Tuesday, October 31, 2006

The Places In Between

To better understand a country it useful to read good travel writing, especially that written by someone who knows a bit of the history and background of the country in addition to having interesting adventures. It may largely be because I don't want to read the detailed history myself, but want to get a sense of how it affects daily life, that travel writing appeals to me.

I can like a book just because of its title. Some titles just dance forth. All of the books I have read about Pakistan and Afghanistan have great titles.

Eric Newby wrote the funny, evocative A Short Walk in the Hindu Kush, that first introduced me to Afghanistan and Pakistan years ago. He went on to write many wonderful travel stories, but this may still be his best. One of the best parts occurs in a short paragraph or two when Newby and his companion meet up with the inveterate explorer and travel writer Wilfred Thesiger. Episodes of two writers meeting up with each other offer the opportunity to see the exact same situation from two sets of eyes. It puts travel writing plunk down in the real world.

Only recently have I found Thesiger's comments on the meeting in a book I borrowed from the library and it was worth the wait. Now checking on Goggle, I learn that Thesiger died in 2003. It is for me, similar to the time I found an obituary for Laurens Van der Post in Utne Reader, a somewhat obscure but wonderful magazine from the heartland of Minnesota or when I learned of Lewis Thomas' demise in the Globe and Mail. I feel personally affected. These men, through their words have influenced me and shaped my world. I feel richer for having known them. My life is more intimately connected to life because of their writing. I suppose because I disavow much of the modern media, I am bound to be late in finding out such things. I know I need to acknowledge the gift they have given me in some way. Some ritual observance is needed.

More recent books about Pakistan and Afgahnistan help to put the current political situation into perspective. Geoffry Moorhouse's To the Frontier won the T.Cook Travel Writing Award in 1984. It draws one along in a series of harrowing encounters, steeped in the politics and people of the place.

When I read a travel book, I make a judgement as to whether I would like to travel with the writer. Oh, I know they hide their worst side from us. I am guilty of it myself. Getting the balance right is partly a matter of having enough of themselves in the book and partly of having interesting views of the place. But it is more than that, because Paul Theroux passes on both accounts, but while I love his writing, I would not want to travel with him based on what I have read.

Theroux lacks a gentleness with the people he dislikes or dismisses. Moorhouse warms to all the strange people he meets, some of whom are very difficult. He isn't soft on them. Some of them are quite dreadful, but I don't end up feeling poisoned by them. This doesn't seem exactly right and maybe I need to take another go at attempting to express it. It's a blog, for Pete's sake, and I get to change it.

Under a Sickle Moon by Peregrin Hodgson chronicles a journey through the steep mountain passes undertaken at the time of Russian and Taliban clashes in wartime Afghanistan. Hodgson travels mostly with just a backpack and his wits. Like Dervla Murphy, he not only itemizes what he carries in his backpack, but he gets you interested in how each item matters to him. Tapes of the Brandenburg Concertos, for instance.

With all of these travellers, I wonder how they stayed alive. Rory Stewart's The Places In Between is in the same vein. The Scotsman decides to walk from Herat to Kabul right after the fall of the Taliban. He wants to retrace the steps of Afghanistan's first mughal emperor, Babur. Having travelled throughout the mountains in Nepal, Iran and India and knowing numerous Persian dialects, he sleeps on villager's floors, explores old ruins and talks with heroes and rogues, tribal elders and teenage soldiers. He is mistaken at various times for a local or an Arab and tries to pass himself off as an Indonesian.

Along the way unlettered tribesmen recite 15 generations of ancestors for him. By the sheer difficulty of the walk, he finally manages to shed the three armed guardians he has been given part way into his journey and gains a toothless Afghan wolfhound who has been fed chapatis most of his life. Stewart is assisted in several tough spots by NGO personnel , such as those of Medicins San Frontier. He reserves his most scathing descriptions for the international aid community in post war Afghanistan.

All of these books provide excellent background information about the current problems in Afghanistan in addition to being great reads. Recommended for all Canadians especially given our current involvement in Afghanistan.

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Grand Rounds is Very Up

Grand Rounds is up at Dr. Hebert's Medical Gumbo. And a very fine Grand Rounds it is, based on Edgar Allen Poe's poem The Raven.

