Updated: Dec 13, 2020
Note: this post was originally written in September, 2019 and primarily written for an audience of friends, family members, and former colleagues.
Aissa (right) and I (left) were both fellows at Muso. This photo was taken on one of the days we were out in the field collecting stories of patients and their Community Health Workers.
Outline: In this post, I want to first give an intro of Muso’s work, how I became connected with them, and my specific role here. I will also include a piece on Muso’s role in overall health care in Mali, although more to come for contextualizing Mali and the scope of our project in a broader arena of national health care and health care systems worldwide. Second, I will move into my observations and personal experiences living here thus far. Last, I will share a global perspective of how this work relates to broader career goals and hopefully answer any questions people may have about global health work or life in Mali. I am catering towards a variety of audiences, so I am giving you an outline now so you can skip over/read what you would like.
Muso overview: Muso is an American-Malian founded and based non-profit with two offices, one just outside of Bamako, Mali, and the other in San Francisco. Muso provides preventive health care for preventable diseases, most namely Malaria, Malnutrition, Pneumonia, and Diarrhea mostly for children, women, pregnant women, and elders. Muso deploys hundreds of community health workers (CHWs) throughout our 2 main sites, Bankass (our rural site) and Yirimadio (our peri-urban site where I also happen to live) to deliver this 3-step model of Pro-Active Searching, rapid access to clinics, and follow-up monitoring and evaluation. To do this, it is vital to include CHWs in this model to bridge cultural, linguistic, and other gaps between patients needing to access care but who face a variety of underlying barriers. First, a CHW will pay a visit to one of our patients. She is equipped with a backpack filled with screening tools for the four diseases I mentioned above, including rapid blood diagnostics, a smart phone to display blood monitoring and health status with a user-friendly interface, malnutrition, diarrhea, malaria, and pneumonia kits/rapid screening tests, pregnancy tests, as well as other information on family planning. Once this pro-active first step has been done, the CHW has a better picture of the household’s health status and if they need to get rapid access to a clinic (here the community-level clinics are called CSCOM’s). The third step is monitoring and evaluation of the patient’s health via population health research. Our organization was founded out of two research teams working together out of UC San Francisco as well as University of Bamako in 2005, and we still carry a heavy research philosophy today. Our first large study first began in 2008 on U-5 Childhood mortality, showing a significant reduction in U5 mortality rates pre- and post-intervention (dropped from 1 in 7 to 1 in 142, with a rate of 7 deaths per 1,000 births. In other words, the communities with Muso’s interventions experienced childhood mortality rates comparable to those in the US post-intervention (https://www.musohealth.org/the-results/). This original population-based survey took place in peri-urban (Yirimadio) and continued between 2008-15 (measuring child mortality & access to care). Our RCT in rural Bankass is underway and by early 2020, we will be able to compare results with the addition of a control group. To end this part on Muso, we have a staff of about 60 (not including our hundreds of CHWs) with the majority based in Mali and a few staff members in SF. I first arrived when the co-founders, Ari Johnson and Jessica Beckerman were also here. They live in SF 3/4 of the year and 1/4 of the year in Yirimadio. They both are fluent in French and have a working knowledge of Bamanankan, not to mention their fluency in medical knowledge in both English and French. They are the fuel to Muso’s operation and are extremely dedicated to Muso’s mission to deliver doorstep care-and producing standardized results to prove our model has positive health outcomes. To learn more about Muso, see some visuals of our model, learn about our funders, and read our publications, go to our website! www.musohealth.org.
How I became connected with Muso: I learned about Muso when I was on the job hunt my senior year. I knew about one of Muso’s partner organizations, Medic Mobile, from an internship I did at Ashoka. Medic Mobile provides Muso’s software diagnostics for the interface of our CHW's smartphones. I was looking for jobs with Medic and they told me there were no entry-level positions, but that I should check out Muso’s website, hence how I found out about the fellowship and applied, not really thinking I would get a response. 5 months later and I’m in Mali.
