonn, S., Lawn, J. (2009). Saving the lives of South African mother, babies, and children. Lancet 274(9692):835-46.

Kandala, N., Manduga, T., Emina, J. , Nzita, P., Cappucio, F.P. (2011). Malnutri-tion among children under the age of five. BMC Public Health. 11(1): 261.

Kasekw, E. (2011). The objectives of the millenium development: DemocraticRepublic of the Congo. Report from the National Health Ministry of DRC.pp. 125.

Sellers, P. (2010). Midwifery: A Textbook and Reference Book for Midwives in South Africa. 12th ed., Vol. I and II, Juta Press, Landowne, 1,800 pages.

Williams, W., Hutchins, S., Orenstein, W,. & Rodewald, L. (2006). Immuniza- toin and preventive care.In D.Satcher and R. Pamies (Eds.). Multicultural medicina and health disparities, New York, NY; McGraw-Hill: 233-243.

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