After the caregivers taught the oldest children at the orphanage how to wash their hands with soap, one child asked me, “Now what can we do to help everyone else?” It took me a moment to appreciate the depth of this question. He sat there, wide-eyed, waiting for me to respond with answers. I was overwhelmed by the humility this young, vulnerable child possessed, and, despite having so little, his willingness to take initiative to help others in need.
As a medical student, I volunteered at St. Andrew’s Mtunthama Anglican Orphanage (AMAO) and a local clinic to learn firsthand about illnesses which I had only previously read of in textbooks: malaria, HIV, and kernicterus. During this first trip, three children from AMAO orphanage died within a week and a half from entirely preventable diseases. This is how my handwashing project began. Over a year later, after pre-intervention data were collected and the initial education intervention performed, these kids were ready to take action.
Malawians wash their hands with warm water before mealtime. In a regular ritual, the matron of the household pours a pitcher of warm water over each person’s hands. Once everyone has washed, the group enjoys their meal together. Soap is not used during this custom. However, soap is used for other purposes, such as washing clothing once a week. Malawians recognize that soap and water help to get rid of germs. In the community where I worked, this had not spread past the use of soap in limited household tasks. Perhaps, the connection among germ contamination, the human mode of transmission, and consequence of illness had not been formed? I did my best to embrace the culture by eating meals with my hands rather than utensils. I awoke with the Malawians when the morning rooster crowed. Before dinner, we took a midday tea together just like most Malawians do. While in Mtunthama, I formed a close rapport with the caregivers at AMAO and the orphans under their care. Together, the caregivers and I analyzed the health problems that exist in relation to their current practices. Together, we formed a plan to introduce hand sanitation, thinking this would be the most beneficial intervention.
Working with local staff, we instituted a curriculum for caregivers and children at AMAO. After 18 months, the children all washed their hands with soap, the caregivers improved their handwashing, and disease rates declined. The study was published recently in Global Health Promotion.1
When I reflect on reasons why this project was successful, I believe three factors contributed. First, the caregivers at the orphanage and I partnered in decision-making. Second, we did not introduce anything new into Malawi’s culture. The tools, such as clean water and soap, were already present and accessible. The program simply took those familiar implements and modified their use. Last, and most profoundly, the children themselves recognized the need for change and acted as that vehicle. Once empowered with knowledge, the children affected the surrounding community as they took on the task of teaching others with open, clean, hands.
The boy who asked “what can we do to help everyone else?” was waiting on an answer.
Instead of telling them what to do next, we sat as a group and discussed what they wanted to do to support others. One girl stood proud and suggested we take the project to Lilongwe, Malawi’s capital. Another suggested we start with the small Mtunthama village. One boy chimed in, suggesting the local church as the first location to raise awareness. After all, Mtunthama’s church is the village’s gathering point for Sunday activities. Over the next several days, I shared with five 18-year-old youths on how to teach the handwashing curriculum and encouraged them to teach the curriculum in their own way. The following Sunday, they were invited to speak at the local church, where they taught the program to the congregants.
After church that day, the newly formed group of leaders were invited to repeat the curriculum at the local schools for children aged 5–16 years. Every day for a week, these five leaders taught their peers at school. I watched the learners thank their leaders for the education. I watched the leaders stand tall in front of their peers. I could not have been prouder of their strength, advocacy, and drive. The most vulnerable children had become leaders in their community, and the outcome of the intervention had spilled beyond its narrow focus at a single orphanage.
These children had taught me so much. I had started with a small project on handwashing in one single orphanage. The children, who by all accounts are some of the most vulnerable disenfranchised people in the world, had taken the reigns and become leaders in their community in their own right. These kids taught more than just handwashing. They taught leadership, kindness, and commitment to helping one another. These effects were immeasurable.
Rissman L, Deavenport-Saman A, Corden MH, Zipkin R, Espinoza J, 2020. A Pilot Project: Handwashing Educational Intervention Decreases Incidence of Respiratory and Diarrheal Illnesses in a Rural Malawi Orphanage. Glob Health Promot. Available at: https://pubmed.ncbi.nlm.nih.gov/33103585/. Accessed: November 23, 2020.
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