My specific role here: My title here is communications fellow. I will mostly be filming and editing interviews between patients and CHWs during their home visits. My main project/purpose here is to create more of a story around Muso’s work, particularly around the relationship and interactions between CHWs and patients. My work also consists of editing our website, updating staff profiles as we consistently are hiring more people, writing blog and op-ed style posts, and capturing film and photos of events like workshops, meetings with Ministry of Health officials, etc. I hope to go out in the field as much as possible to capture video and get a good sense of how Muso operates.
Broader scope of Mali: Mali (not Bali) is a land-locked country in West Africa bordered by Mauritania and Senegal to the west, Guinea, Côté d’Ivoire, and Burkina Faso to the south, Niger to the east, and Algeria to the north. Mali is a former French colony and gained independence in 1960. For westerners, Mali is probably most known for Timbuktu, a notorious backpacker’s destination and ancient trade route where Arab, African, and Maghreb cultures meshed in the heart of the Sahel region. Now, Timbuktu is off limits to tourists given the security issues which have emerged in the region in the past 5 years. Terrorist groups and civil rivalries (most notably between the Dogon and Fulani tribes) plague the Mopti region. The death toll and trauma that these feuds have caused have destroyed people’s livelihoods, leaving a scar on innocent civilians in Mopti. This has also affected Muso’s work in Bankass (about an 8 hour drive from where I live and work). In an attack earlier this year, approximately 150 of our patients were killed. None of Our CHWs or other staff members were killed or injured, although we are providing psychosocial support to those affected in the wake of this recent attack. With regards to Mali’s security crisis, it is important to remember that all news and journalist entities have their own agendas. What is being said is not necessarily what is happening on the ground. To say that it is unsafe to travel to Mali is sort of like saying you shouldn’t go to DC because there have been shootings in Southeast or you shouldn’t visit Florida because there were Parkland shootings. I trust the people I work with and my family who I live with now with knowing what is happening where we are in Yirimadio and Bamako. To read more on Mali’s security situation, here is a link: https://www.hrw.org/world-report/2019/country-chapters/mali. Ministry of Health and Muso’s relationship: Muso plays an integral role in providing preventable health care in the two districts we cover, Bankass and Yirimadio. We have a strong relationship with the Ministry of Health and meet regularly. The MoH supports us and our mission, recognizing the importance of integrating CHWs into an existing health system. With that said, we’ve still got a lot of groundwork to cover! For instance, we would still need to deploy tens of thousands of more CHWs in order to cover all 18 millions Malians, not to mention ensuring that these CHWs are paid and are delivering quality results. When comparing Muso to other models abroad, we can compare their CHWs’s work to the CHWs in Living Goods, Last Mile Health, and Partners in Health. One aspect that is unique to Muso is that we pay our CHWs and also provide them with health care and social security benefits. Personal Experience Here 1. Language barrier(s): For anyone who has moved abroad and cannot speak in the native language, you must know how difficult and frustrating it can be when you cannot express yourself or your level of intelligence accurately. It is frustrating for me to not be able to say what I want. The first night I was in Yirimadio, I didn't know how to tell my host mother, Tata, that if I drank the water directly from the well I would get sick. My body was and still is acclimating to water and foods here. Another example of this language barrier was when one of my co-workers was trying to have an intellectual conversation with me about my overall opinions of foreign aid. I obviously have many opinions on this. These opinions are hard to get across though when I have limited vocabulary! However, I know that both languages, French and Bambara, will come with time. My host family only speaks French and Bambara which will help me become fluent. I can understand my host mother, Tata, and one of her sons, Agisa (mon grand-frère). The other children either don't speak as much French or they don't slow down enough for me to understand them. Tata and Agisa both know that I understand them when they speak slowly, so that is how we communicate-slowlllyyy. I also meet with a French Tutor for 2 hours each morning at work. His name is Diatrou. Diatrou is super helpful and corrects me on every grammar mistake. If someone walks by and I greet them incorrectly, he will interrupt this interaction with a cry out loud or pound of his fist on the table. I am very grateful for such a good teacher. 