THE SUMBA
PROJECT
Post Trip Report 2019
This year the Sumba Project Team embarked on our sixth annual trip to the island of Sumba. Year by year the group continues to grow with a healthy mix of experienced members and fresh new
faces, eager to get involved in the numerous projects we have worked on. The trip is always a highlight of the year for the Sumba team. We were all keen to finally get on the ground after many months of hard work behind the scenes back home in Australia. This year’s trip was centred around further development of two of our core projects: the hand hygiene and malaria books, and the tuberculosis course, which had been the mainstay of our focus over the past two years. Our aims were to gain information on the status and implementation of each of these projects, and also provide our newest members with a unique insight into the various projects we have been involved in since the group’s conception.
The team were fortunate enough to be invited to attend the official opening of a newly constructed educational centre in Lamboya, South West Sumba. The centre was funded by the Sumba Foundation, an NGO with whom we have been working closely with for the last two years on the Tuberculosis course. We were greeted by members of the foundation, six teachers, a group
of excited school children, the heads of the 4 main regions of Sumba known as ‘bupati” and the local member of parliament for the island. The team were lucky enough to observe a traditional Sumbanese ritual and sacrifice which was performed as part of the opening of the new facility. This ceremony ensured the building would be protected from evil spirits and served as an insight into the local Sumbanese culture and traditional practices for those new to our group. The new building will be
used by the Sumba Foundation team to teach the local children english and computer competency, hugely valuable skills in light of the inevitable wave of tourism bound for the island in the coming years. The Sumba Foundation employs 6 full time teachers to teach english and hygiene to thousands of children across the Gaura and Lamboya regions. The teachers requested our books to help them maximise engagement and content uptake during their sessions. To better understand their needs and teaching styles we proposed a trial teaching day with about 40 children at the new education centre. After the opening ceremony the Sumba Project team sat down with the teachers to plan how best to
execute our day with the kids the following day. This included troubleshooting potential problems, discussion of the logistics of running the sessions and setting up learning activities for the kids, such as “Tippy Tap” washing stations for teaching hand hygiene.
Day 2: Hand Hygiene and Malaria education with the Miss Doggy books
Our second day included a full day at the English Learning Centre with the teachers and students. The day didn’t start as planned as more than double the expected number of students arrived eager to participate in the day’s activities. The group consisted of around 80 students of varying ages ranging from 4 to 16 years. Seeing so many children arrive excited to learn, despite it being their school holidays, reinforced the value the Sumbanese children place on education. Prior to beginning the morning session, the students showcased their English skills by welcoming the team with songs they had learnt as part of their course.
The day was split into two sessions, with the morning being spent on the hand hygiene book and the afternoon focussing on the malaria book. During each session, the students were split into smaller groups of 10-15 children and were led through the books by their teachers. The team were able to observe a range of different teaching styles during this exercise, which was extremely valuable. After each session, the children were able to implement the key messages of the books through practical exercises. The morning exercise included using the “Tippy Tap” stations to practice effective hand hygiene. This was extremely well received by the students, who were able to enthusiastically and efficiently show their skills in hand washing. In the afternoon, the children were tasked with identifying good and poor-quality malaria nets. This was done very effectively, with students being able to determine faulty nets and also show an understanding that they were unsafe for use. The day concluded with a debriefing and feedback session with the teachers. The feedback we received was hugely positive and we were able to gain valuable insight into the most effective ways to implement the books in schools in the future.
Day 3: Tuberculosis project, Low smoke burners and future directions
Our third day on the island was spent with members of the Sumba Foundation team, Dr Claus Bogh, Dr Jacklyn Adella and experienced malaria diagnosticians Andy and Augustina. Dr Bogh and his team will be responsible for the implementation of the tuberculosis diagnostics program that we have been involved in over the last two years. The course is in its final stages of development and there are plans to run a pilot course as early as August this year. Given the sophistication of the material it is intended to take up to 3 weeks to deliver. This was extremely rewarding news for the team, given it has been the majority of our work over the past two years. We discussed edits and amendments to some core material and also the development of course examination.
Dr Bogh was also eager to discuss his latest project with the team. Respiratory diseases such as COPD and asthma are major health issues in Sumba, so Dr Bogh and his team are looking into researching the impact of introducing a low smoke burner stove into homes to replace the inefficient traditional three stone stove setup. Many Sumbanese people experience chronic smoke inhalation due to traditional cooking practices within the home, and this is thought to be a major causative factor for these diseases (it is estimated up to 3 packets of cigarettes a day passive smoking in some circumstances!). The low smoke burner stove is simply a small ceramic circular stove which would act as an insulator, maximising heat usage and allowing for a higher temperature and more efficient burn which produces less soot. The session involved developing a study questionnaire with Dr Bogh and his team that will be used to not only evaluate the impact of the low smoke burners on the participants health but also a number of socioeconomic factors. Formulating a questionnaire that succinctly and simply assessed these factors proved challenging and took some hours of discussion.
