A VISIBLE DIFFERENCE: IMMUNIZATIONS IN ETHIOPIA
Nine month old Bokallu Mofson scoots a toy car across his family’s brown laminate floor, pushing it through a shaft of evening sunlight. Finally, he throws it near a shelf that holds one of his mother’s newest prized possessions: a piece of yellow paper.
The neatly-folded sheet is a health record showing that, earlier in the day, Bokallu received the last of nine immunizations required by the Ethiopian government for children under one. For Bokallu’s mother, Haymanot Aimro, the paper proves that her son is healthy – and will continue to be.
Bokallu is one of a slowly growing number of immunized Ethiopian children. Just 51 percent have been inoculated against DPT (diphtheria, pertussis, tetanus) and 62 percent against polio, according to the United Nations Children’s Fund and World Health Organization estimates from 2011. A measles outbreak in 2011 underscored just how vulnerable the country’s young are to disease: about 2 million children were at risk of contracting measles, the WHO said at the time.
Increasing the country’s child immunization rates is vital to the health of millions of Ethiopian children. But doing this requires not only improving the ability to distribute immunizations – lack of refrigerators and deep freezers for storing vaccines is a problem, for example – but advocating the government for a stronger national immunization system overall.
Ensuring strong immunization policies
About 120 km away from Aimro’s rural home, Semu Teffera looks like any other office worker in the world. He types at his computer, talks on the phone and sits under dim fluorescent lights as the bustling sounds of Addis Ababa drift in through a window. With each keystroke, Semu ensures coordinated CSO efforts for health and immunization services in Ethiopia.
Semu’s latest accomplishment is a just-published directory listing all the country’s civil society organizations (CSOs) working on immunizations and other health issues. The directory, nearly 200 pages thick, helps organizations see where they might partner on related programs and geographic areas. It also allows for more collaboration in organizing health advocacy activities, thus improving health services overall.
“Before, there was no well-coordinated effort to bring together the voice of civil societies and to strengthen the health sector for immunizations,” said Semu, the forum coordinator for Ethiopia’s CSO platform led by the Consortium of Christian Relief and Development Associations. “But nowadays, we know which organizations are working on which specific interventions.”
The directory is among several projects funded by a grant administered by Catholic Relief Services to increase advocacy for immunizations and to strengthen CSOs working on those systems in Ethiopia. Among other projects the grant has funded in Ethiopia is the creation of a national health forum that brings government and CSO officials together to discuss immunization issues, and CSO participation in government meetings about health policies. Semu said the CSO network will be a success when it consistently coordinates its work on a national level. He figures the network is about 75 percent there.
“Our [CSO platform] work in the office and [our] representation of CSOs to government, policy makers and other partners is very important,” he said. “We represent the grassroots level CSOs working in health, advocating on their behalf for an enabling policy environment.”
An astute observation and a small regret
Back at Aimro’s home, abstract policies are not part of daily life. Like many Ethiopian mothers in rural areas, where people are often illiterate and can’t easily access radio or television, she personally witnessed the benefits of immunizations in other children. “I have been observing that vaccinated and unvaccinated children have quite a difference,” said Aimro. “Those unvaccinated children are suffering from measles and polio and I see various other health problems.”
Aimro wavered only once in her decision to immunize Bokallu. It was his 45th day of life and he had just received his second immunization. Afterward, Bokallu had trouble sleeping that night and Aimro regretted taking him for his vaccination. That feeling soon dissipated, though, when she focused on the positive impact the immunization would have on her son.
“I normally tell mothers that they should vaccinate their children to protect them from tuberculosis, to protect their eyes, their ears and to protect them from other health complications, and to bring health and strength to their future,” she said. “I love my child and I will do whatever I’m told to do for him.”
— By Laura Elizabeth Pohl for Catholic Relief Services and the GAVI CSO Constituency
KEEPING INFANTS HIV-FREE THROUGH NUTRITION
(The identities of the mothers and children could not be revealed so at protect the research being conducted.)
It was Juliette Mukayinga’s worst day of work in the past year.
Mukayinga, a nurse working on a research study for the Elizabeth Glaser Pediatric AIDS Foundation in Rwanda, learned that one of the mothers in the study had just found out her baby was HIV-positive.
“I can’t forget the tears of the mother, how she was grieving when she was informed about her child’s status,” said Mukayinga. “I explained to the mother that normally one result does not confirm the baby’s status, that we have to wait for confirmation from another test.”