2. The food: Overall, there is not nearly as much variety in foods as there is in The United States. I expected this. For breakfast, my family starts the day with cereal, either rice or millet mixed with hot water. It is sort of like rice oatmeal. Tata also makes one of my younger brothers go out to buy French baguettes for the family. I will eat these with either sugary tea or sugary nescafé coffee. Malians like sugar. A LOT of sugar. For lunch, I eat at Muso with my other female co-workers. In Mali, men and women eat separately. Around 2pm, the men and women gather for lunch and each group forms a circle around a big bowl of rice with different sauces, fish, or meat (usually sheep meat). Here, we eat with our right hand (the left hand is considered unclean and so everyone eats with their right), balling up handfuls of rice with meat/sauce/fish before popping the morcel into one’s mouth. For dinner, I eat with my family again. We usually eat rice with meat or fish sometimes. Sometimes we have spaghetti. I'm not sure how they make it, but it sort of tastes like mac and cheese with mild hot sauce. I know it is not actual cheese though; cheese is rare here and we also don't have a refrigerator. I have two favorite foods here so far. My first is called « faari », little dark chicken nugget-looking things which are actually made from black eyed peas ground into a flour texture with banking soda and water. These are bland but they have a lot of nutrition in them. My second favorite food here is called "juka" with sheep meat. It sort of looks like couscous made with peanut sauce (there are a lot of peanut dishes/sauces here). We had juka with a sacrificed sheep/goat meat during the holiday "La Fête" which was last week (literal translation is "The Day" in French when Abraham reached down onto a rock in the center of Jerusalem and called out to Joseph to sacrifice his son, and so the son turned into a sheep. Mali is predominantly Muslim, so there are many sacrificed goats all over the country on La Fête.
3. Directions: Unfortunately, my poor directional skills followed me all the way here. I take taxis or sotoromas (vans which serve as public transportation) to get most places, since Bamako and its surrounding peri-urban districts like Yirimadio and ATTBougou (the district of Muso's office) are all 2-7 km away from each other. Most people do not use a map, so you must use visual landmarks to describe where you're going. When I call a taxi home from work, I tell them I am going to the district Yirimadio behind le stade du vingt-six mars (The 26th of March Stadium). Once I get to that point, the taxi man must go right down a bumpy road, across a little canal, left at the lycée privée (private highschool), left again around a tower of tires, then right after we pass l'eglise catholique (the only catholic church here I have seen thus far). After about 12 houses, I will have reached Tata Koné's house. Yes this definitely took some time to get these directions down, and I have become lost more than a few times.
4. My family and co-workers: I don't know what I would do without my host mother, Tata Koné. She is a saint. I sometimes feel like a big baby walking around unknown territory here, since I still speak mediocre French and basic Bambara. Everyone at Muso and at my house are very kind and understanding-they know it will take some time to learn everything and become accustomed to everything. I have 8 siblings and some others who aren’t biologically related to Tata but whom she considers her own, including: Amadou (Baba), Ali, Cadwa, Awa (these girls are twins), le petit Amadou (baby Amadou) and his mother Oumou, Yah, Levieulle, Bala, Agisa, and Djeneba. All of us live here at Tata’s house except Djeneba (she works in the forest industry in Kurukuru) and Bala lives here part of the time (he is in the military and is often away). Ableau is my host father, Tata’s husband. Every night he comes home from work and we all stand up and go to greet him, regardless of what we are doing. Abdeu is a mechanic. He fixes motos and bikes. Tata works part time at Muso in the nutrition department and also at the local CSCOM to treat and consult on malnutrition. Tata’s mother, Nana, lives right around the corner from us and is also a saint. Last weekend I also met Tata’s grandmother, Nana’s mother, Nagé. Nagé is 99, which is considered very old in the U.S. and extraordinarily old in Mali. She is losing her eyesight a little but other than that she isn’t a day past 29.