While Dr Bogh had the low smoke burner stoves imported for this study, it is hoped that if the burners are well received they could be made by local clay makers to stimulate further industry on the island. The burners greater efficiency should result in less firewood being required, freeing up time and money which would otherwise be used to acquire it. Overall this project has the potential to have clear economic and health benefits, increasing the local Sumbanese people’s quality of life.
The final parts of the day with Dr Bogh and his team were spent discussing potential future directions for the Sumba Project. Dr Adella was able to provide us with valuable insight regarding health issues that are unique to Sumba, given her experience as a first line practitioner in local clinics. Overall, the session was extremely productive, with multiple potential areas of focus being identified for further discussion.
Day 4: Consolidation and future planning
Our last day on the island was spent debriefing with the team to consolidate the information we had learnt over the last three days and to further discuss our future direction. The key areas identified included the need for educational resources for nurses and midwives to use to educate families about malnutrition, the potential to create a resource for identification of tropical dermatological skin infections for primary health care providers such as nurses and Dr Adella, and the potential need for education regarding sexual health issues on the island.
Wrap Up
Every year we visit Sumba, we fall more and more in love with the island, its rich culture and astounding beauty. It really is a privilege to work with the people of Sumba and contribute to the programs of such incredible NGOs who empower the locals to improve their health and quality of life. We look forward to the challenges ahead and further expanding on the ideas proposed for our future direction when we return home to Australia.
From all of us here at The Sumba Project, we’d like to say a huge thank you for your on-going support. Without it, none of this would be possible.
Until next year!
The Sumba Project Team.
Post Trip Report 2018
OVERVIEW
The Sumba Project team was incredibly excited to be undertaking our fifth annual trip to Sumba in June 2018. After many months of hard work in Australia, it was time to get back to the island to build on the success of last year’s trip and take our project a step further.
In 2016-2017, the group had embarked on a new project, which involved working with Dr Claus Bogh of the Sumba Foundation, to set up a tuberculosis (TB) training centre alongside his already world-class malaria program. On the last trip, we had taught a preliminary course in English to the health care workers from the Sumba Foundation. We were returning this year having worked hard to rectify areas of the course that the healthcare workers had highlighted through their feedback in 2016-2017. We were also planning to deliver a number of ancillary resources to aid comprehension of the course. These resources included a TB workbook to be used as a future reference by the students, multiple interactive workshops to practice the practical side of the course, and a Sumbanese-designed flipbook, which could be used by health workers to educate patients diagnosed with TB. Another initiative of this year’s trip was to have local health care workers deliver the course in Bahasa to a group of Sumbanese students. This meant our role focused more on gathering feedback from the teachers and students for the last iteration of the course which we are aiming to have finalised for the first official (and government supported) run of students in December 2018.
TRIP OBJECTIVES
Our first objective for this trip centred on better understanding the Sumbanese health care system to ensure our course complemented the structures already in place on the island. We also hoped to gather feedback from key stakeholders on Sumba intimately involved in the identification and treatment of TB. We hoped that we could gain critical insight into the challenges healthcare workers were currently facing and then implement strategies to overcome these barriers using our course. Some of the key stakeholders we planned to meet included practicing clinicians and local government workers.
Lastly, we aimed to test the delivery and uptake of the latest iteration of our course, which for the first time, would be delivered in Bahasa and taught by Sumbanese healthcare workers to local students. By staggering multiple structured feedback sessions throughout the course, we hoped to gain a comprehensive assessment of the course’s usefulness, relevancy and feasibility as well evaluating the effectiveness of some of the newly developed resources.
DAY 0 in the field: Arrival in Bali and first meeting
The group arrived to a lovely tropical day in Bali and settled in to our accommodation after a busy week of exams for the 3rd and 4th year medical students. A group discussion was organized for that afternoon where we discussed the plan for the next 5 days. We also discussed the feedback process and how we could best elicit the thoughts of the Sumbanese students whose lovely and respectful nature may mean they would be reticent to critique the course. After the discussion, we then all turned in for an early night, excited for the upcoming activities over the next week.