When the confirmation test came back, it showed that the child was HIV-negative – a relief for the mother, but only after riding an emotional roller coaster that too many mothers experience every day all over the world.
Globally, nearly 700 children are infected with HIV daily. About 90 percent of those infections are from mother-to-child-transmission, in which the virus is passed from an HIV-positive mother to her baby during pregnancy, childbirth, or breastfeeding. Almost all of these infections are preventable through giving anti-retroviral drugs to the newborn or to the mother.
The research study Mukayinga is working on, the Kabeho study, looks at a new approach to preventing mother-to-child transmission of HIV (PMTCT): giving a mother anti-retroviral drugs for life and analyzing her child’s diet from birth to 18 months to see how both the drugs and proper nutrition impact the child’s HIV status.
Nutrition is extremely important when living with HIV. Maintaining a healthy diet is key to maintaining overall health while on HIV medication. Many medications need to be taken with food. For children, nutrition is especially important. In order to grow at a healthy physical and cognitive rate, a healthy diet is essential for infants and young children, particularly those exposed to HIV. The combination of a good diet and HIV medication could reduce the chances that HIV-exposed children will contract the virus.
“The findings from this study are going to help us understand what is happening in terms of feeding the babies and anything we can do to accelerate what the babies’ needs are,” said Dr. Jeanine Chondo, a medical doctor by training and the deputy dean of Rwanda’s School of Public Health. “Many, many people are watching this study.”
If the Kabeho study shows that this new process is more effective than other methods of PMTCT, it could mean a revamping of public health policies around the world and thousands more children living an HIV-free life.
“We May Lose Our Children”
On a recent morning, Vincent Iyamuremye, a research study nurse at the health center in Kimisagara, pokes his head out of his office into the hall. A half dozen colorfully-dressed mothers and their babies wait on wooden benches. Vincent waves one woman in. She sits down, baby squirming in her lap, and Vincent spreads out a pile of kitchenware and utensils on the desk in front of her. The woman is one of 104 mothers he sees, the most of any health center involved in the Kabeho Study.
“What did you feed your baby in the last 24 hours?” Iyamuremye asks the mother. How much? He holds up a clear baby bottle with markings on it. This much? The mother points to a mark near the top, and Vincent writes something down in the mother’s binder. The questions and answers about the baby’s diet go on for about 30 minutes.
This 24-hour food recall, which happens once a quarter with each mother, is one of the hardest parts of being a research nurse. But it is one of the most important parts of the Kabeho study, because collecting accurate nutrition data is essential to understanding what role nutrition plays in preventing mother-to-child transmission of HIV.
Chronic malnutrition among Rwandan children aged six months to five years stands at 43 percent, according to a 2012 report from the Rwandan Ministry of Agriculture and Animal Resources and the World Food Program. The government has been combating this with a number of recommended practices, including exclusive breastfeeding for a child’s first six months, a standard set by the World Health Organization (WHO). After six months, WHO recommends adding in other liquids and solid foods until 24 months, at which time breastfeeding can stop. But a breastfeeding HIV-positive mother poses a risk to her child. Unless, that is, she rigorously sticks to her antiretroviral (ARV) drug regimen, which helps prevent the passing of the virus to her child.
“Not only is malnutrition a problem in Rwanda, where we have around 45 percent of our children under age five who are stunted [low height for age], but in other countries as well. If we let malnutrition be a problem for that particular group exposed to HIV, we may lose our children,” said Dr. Jeanine Chondo.
Therefore, research nurses work hard to make sure mothers remember as much as they can. For instance, the bowls, plates, bottles, and cups are there to help mothers accurately remember how much of which kinds of foods their child ate.
During the 24-hour recall, mothers sometimes don’t remember what they fed their child. Or someone else – a nanny, a neighbor, a relative – fed their child, so the mothers aren’t clear on what their child ate the day before.
Since the study started in March 2013, these quarterly food quizzes plus once-a-month health Q&A sessions have yielded close relationships between the nurses and many of the 608 mothers participating in the study. This despite the fact that the 13 research nurses can’t give advice, provide care, or intervene in the mothers’ lives in any way that could influence the data they’re collecting. Instead, the research nurses work closely with other health center nurses and encourage mothers to seek actual care from the non-study nurses and doctors at the same health center.
“We have become like the brothers and sisters,” said Iyamuremye, “They tell me their news, some of them they are doing business, they come and tell me about their business. We are very happy.”