5. Les Salutations et Benedictions! The most important part about speaking Bambara and living in Mali is learning the benedictions and salutations when greeting others in Bamanankan (the pre-colonized name for « Bambara »). When you greet someone in the morning, for instance, it is important to ask about their health, their family's health, their wife’s health, husband’s health, etc. They will respond with « tu’ro si tu la » which literally means « no problems at all ». Then they will exchange the questions with you and you will respond the same way. Once those initial questions are asked and responded to, it is important to also exchange benedictions and sets of benedictions for which you will ask for them to be passed on to other people one may see during the rest of the day. For instance, a general greeting may go something like this: I ni sogomo? (How is your family?) Nse, sogomo bedi. Tu’ro si te. I ka kene? (And your health?) Tu’ro si tu la. I Muso ka kene? (And your wife’s health?) Tu’ro si te/Muso ka kene. (Wife is fine.) I fa’ba be di? (And your father and mother’s health?) Tu’ro si tu la. Here sira (Peace upon you). Nse (response for girl) or Mba (response for boy). Allah-ka keneye di (May you have a peaceful day/journey). Amina. Allah-ka cle here caya. Amina. Allah-ka kilen kilen wuli (blessing for the night which literally means « May your children wake up one by one », because if they wake up all at once that means there was an emergency in the middle of the night and they did not have a good rest. You want your children to wake up one by one, with leisure.) Amina. Kambufo (greetings passed on) Uname (acceptance of greetings) *There are also blessings reserved only for the day of La Fête and other holidays but I won’t go over them now. *It is common to exchange blessings this way with almost everyone you see or talk to during the day. I say these blessings with my family when I wake up, before I go to work, with all the employees at work, people at the store, in the taxis, on the street, before I go to bed, anywhere and everywhere. 6. Du sport (exercise): I have found a great way to stay in shape while abroad—Jumping rope. I wake up around 6:30 or 7 each morning and do a combination of push ups/cardio/jumping rope to stay at least a little in shape. My goal is to do at least over 500 consecutive jump ropes each morning. There is also a 50 meter pool at le stade de 26 mars which is a 10 minute walk from my house. This is amazing and frankly bizarre that the first time in my life I live a 10 minute walk away from an Olympic-sized pool is in Mali. I didn’t bring goggles or a cap with me because I certainly didn’t think I’d be swimming, but I brought my suit which I am ever grateful for! Now working on getting goggles somewhere. Working alongside Muso and why I think it is important for those interested in global health to live/work abroad: I chose Muso for particular reasons. 1. They are research-based and back their implementations with qualitative and quantitative results. 2. They are not just churning through publications though; Muso is dedicated to the second part of this equation- implementation. 3. Unlike many other international development projects which fizzle out or cut funding after 4-5 years, Muso is committed for the long haul. We have American and Malian staff both moving interchangeably between the U.S. and Mali for a reason-we are a non-profit organization dedicated to providing quality health outcomes through dedication, diligence, and expertise. 4. I wanted to avoid doing a fellowship with other Americans or westerners/anglophones who were my same age/in the same position as me. While I have nothing against programs like Peace Corps, CLS, Global Health Corps, or Princeton in Africa (some of which I applied to!), I am very happy I ended up at Muso as a singular fellow. If I lived with other American fellows, this experience would probably be very different and potentially not quite as immersive. With that said, I do speak in English with my American colleagues on a daily basis. And yes, I can already say it will be occasionally really nice to go to a western-style restaurant for some country-style omelettes, a burrito, or a beer. Overall, if you are interested in a career in global public health, I think it is crucial to live in another place other than one’s own. While I certainly have not moved mountains in the public health arena, living here will make me grapple with the deep social, cultural, economic, and political complexities which make health systems function (or not function) the way they do. I am very very grateful for this experience and am still surprised that I’m even here/made it to Mali. Please send any questions.