We call these birds Thompson Turkeys in northern Manitoba and the Haida on the west cost where I live now, credit them as the creators of the world. Go see what Dr. Hebert has done with this bird and the poem. It makes a fine theme for this eerie time of year.


Saturday, October 28, 2006

The Singing Bus

I have been in Uganda for one week and have been cooling my heels. Francis, the project coordinator sympathetizes, “We Africans take a while to realize someone is here and then when they are leaving, we suddenly wake up.”

I should be better prepared for it. There are a few things I can work on, but I am only here for one month and I have a long To Do list. A muzungu, or white person, with a To Do list is a terror to behold. There is a fair amount of coordination required
to organize the training I will do, however right now the quarterly financials for funders are top priority for the project staff. As well, a research conference on sustainability is underway, so I am just going to have to bide my time.

I will use my time to tag along on an exchange visit. This gives me a chance to see how one of our new areas is doing. The Community Owned Resource Persons (CORPs) are child health volunteers, who work in pairs. 117 were trained originally, starting more than two years ago. Exchange visits were their idea. When offered an annual party, they opted instead for an opportunity to visit sites where small projects in beekeeping, rain water collection, bio-gas generation from cow dung and solar heating had been started. The exchange visits were so successful in stimulating development of small projects that we have incorporated them into our program.

Today’s exchange visit involves a group of senior CORPs from one parish visiting newly trained junior CORPs in another. Twenty-six CORPs have been waiting under a large mango tree outside the Bwinda Health Center for more than an hour. Laughing and exchanging greetings, they clamour onto the bus. Then, we return to the university because the report forms were left behind.
Consolata, one of our trainers as well as the acting in-charge at Bwinda Health Center IV, laughs saying that our day is having an African start. As soon as CORPs are settled, they begin singing. It is a gloriously sunny morning and they are glad to be on their way. Their exhilaration is infectious.

Passing a local weekly market, we turn off the main road. Bicycles, loaded with as many as seven bunches of matooke are jockeying for spaces in the market. Matooke, cooking banana, is the food staple in this region.

Rain begins to pour down heavily as our bus climbs high into the hills. The hills have been terraced to their crests, many covered with matooke plantations. Scattered homes can be identified from afar by their gleaming tin roofs.

For the first few miles off the main highway, the surface of the road has been mixed with chipped rock which provides better traction. As we proceed deeper and higher we are mostly on red murram or clay. Chris, our driver is carefully navigating around huge pot holes when suddenly, with a jolt we are stuck in a deep rut. The singing continues. The incline looks steep. By this time we are looking down on clouds. Chris backs the heavy bus up and takes a couple of different approaches to the pot hole, nearly clearing it each time. The men get out, wrap their pant legs inside their socks and begin placing rocks in strategic places. The bus continues to slip and slide from side to side in the mud.

Passengers are asked to alight. A wind has come up, making it quite chilly, so wrapping their thin cotton wrappers around them, the women head up the hill to the nearest home for shelter. A one room hut, it is too small for all of them, so a group continue on to the next home.

Chris and Consolata invite me to stay on the bus with the two breast feeding mothers and their babies. But my inner alarm is starting to vibrate. Road accident rates for East Africa, corrected for kilometers of road and number of vehicles, are among the highest in the world. I thank them nicely for their concern and soon I, too, am slip-sliding on the road.

The bus continues to lumber up and down the hill. On the 10th run, it finally surges out of the hole with the wheels kicking up red murram on the men at the back who are pushing. Those of us still on the side of the road cheer and run to catch up as it continues to the top of the rise.

There is no grumbling about the problems with the bus, the chill on the hill top or the long scramble to shelter. Although everyone’s shoes are caked with mud, they are delighted to be back on the bus. As soon as the group is seated onboard once again, the singing resumes. I can pick out more words such as Yesu (Jesus), Katonde wange (my God ) and Mukama (Lord) in the songs now, as well as improvised tributes to the driver, the pilot and the men who helped push, so it is clear they have understood how dangerous it was.