“It’s for those who will be born later and have a great chance of being negative”
As the nurses collect information and input it into tablets, Dieudonne Ndatimana is sitting in a sparse office in Kigali downloading, compiling and evaluating all that information. Ndatimana is the data manager on the Kabeho study, and he’s a big fan of clean data — meaning the information collected by the study nurses is valid and accurate. So if, for example, a nurse inputs that a mother is 30 years old, the mother must really be 30 years old.
“When the research is published and is available to the public, the first thing people will look at is the data,” said Ndatimana. “So it’s very important to have clean data.”
Since the Kabeho study tracks mothers and babies through the children’s first 18 months of life, results won’t be ready for another 18 months, with results published shortly thereafter. Ndatimana and the study nurses and even the mothers are excited to find out the results.
“The women, they have the feeling they’re providing information that would help lead to elimination of HIV,” said Mukayinga, research study nurse at the Remera Health Center. “They usually say, ‘Even if this might not be very helpful to our current babies, but at least it’s for those who will be born later and have a great chance of being negative.’”
— By Laura Elizabeth Pohl for the Elizabeth Glaser Pediatric AIDS Foundation
UNEXPECTED LIVES: NORTH KOREAN REFUGEES IN SOUTH KOREA
Lee Kyung-Hee sits on the floor in a sparsely-decorated apartment, just thinking: about her uncertain future, about her inability to find steady work, about the circumstances that have led to her present life. It’s daytime but the floor-to-ceiling blinds are drawn and the overhead light is on, casting a yellowish glow over the room. A Korean comedy show flickers on the television but Kyung-Hee stares and does not comprehend.
Thinking is how Kyung-Hee, a North Korean by birth, has passed much of her time since coming to Seoul, South Korea, in 2004. She sought a better life for her and her 22-year old daughter, Mi-Young. Instead she has found isolation, depression, health issues and financial problems. Kyung-Hee, 54, feels alone even among other former North Koreans living in the neighborhood, which is home to the second-highest concentration of defectors living in Seoul.
“They have daughters, sons, husbands, good lives and money,” she said, forgetting for a moment about her daughter. She shakes her head, animating her short black curls. “I’m jealous. Among all other defectors, I’m alone.”
Though she feels alone, Kyung-Hee is one of over 8,000 former North Koreans living in South Korea. The number of defectors coming to South Korea has been rising for the past five years and brings to the fore the sensitive issue of how to socially integrate people who share a recent history but have grown culturally apart from their South Korean counterparts. The experiences of this growing minority are a microcosm of what could happen in the event of unification, which many experts say will lead to thousands of northerners migrating to South Korea.
North Koreans arrive in South Korea often expecting to feel a bond with South Koreans; the north and south share historical and cultural ties that date back thousands of years. But for many, the reality is different and the adjustment is hard.
A growing minority
Between the end of the Korean War and the end of 1989, 607 North Koreans came to South Korea. Most were welcomed as heroes who defied the evil communists intent on destroying the south. South Koreans called these North Koreans “gui-seun-yeong-sa” or “freedom fighters following the righteous path.” The government lavished them with gifts and money.
“Even South Koreans have a hard time living since the economic situation is not so good. They think that if the government has money to support North Koreans, why don’t they help me?”
But over the past five years, the number of North Koreans coming to South Korea each year has risen sharply and caused a shift in South Korean society’s attitude toward them. The number of arriving North Koreans rose from 583 people in 2001, to 1,139 people in 2002, to a one-year peak of 1,894 people in 2004. Almost 600 people entered South Korea between January 2006 and the end of April 2006. The South Korean government expects that in the next two to three years, 10,000 North Koreans a year will enter South Korea.
The sharp increase in arrivals is due to ongoing North Korean food shortages, a breakdown in North Korea’s social surveillance system and a rise in the number of non-governmental organizations (NGO) workers and missionaries helping North Koreans who have escaped north out of their country to China. Leaving North Korea is dangerous as it usually involves bribing a border guard swimming or wading across a river and then hiding in China.
Although South Koreans understand the situation and see why North Koreans would want to leave their country, many South Koreans harbor an extreme dislike for the northerners living in their borders. In the view of South Koreans, North Koreans live off the South Korean government and show little gratitude.
