[MUSIC] So this is a story about an experience I had in a southern African country. I'm not going to name the country to protect the guilty. But this was shortly after I defended my dissertation at Hopkins, finished my PhD. And within about two weeks of finishing, I had to fly off to this country to do a project on the use malaria rapid diagnostic tests at the community level by community health workers. This was a novel thing at the time because in Africa people had been reluctant to allow community health workers to use rapid tests because of the fear of blood borne disease transmission particularly HIV, AIDS transmission. And the fact that you had to take a blood sample to use the test was something that Ministries of health were not sure they wanted to risk. So part of the point of this project was to find out whether community health workers could use rapid tests safely and effectively. And this had been arranged in conjunction with WHO and with the National Malaria Control Program for the host country. And I flew in, I was scheduled to give a brief presentation about the fieldwork to the National Medical Council, the country's National Medical Council on Monday morning. And Monday afternoon we were going to take off for the field and we had about three weeks planned to do focus groups, interview community health workers. Observe them trying to use the test, show them how the test worked, and then develop a job aid, a pictorial set of instructions that people who maybe have very limited primary education, two or three years of primary education or may even be completely non-literate could use and see whether or not they'd be able to do it safely. So I show up at the National Malaria Control program Monday morning, give my presentation to all the very serious-looking doctors wearing suits and ties around the table. And as I'm presenting the very serious-looking doctors wearing suits and ties begin to look more and more serious. And at the end of the presentation, somebody says to me, thank you very much. Could you please step out of the room while we discuss this for a little bit? And about three hours later they called me back in. And they said, actually we didn't get ethical approval to this yet. So, we're really not ready to let you go ahead with this study. Maybe you could go home and come back in two or three months. So here I was sitting in the capital of this country thinking, great, I arrived here last night, I was here for a day, we spent all the money to get me out, we made all these arrangements, people from WHO are here, and now I'm going to have to get on a plane and go home. So we spent the rest of the afternoon negotiating with medical council. And at the end, they decided they would let us do the first phase of the study. Because the first phase wasn't going to have community health workers actually using the rapid tests. It was just going to be community health workers observing somebody else doing it. Talking to us about what they understood and us, then, using that information to develop pictorial instructions. And testing those instructions with them to see whether or not they understood the instructions. Whether the instructions were clear, and they could carry out the task using those instructions. So the medical council said okay we guess that's safe, and we'll let you go ahead and do that, but the rest of it you're going to have to come back and do some other time. Now the reason why we needed to do something other than the instructions that came with the test, is that the instructions that typically come with these tests are very brief. They are almost always in English. They are in a type size that you can't read unless you've got a magnifying glass or a microscope. You can see on the back of the package here that this is almost impossible to read. And you might even notice that there are a couple of images here of tests with lines on them. But those lines, when you see the actual test, turn red. And so if you look at these pictures and you don't know what to expect, you're not expecting to see a red line on the test. You're expecting to see a blue or a black line and people don't know how to interpret them. So, in any case, we had to come up with a better set of instructions. So we got permission from medical council and we were supposed to leave on Tuesday morning. Tuesday morning I showed up at the National Malaria Control Program and they said well there's a little problem, actually the money hasn't arrived yet to pay for the field work. Now, the money had been sent by WHO in early December, this was now early January. And it turned out that because it was WHO money, it had to go from Geneva to Brazzaville before it could be sent to the country in which we were working. And because it was the end of the year, Brazzaville was closing out its budgets. And the money didn't arrive in time to get in on the previous year's budget and it was never transferred. And we had to wait for them to open up the current year's budget before they could transfer it. So we spent the next two or three days on the phone with the WH office in Brazzaville, doing everything we could to get the money transferred. The money finally arrived on Thursday, I think it was, then we had to get somebody at the Ministry of Health to sign the letter