We arrive tired but happy to be greeted by the host CORPs who are shifting school desks into the room where we will gather. The walls are roughly sawed planks with window openings cut out and a mud floor. Long pine needles have been sprinkled about the floor in preparation for our arrival. A small rivulet of rainwater streams in the door. Our hosts soon have hot African tea, which is half milk in this cattle country, and buns for us which are greatly appreciated.

The area is very remote. There are few muzungus who pass this way. Maybe none. The kids crowd around to watch me. When this site was first suggested, we were advised by the university that it was too remote. We heard them out but in the end decided it was just the place for us. And so it seems to be.

As they are far from the Health Center which supervises them, the local CORPs will be combining this visit with their monthly reporting. Consolata returns from meeting with them, brimming with admiration for all that they have managed to do in the four short months since they were trained. Unfortunately, because of the ongoing deluge, we will be unable to view the demonstration gardens, visit the model homes or inspect the new latrines. I am amazed that they are doing all the cooking as well as organizing and entertaining for this event. Consolata and I discuss how it seems as if the second group of CORPs, seeing what the first group have accomplished in two years, have been inspired. It is as if they have a jump start.

Jumping is what has been going on in the meantime as the senior CORPs have been Ankole dancing to keep warm. This involves a lot of leaping and stylized arm movements. Everybody joins in singing, drumming on the desks and taking turns dancing. Even I have a go at it, which causes much hilarity.

The meal has been pre
pared in large aluminum cooking pots called sikiri which are balanced on three stones over a fire. The matooke, posho, cassava, rice, groundnuts and even the meat are all wrapped in banana leaves. Steaming food in banana leaves produces a distinct and delicate flavour, similar to smoking. If Ugandans want a good meal, they say they have to go to the village, where all food is prepared in this way.

The rain has finally stopped, desks are brought outside and food wrapped in banana leaves is offered in Ankole baskets. A portable water tap from the local health unit has been set up for handwashing. The host CORPs proudly serve the entire group which by now includes representatives of all five levels of government.

After eating our hosts present a short drama on ante
natal care for high risk cases, sing several songs lead by a strong tenor and do some serious Ankole dancing complete with costumes. The visiting lady counsellor from Mbarara tells us that because she has married this place, meaning her husband is from here, she is especially happy to see the authentic Ankole dances. Living in the city, she hasn't seen the real thing since she was a small child. At that time, she tells us, it was dark outside so she didn't see much.

Our hosts have also organized a gift exchange. This is an innovation. One after another they present gifts to their special friends among the visiting CORPS. Baskets, mats, glasses, china bowls, handkerchiefs, even a chicken are exchanged. One friend is absent so the CORP gives her gift to Consolata because she has been a friendly trainer.

On the way back, it takes us more than three hours to get down the hill. In one long stretch of flat road, all of us leave the bus to walk alongside as the back end swings from side to side in the slippery clay. Local men come to help push. Then that too is behind us and the singing bursts forth once again. It is pitch black when we arrive back at the highway. Chris agrees to make two trips up side roads that will deliver many of them closer to their homes. Two by two they are dropped off.

The singing keeps up until the very last group is deposited at a small trading center. Their singing has keep us going the whole day long. They sing in harmony, often in a call and response pattern. Like geese in formation, the lead frequently changes. There are enough repititions that I can sing along. Strong male basses boom out a background beat. Hands clap, rattles shake, drums beat and feet stamp. Laughter puntucuates the musical selections. Even sitting in the bus, bodies are moving and shaking in time to the music. What an exuberant, joyful group!

Up the side roads, there is no electricity, only scattered candles behind doors. With Ramadan just a few days behind us, there is only a sliver of a moon in the sky. Kerosene lanterns gutter in the night breeze as a few people move in and out of small shops. Most of the CORPs still have a way to go before they reach home, even the two mothers with the babies on their backs. But they are happy to be dropped away from the main highway and seem almost euphoric from all the singing.

"Some of them still have a long walk up the hills", Consolata reassures me,"but they will be OK now. "

There is complete silence as the five of us remaining on the bus head back to the university. I think Chris will be glad of some peace and quiet after this stressful day, but after a few minutes he turns on the radio. It seems the singing has also sustained him.