“As the number of North Koreans has increased, South Koreans have had more opportunities to have contact with them and see they are very different in attitude, work behavior and accent,” said Choy Yong Seok, deputy director of the Ministry of Unification’s policy agenda management team. “South Koreans feel North Koreans are very dependent and don’t show appreciation for the help given to them.”
North Koreans spend their first three months in South Korea at Hanawon, a government-run facility where they are debriefed and taught Korean history and cultural norms. They are also taught skills such as how to open a bank account, how to use a computer and how to find a job. Then, for their first year in South Korea they receive a yearly government stipend of between $10,000 to $15,000 in monthly or quarterly installments. The government also gives them job training, educational fees assistance and an apartment where they have to pay rent but not the deposit (deposits in South Korea start at about $20,000 for a one-bedroom apartment).
“Even South Koreans have a hard time living since the economic situation is not so good. They think that if the government has money to support North Koreans, why don’t they help me?” said Choy.
The answer has much to do with the ways in which South and North Korean society have diverged over the past 50 years. After years of living in one of the world’s most isolated communist nations, many North Koreans have trouble coping in a competitive and capitalist society. Indeed, many lack any marketable work skills. In addition, northerners often face discrimination and questioning because of their accents and “strange” Korean vocabulary, which has grown markedly different from the Korean spoken in the south since the division of the Korean peninsula.
With these strikes against them, people who found the strength to leave North Korea, evade authorities in China and make their way to South Korea sometimes become listless, disenchanted and meek in their new country.
“They’re docile (here in South Korea) because it’s a dominant culture. They’re relatively marginalized and that tends to make them docile,” said Tim Peters, founder and director of Helping Hands Korea, a non-profit Christian organization that helps North Koreans get out of China and eventually into South Korea.
Further complicating their adjustment is the memory of difficult experiences in China and the sadness of leaving behind family and friends they may never see again. It’s no wonder, then, that many suffer from depression, post-traumatic stress syndrome and other health problems.
“They’re more likely (than South Koreans) to say they have heart problems, headaches, backaches and pains,” said psychologist Lee Ha Young. She counseled North Korean defectors for Doctors Without Borders before its South Korean mission closed in the spring of 2006. “But if you go through talking with them you learn all these things are related to psychology.”
A survey published by the Seoul city government in December 2005 found that about 90% of North Koreans living in Seoul are unemployed. Choy at the Ministry of Unification said that number may be closer to 20%-30% when taking into account people who lie about their status to keep receiving government welfare. Either way, the number is higher than the 3.7% unemployment rate reported for all of South Korea in 2005.
Critics have said for years that the South Korean government should focus less on financial support of North Koreans and more on job skills training. It seems the government finally agrees. Beginning later this year, North Koreans arriving at Hanawon, the resettlement facility, will spend half of their three months there receiving job training. In another program begun in late 2005, the South Korean government pays employers to hire North Koreans, who have been stereotyped as unmotivated workers.
The Ministry of Unification has also made it a top priority this year to educate South Koreans about North Koreans. Among its initiatives is pushing usage of the term “sae-teo-min,” which means “newly-settled people” to describe North Korean defectors, instead of “tal-buk-cha,” which means escapee from the north” and has been in common use for 10 years.
But even as the government works to improve North Koreans’ lives and change society’s attitude toward them, some people believe it is North Koreans themselves who need to change their attitudes about what to expect from South Korea.
“You have to forget the past and start over,” said Nam Sung-wook, a professor of North Korean studies at Korea University in Seoul. “I think they (North Koreans) have to work in 3D jobs – dangerous, dirty and difficult jobs. The first generation has to work hard so the next generation will have better opportunities. But they (the first generation) think that when they come to South Korea their happiness starts. They misunderstand capitalist society.”
Lee Kyung-Hee’s Story
Kyung-Hee was born in what is now North Korea in 1951 during the chaos of the Korean War. By the war’s end, her soldier father was in the south while she and her mom, older brother and older sister were in a city near the border with China. Only after Kyung-Hee came to South Korea in 2004 did she find out that the father she never knew died years ago.
Kyung-Hee, a petite woman with a thin face and piercing black eyes, grew up happy. She married, had a daughter named Mi-Young and then lived alone after her husband died. She worked as a seamstress. She and her family celebrated her mother’s 60th birthday, a landmark birthday in Korean society. But then came the famine of the 1990s hit. There were many days when she didn’t eat. Kyung-Hee became convinced that life in China would be better. So she packed up her daughter, crossed the border in the dead of night and lived in China for the next five years.