of authorization. That person was gone for the day. We couldn't get anyone else to sign the letter of authorization because, of course, there's only one person that can sign letters of authorization. So the next morning, because the Ministry of Health offices was located across town from the National Malaria Control Program, we sent a driver over with the letter to get the person who needed to sign it to sign it. The driver was gone for several hours, takes about an hour to get there an hour to get back. After about three and a half hours we called and said what's going on, where's the letter? And they said well the person isn't here. And we said well that's a problem because we really need to leave for the field or we're not going to be able to get this work done, where is the person? And the driver said I don't know let me check and he called us back a few minutes later. He said actually that person is at the National Malaria Control Program. In fact, it turned out that person was in a room just next door to our room, in a meeting with the director of the National Malaria Control Program. So the driver had to spend another hour driving back across town. Show up with the letter. Then we had to wait for the meeting to be over because we couldn't interrupt these two important officials in their meeting to get a signature. And by the time this all happened it was 4:30 or 5:00 o'clock at night. And we were getting ready to leave for the field site in the dark, not always the most advisable thing to drive on narrow roads where cars are not in great repair, and don't have headlights, and things like that in the dark. But what are you going to do? So we set off and within the first 15 or 20 minutes down the highway, we had a blowout. Tire went flat. So we pulled off and we changed that and that took about an hour, and then we kept driving, and we had been told that the field site was about three hours away. So, three hours later, at that point about 10 o'clock at night, we turned off the highway and I thought, okay, well great, this wasn't too bad. We're almost there and we'll get a chance to get settled in the guest house and get some sleep, and we'll be up tomorrow morning fresh, ready to go to work. So we turned down this dirt road and we drove down the road a little ways. And I thought, I'm sure we're going to get there soon. And we kept driving down the road a little ways further, and I kept thinking, okay, I'm sure we're going to get there soon. And we didn't get there, and I finally asked, so, where is this place exactly? And they said, it's about another two and a half hours down the road. So we spent another two and a half hours on this dirt road, very poorly maintained. There were about 12 of us in a Range Rover that was supposed to have space for 7. So it was quite crowded and all the luggage, and all the field equipment, and everything else, brutally hot. We arrived about one o'clock in the morning, in this little village where we were suppose to be staying. We knocked on the guest house door, and the manager of the guest house said, well since you didn't show up we thought you weren't coming and we gave your rooms away. So great what do we do now? We scramble around with the help of local health officials we found some local people in the village were willing to let us sleep on their porch for a night. And we divided up the terms into various pieces and people went to sleep on different porches and tried to rig up bed nets as best we could to try not get all our blood drained by the mosquitos that were flying around in dense clouds. Made it through the night. Not the most pleasant I ever spent but not the worst either. And the next morning, we got to the business of hiring our field workers and training them and starting to do interviews. And that's what we did for the next couple of weeks. So over that course of time, over the course of those next couple of weeks, we were up and down that three hour dirt road probably 20 times. We interviewed every community health worker in the district. We did demonstrations of the tasks, we had them talk to us about what they saw. We put pictures together, we tried out different mockups of the job aid. In the mean time we were staying in this guest house and the guest house actually looks quite picturesque. The kind of place you might imagine staying on a beach in Bali. You can see a picture of it here. Nice pink walls and palm trees, all very pleasant. But in the picture, you can't feel the heat or what it's like on the inside of the rooms. When it's very humid, and over 100 degrees everyday and there is no ventilation. And the electricity works for maybe two or three hours a day, goes off at odd times. There's a generator, because they need to run their operation, we need to be able to charge our laptops. But the generator depends on gasoline and often runs out, and the guest house often doesn't have money to buy the gasoline. So we give them money, but then they have to go to the gas station and sometimes the gas station doesn't have gas and we've got to wait a day or two for the truck to show up with the gas, you get the picture. Water's also a bit of a problem. It goes off quite frequently, several periods of two or three days with no water. Even when there is water, it's not the most appetizing