DAY 1 in the field: Q&A with the teachers and visit from Dr Martha Loru
In the morning of our first day, we were introduced to Andy and Augustine, the two healthcare workers tasked with teaching our TB course. We were impressed by their knowledge and the work they had done learning the complexities of TB pathophysiology, identification and treatment. Furthering one’s own education is problematic in Sumba given the lack of opportunities to access tertiary education or travel. Therefore, we were extremely pleased to have the opportunity to team up with two experienced healthcare workers. After a brief rundown of the course, we fielded some of their questions regarding the course. This morning reminded us how valuable field-testing the course and input from key stakeholders over multiple trips was for the ongoing success of the program. For example, the teachers highlighted that night sweats, a common clinical feature of TB, is a very common complaint amongst non-TB sufferers on Sumba given its hot climate and lack of electricity. We were able to help clarify the differences between physiological night sweats and night sweats caused by TB in our course. Such feedback is crucial to ensure ongoing improvement of the course and would be missed if the course was solely developed from textbooks. We also emphasised that we would undertake an extensive feedback process throughout the course and the important role the two teachers would play in facilitating this discussion. We were so glad they both seemed so enthusiastic about the coming week.
During the afternoon Dr Martha Loru, a Sumbanese doctor with extensive knowledge of TB who works in the two main hospitals at Waingapu and Waikabubak, visited us at The Sumba Foundation offices. She was extremely generous with her time, especially given she had just finished consecutive night shifts. Martha started by giving us an informative seminar on the current state of TB on the island, after which she described some classic TB cases she had treated. One of these cases included the first recorded case of multi-drug resistant tuberculosis on Sumba, which had been identified using the new PCR machine, acquired through funding from an NGO source. The patient had recently moved to Waikabubak to be closer to the hospital as the course of treatment was approximately two years long with more than 20 medications. Such stories really emphasised the devastating impact TB and its treatment can have on the quality of life of its sufferers. It also highlighted the worth our course could have in improving the lives of the local Sumbanese people. We learned many things from the visit including insight into the structure of the healthcare system and the crucial role community healthcare workers play in TB diagnosis in clinics where doctors are often scarce.
DAY 2 in the field: field-test the course in Bahasa
Course field-testing at the microscopy-training centre in Waikabubak began on Day 2 of the trip. The students included three government health workers who work as TB microscopists in the puskesmas (local hospitals), and three Sumba Foundation employees who specialise in malaria identification at The Sumba Foundation health clinics.
Prior to commencing we had estimated the full course would run for approximately 7-10 days. With this in mind, prior to the trip a decision had been made to trial an abbreviated course of 3 days duration that would only include the most important sessions, as this would maximise the time to gather feedback in a short time frame. We could then use this feedback to help guide our improvements for the other sessions that were not being field-tested on this trip. The sessions we introduced on Day 1 included an overview of TB, formal seminars about history taking and TB in paediatric patients and a history-taking workshop to practice some of the skills learnt during the sessions. All the sessions ran smoothly and it was great to see the students enthusiastically hone their skills in the history-taking workshop where they practiced eliciting a TB diagnosis from another student pretending to be a patient. Overall, it was a very successful day with lots of important feedback gathered.
We also heard a saddening story from Rainy, one of the Sumba Foundation health workers. She recounted the story of a 3-year-old boy brought in with TB by his 13 year old brother because their mother had recently passed away from her own battle with TB. Unfortunately this little boy had developed Potts disease, a rare but serious manifestation of disseminated TB where arthritis develops in the vertebrae (as a result of TB spreading to the bone, just like cancer).
It was another stark reminder of the disparity in standards of living and access to healthcare that is present in two places separated by a distance less than 400 km. It also re-emphasised the importance of undertaking work such as this given the health disparity in Sumba.
In the afternoon session, some of our members were lucky enough to accompany Dr Loru to Waikabubak hospital. Waikabubak hospital has a very large catchment area servicing the majority of western Sumba. Here we were lucky enough to meet Dr Adeline who heads up the TB clinic at the hospital.. It was a truly eye opening experience for the group. We were obviously acutely aware of Sumba’s status as a poor and under-resourced island however seeing the scarcity of equipment, personnel and beds juxtaposed against the packed waiting rooms was staggering. Dr Adeline took us through the hospital demonstrating the typical experience a patient presenting with TB-like symptoms would have. We first visited the emergency room where a patient would present for a history, physical examination and sputum sample. Moving on from the emergency room we investigated the make shift lab and met the pathologist, who showed us where the sputum samples are analysed under the microscope. We then next observed the X-ray machines in the radiology department where the technicians estimated that approximately half of all X-rays undertaken showed evidence of tuberculosis. Interestingly many of the machines were in doorways and had the Indonesian ‘out of order’ sign written on them.