Like many other North Korean women in China, Kyung-Hee married an ethnic Korean-Chinese man to guarantee her survival. She worked on a farm. Life was OK. However, the constant threat that the North Korean police would find her and take her and Mi-Young back to North Korea made her decide she should go to South Korea. Kyung-Hee paid $5,000 to a broker, sent Mi-Young to South Korea in 2003 and followed her daughter a year later.
A little over a year since first arriving in South Korea, the reality of life is bearing down on Kyung-Hee. She has unexplained aches and pains in her body. She takes five medicines a day and can’t find a job. She feels the ability to do housework is one of her few skills. She briefly worked as a call center operator, but she can’t find a permanent job. The lack of work feeds Kyung-Hee’s depression and her worries about the future. Her government stipend ran out last year.
“I’m getting old, so where will my money come from? It’s hard because I’m older so I can’t find a job,” she said. “I’m worried.”
For now, she is supported by Mi-Young, who works at a restaurant. While Kyung-Hee’s life stands still, Mi-Young’s life moves forward. She recently had plans to marry her South Korean boyfriend and move south with him, causing Kyung-Hee to worry about what would happen to her. Kyung-Hee’s worries did not subside after Mi-Young and her boyfriend broke up.
“She will marry one day, and then where will I go?” she said. “I have no friends. I have no one else.”
Recently, Kyung-Hee has begun to idealize her five years in China, saying, “if there were no North Korean police I would have kept living there.” However, she acknowledges that her life in South Korea is an improvement over her situation in North Korea.
“I don’t regret coming here,” she said. “Life is better here, but it’s still hard.”
Park Mi-Hye’s Story
When Park Mi-Hye arrived in Seoul in 2002, she felt overwhelmed. Tall buildings surrounded her, people rushed around her and the ways of this foreign society were hard for her to understand.
“It was so complex,” she said.
Mi-Hye grew up in a middle-class family just outside Pyongyang, living a relatively comfortable life in a country where proximity to the capital city indicates a higher social status. She married in 1991 and became widowed in 1995. After her husband’s death, Mi-Hye wanted a fresh start on life for herself and her two children.
Listening to her father-in-law cry as he told stories of his hometown of Busan, on the southern tip of the Korean peninsula, Mi-Hye started to think of South Korea as an option. She sometimes had a chance to watch smuggled videos of South Korean TV dramas. The TV characters wore nice watches. There were lots of cars on the streets. South Korean life seemed good — really good, in fact.
Adding to her sense of wonder about South Korea was a friend who relayed stories of North Koreans she knew who went to South Korea and lived happily. The North Korean government tries to block information like this from seeping into the country, but increased trade between China and North Korea, the rising use of cellphones along the border and the smuggling of videos into the country mean information is practically free-flowing compared to the days before high technology.
In early 2002, Mi-Hye crossed the border into China with her then-11-year-old son Yu-Jin; her daughter hid with relatives because she was too young for the dangerous journey. Mi-Hye and her son spent three days in a city in northeastern China before flying to a southeast Asian country. They spent two months there, during which time Mi-Hye came to know Christianity from the missionaries helping her and her son. Then they gained asylum in South Korea.
Mi-Hye spent the next three years working to get her daughter out of North Korea. She cooked and cleaned all day in a restaurant. She reconnected with an old Pyongyang friend who left North Korea a few years before her. She found God.
Finally, Mi-Hye saved enough money to bring her now-11-year-old daughter Yumi to South Korea. Yumi came to Seoul in May 2005 via China, where she spent about a week hiding with a guardian. During that time she cut her hair short and dressed as a boy so as to avoid being kidnapped into prostitution rings that prey on North Korean women in China. Yumi calls that week away from her family “kind of fun,” but she now wants to grow her hair as long as possible.
Five years after arriving in Seoul, Mi-Hye can be described as a person living a busy immigrant’s life: for eight or nine hours a day she runs a newspaper stand in a subway station and for four hours in the middle of the night she cleans a hagwon (tutoring school). In between she takes care of her two children and keeps in touch with brokers in China who are helping her get the rest of her relatives out of North Korea. Last year she succeeded in bringing her brother and his wife to Seoul. Mi-Hye’s dream is that her whole family will be successful and move to the United States one day.
“I don’t think about stress and if I do I just forget about it,” she said.
— Reported by Laura Elizabeth Pohl in 2006