looking water in the world. You can see in this picture here, running in the sink that it actually looks more like chocolate milk than water. But anyway it was enough to sort of get clean in the bathtub but certainly not to drink. And that's where we did our work. But the end result was quite good. We developed this job aid that's become very successful. It took us a little while to get back to the capital city in the end. Now I'll finish up the story about the job aid. So the day we were supposed to leave, I had a flight in the evening that night from the capital city. I knew it was going to take us about six hours to get back because it had taken us about six hours to get there. And, I'd been told that we'd leave at nine in the morning and we'd have plenty of time we'd be back by 3:00PM and I have plenty of time to get to the airport by 6 and catch my plane at 8 or whatever it was. But at 9 there was no car and no driver, and at 9:30 there was no car and no driver, and at 10 there was no car and no driver. And so I said, what's going on? I'm getting a little worried and our counterpart, our local counterpart and teams said don't worry it's fine. The driver will be here any minute. So, we waited about another hour and the driver still wasn't there. And I finally decided I'm going to ask around and see if I can find the driver. It turned out the driver was down by the river, because he thought he'd get some fish to bring back to the capital. There aren't fish like this in the capital. Fish like this, by the way, mean fish that were caught that morning in the river and have been sitting, drying out on the riverbank for four or five hours by that point in 100 degrees sun. So they were quite fragrant. So anyway, the driver was selecting his fish and he filled up a couple of coolers full of fish. And we loaded them up with everything else in the Range Rover for 7 people with 12 of us and the luggage and the fish. And we started down the road. And after about 20 minutes or half an hour we pulled off into the parking lot of a health center, one of the health centers we visited. And stopped and I asked our local counterpart, why are we stopping here? We've got to get back to the capital, I'm starting to get worried about my flight. And she said well I decided I'd get a goat to bring back to the capital because they're a lot cheaper here than back there, so I'm going to bring a goat home. Okay, that's interesting. Where are we going to get a goat in here with everything else? We waited and in about 15 or 20 minutes, I see a community health worker walking down the road carrying a burlap bag. And out of the top of the burlap bag, there are two legs sticking out and hooves. And out of the bottom of the burlap bag I can see that there's blood dripping onto the ground and there's the goat, freshly slaughtered, ready to come in the Range Rover with the fish, and the luggage, and the 12 people, and everything else. And we drive down the road a little further and we get to a truck stop and they're selling baskets. And somebody in the car says, I think I'd like to buy a basket. So we stop, and we're about a half an hour at the basket market. And everybody gets their baskets, and they get back in the car. And then one last person says, actually, now that I'm thinking about it, maybe I'll buy a basket too. And they get out of the car and we spend another half hour buying baskets. And then we finally get on the highway and we get back to the capitol, and I make my plane with maybe 15 minutes to spare after this very long trip back from the field. But it took us a while to get the rest of it together, we had to come back and do two more phases of the project. One about six months later and one a year after that. Both of them took longer than we expected, the second phase that happened six months later, was suppose to happen a month or two later, got delayed a million times for any number of reasons. But in the end, we published what we thought was a very good set of instructions, and a very good training manual for community health workers to use. In fact, it was so effective the WHO wound up adopting it as their standard material for training community health workers about the use of rapid tests. And it's on the WHO website now, almost 10 years later, in a generic version that people can download, and adapt to whatever brand of test they're using in whatever language they're using. And it's been translated in French and Burmese, and Swahili, and a whole bunch of other languages. And the article we published on this turns out to be the most frequently cited article that I've ever published. So, in the end, it was not the smoothest project I've ever worked on but it was certainly worthwhile. It's had a reasonably significant impact on this particular aspect of public health. It's work that I'm proud of and that I think has turned out quite well. And it's the kind of work that you might be able to doing also in your internships, as you're getting ready for them or later on. But you have to expect that these sorts of delays and sorts of aggravations and these sort of set backs are going to happen, because it's what happens everywhere. And oftentimes if you manage it well and you're patient and roll with the punches, it can have very good results. And that's the story.