Dr Adeline’s TB clinic was our next stop. This was where patients were counselled on their diagnosis, followed up at their next visit and had their medications dispensed. It also was home to the PCR machine used to assess multi drug resistant TB. The introduction of this new tool is a significant boost to combating what is an already difficult disease to diagnose. In the 12 months since we were last here the addition of this tool will further add value to our education course, while our course will emphasise how best to use this machine and when to refer to it in day to day clinical practice, a sophisticated step in the direction with first world anti-TB therapy.
Our last stop was to the pharmacy where we inspected the stock of medications. Although there was adequate supply of TB medications during our visit, the pharmacist mentioned that it was not uncommon for the hospital supply to run out and that treatment of TB was solely dependent on the delivery of medications from Jakarta. Before we left, the pharmacist showed us the many medications reserved for the patient with multi-drug-resistant TB that Martha had told us about. Amazingly the medication boxes reserved for this patient took up a whole shelf, the space usually reserved for the medications of 5 standard TB patients. We were told it had taken over three months from the time of diagnosis for the medications to arrive in Sumba from Jakarta, a deeply concerning fact given the very real risk of spread within the patient’s family and community.
Day 3 in the field: Sputum collection and microscopy, flipbook workshop and taboo workshop
The second day of the abbreviated course saw the teachers demonstrate many of the practical aspects of the course. This included the students learning and then demonstrating how to safely acquire sputum, fixing and staining it to the slide and then interpreting it under the microscope.
The flipbook was a new addition to this year’s course. It was developed in order to provide an interactive resource to help a healthcare worker counsel a newly diagnosed TB patient about what it means to be diagnosed with TB in a time poor environment. A flipbook workshop where the students could practice the delivery of this information with one of the students playing the role of a healthcare worker and the other as a patient was very successful. The feedback we received from the students was extremely positive and they fully appreciated what a great counseling aid this would be in their future practice.
The final workshop of the course was a taboo Q&A with the students, which aimed to elicit the barriers the students thought might affect effective diagnosis and treatment of TB patients. Some of the feedback included the idea that patients often believe shamans are superior to health workers. This belief apparently arises because of their supposed ability to heal ailments such as common colds and other illnesses which we know usually resolve without intervention. Unfortunately this results in a false belief that the shaman was responsible for the cure. They also postulated that the reason treatment failure most commonly occurs is because people stop taking their medications because they feel better after a couple of months, one of the biggest known challenges of treating TB worldwide.
Some of our aims in this latest iteration of the course were to be as interactive as possible in the hope that this would maximise the comprehension of key concepts. We anticipated that there was a real risk of this becoming confusing given the course was developed in another language and cultural setting. Both the teachers and students involved showed incredible dedication and enthusiasm. This was reflected in the feedback we received which showed a level of understanding only possible with a group of extremely clever and motivated participants. We were also impressed by their eagerness for more questions and activities throughout the course, something you rarely hear in Australian classrooms.
Day 4 in the field: Group discussions and future planning
Our penultimate day on the island was a day of reflection on the successes and failures of the course and a discussion of our vision for the future. From the meeting held on Day 4, we agreed our major focus would be to continue to develop the course to the point where it would be ready for the first official intake of students in December 2018. This would involve updating all the sessions and workshops with the feedback gathered during the course, producing a final colour version of the flipbook and workbook, translating all the resources into Bahasa and further developing the TB software. We aspire to emulate what has been achieved by the previous malaria course developed by The Sumba Foundation, which now trains healthcare workers across East Nusa Tengarra and beyond.
It seems to get harder and harder to leave the island every year. Our crew has fallen in love with the incredibly warm and welcoming people, the rich culture and astounding beauty of the island. With every new adventure comes a deeper appreciation for what has been achieved by The Sumba Foundation and further inspiration for the work ahead of us.
From all of us here at The Sumba Project we’d like to say a huge thank you for supporting us and enabling us to contribute to the positive sustainable change occurring on the island. Without you, none of this would be possible.
Post Trip Report 2016
OVERVIEW
The team was incredibly excited for our third annual trip to Sumba. After many hours of hard work at home it was time to get back to the island to build on the success of previous years’ trip and take our project a step further.
In 2015 the trip confirmed our first hygiene education book was on the right track. Initial testing demonstrated that the children’s understanding of healthy behaviours were bolstered considerably with an improvement in test scores of around 60% after a single reading. It was also clear that further texts were needed, with malaria being the area of focus for the next resource.
Twelve months later we were back on the plane, carrying copies of both new and old texts. Our trip objectives centered around how we could effectively integrate these books into the sustainable programs the SurfAid team already had in place on the ground. With this in mind we planned to test our latest text through another platform - mother and child health clinics or “posyandus” now taking place in the area. We also aimed to revisit the hygiene book in schools, and scope out topics for a third book.
DAY 1 in the field: Mother and child health clinics
After an initial day of planning and discussion with the SurfAid team, we were excited to venture out into the field on our second day and see our book in action at the posyandu. These clinics are monthly events run by health literate members of the community called “kaders”. These kaders are educated on a myriad of health issues by the SurfAid team and then act as the conduit through which health messages are spread within the villages. The posyandu sessions are made up of stations where mothers receive information on health topics such as nutrition, infant growth tracking and antenatal care. At the end of these clinics our book was used as part of a general hygiene education session. Copies of the text were handed out to all the mothers and it was exciting to see how engaged all the women were as they followed the reading, took turns in contributing to the discussions and asked questions relating to the distinct concepts expressed. At the end of the sessions many women refused to leave without a copy of the text because they wanted to teach the rest of their families the material they had just learnt. These were incredibly positive sessions that reinforced the posyandu as another great platform through which to implement our educational resources.
DAY 2 in the field: Hand hygiene visit to Gaura and Lamboya primary schools
The next day was spent with the children in schools of the Gaura and Lamboya regions. Similar to last year, this was something really special for the team. The children are so bright and inquisitive, offering such huge smiles and excited questions. To many children in Australia who have access to an abundance of gizmos and gadgets our book mightn’t be very appealing, but to the children of Sumba the book was enthralling. The classrooms were silent as the talented SurfAid Sumba team took the kids on an educational journey with Miss Doggy as their guide. Our testing yielded results in line with those attained on our previous trip and conceptually the teachers and principles felt there were no amendments needed. We received hugely positive feedback from all stakeholders during this exercise and are committed to rolling the book out in a manner that suits the needs of the local curriculum.
Day 3 in the field: Future Planning for The Sumba Project and SurfAid collaboration
Our penultimate day on the island was a day of reflection with the SurfAid team on the previous few of days in the field and discussion of our vision for the future. One of the big issues with integrating the resources into the school curriculum and posyandu schedule was the time required for a full reading of the book. To address this issue we decided to create modules that split the content of the book into lessons that are easily deliverable by teachers and kaders in a 15-minute timeslot. We hope these will make the resource user friendly and ensure content delivery is standardized across different schools and posyandus.
After our days of reconnaissance in the field it was decided that our next book would target nutrition. Malnutrition is still a huge issue in Sumba and a major contributor to mortality in children under five years of age. Since the rollout of SurfAid water projects to remote communities in Sumba, greater availability of water has enabled the locals to cultivate more produce then ever before, and within the villages themselves. Patches next to the village huts are dubbed ‘nutrition gardens’ and their growth in size and number is encouraging. We collectively identified this an outstanding opportunity to educate the Sumbanese about some areas of nutrition not well understood in the hope of alleviating some of the present rates of malnutrition.
Day 4 in the field: Communities impacted by the water projects
Our final day on the island involved travelling to some of the SurfAid water projects. The size and scope of these projects is impressive, all the more so because of the short time in which they were built. As with all SurfAid projects, the organization provides the materials along with engineering know-how, but with the prerequisite that the communities themselves provide the labour. This leaves the communities with a sense of achievement and ownership over the system. Coupled with the education provided around maintenance, this creates a safe and sustainable water source. These water projects have been the stepping-stone for vast improvements in both the health and education of local Sumbanese people. The impact of safe drinking water on health is quite obvious but there have been flow on effects of the projects that were somewhat unexpected. With water more readily available the children of the communities no longer needed to walk several hours a day to collect water for their families and were able to start attending schools to receive a formal education. With further resource and module development we hope to contribute to this education and improve health outcomes on the island through generational change.
It seems to get harder and harder to leave the island every year. Our crew has fallen in love with the incredibly warm and welcoming people, the rich culture and beauty of the island. With every new adventure comes a deeper appreciation for what has been achieved by SurfAid and further inspiration for the work ahead of us.
From all of us here at The Sumba Project we’d like to say a huge thank you for supporting us and enabling us to contribute to the positive sustainable change occurring on the island. Without you none of this would be possible.