It is after ten pm when I reach home and still so dark that I stumble on the uneven ground as I make my way through the compound. Instead of focusing on that, I notice that it is a great night for star-gazing. The stars fill the night canopy of the sky like small brilliants, winking off and on in a manner I could never see in the city. I know down deep that this day captures the essence of why I love Africa and my work here. Being in another culture, I am encouraged to notice what is happening, not what I think should be happening. I have been given what I needed and not what I thought I wanted.

Photos: Mwizi hills, singing CORPs, weekly market, bus in hole, runing for shelter, children at the door, Ankole dancing, entering the room, local hand washing, bringing out the food, communal meal.


Friday, October 27, 2006

The Vagaries of Fame

A moving tribute to my friend and mentor, Don Hillman, appeared in a national newspaper recently covering his colourful life dedicated to international health. A short part of the story I wrote in my blog Remembering Don is quoted.

Dr. Borneo Breezes*, "a former colleague at Newfoundland's Janeway Hospital, described how Dr. Hillman helped her deal with a case of child abuse in Davis Inlet. The community had expected the child's parents to be arrested but instead they continued to be at large. He "heard me out and asked a few pertinent questions. He seemed to appreciate what a miscarriage of justice this would be and how devastating [it would be] in this small community. Then he asked, 'What can I do?' I was so taken aback, I was, for a short minute, speechless. I had been hearing so many versions of, 'It really isn't my problem' that I was totally unprepared for someone who cared."

I was pleased to have the journalist use my story, chuffed even. Central to the story, however, was the fact that there was no child abuse happening. We managed, through Dr. Hillman's high level intervention, to put a stop to having parents who did not abuse their child, hauled out of a remote community and charged with doing it. And we managed to avert this horrid outcome before anyone in the community got wind of it.

* Actually they used my real name, but my anonymity has only ever been skin deep on this blog so I am going to continue as if they hadn't.

What do you think, was I that unclear about what happened?


Tuesday, October 24, 2006

Medical Blog Grand Rounds 3.4 is Up

Medical Grand Rounds 3.4 is up at Health Care Law Blog. It is an extensive collection of the past weeks medical blogs and covers everything from a Yupik funeral in Alaska to a story about body parts made from bread in Thailand. My tribute to Mohammed Yunus's Nobel Peace Prize can also be found. Enjoy by clicking on Health Care Blog above.


Monday, October 23, 2006

Pediatric Grand Rounds Vol 1:14

The Halloween Scary Medicine edition of Pediatric Grand Rounds is up at The Wait and Wonder. This is the first time I have taken part and I am honoured that the Puppets for Health post has been included. You can check it out by clicking on the picture of the witch.

Pediatric Grand Rounds is relatively recent itself, so Moreena at The Wait and Wonder has searched around for other appropriate blogs to include. We applaud her initiative in making Pediatric Grand Rounds more encompassing and far reaching. It makes for a great Halloween reading treat.


Sunday, October 22, 2006

Grameen Bank Wins Nobel Peace Prize

The Nobel Peace Prize will be awarded this year on Dec 10th to Mohammed Yunus, a Bangaladeshi economist and the organization he founded, called the Grameen Bank. This is wonderful news on two fronts. It is a well deserved award for Mr. Yunus who has spent almost thirty years spreading a truly revolutionary idea of the sustainability and benefit of providing credit to the poorest of the poor. It is also high level recognition that ending poverty is a fundamental prerequisite for bringing world peace.

Health workers have long known that poverty is one of the root causes of ill health. Maurice King published what became one of the classic texts about Primary Health Care in 1966. Called Medical Care in Developing Countries-- a Primer on Poverty, this book presents the symposium held in East Africa and attended by a group of his colleagues interested in what could be done practically to extend health care beyond the hospital.

At the time, Dr. King was a medical microbiologist teaching at Makerere University. A locum for a colleague in a remote region of Uganda called the Karamoja, brought him face to face with the wider implications of poverty for health. Medical assistance to the developing world up till that time consisted mainly of bulding hospitals and providing physicians, thus replicating the Western model.

Maurice King's experience in the Karamoja convinced him that a different approach was needed. At the symposium he presented a paper showing how health units served patients drawn from within 5 km. of the institution, rarely further. This was also true of the teaching hospital in Kampala, which was intended to serve the entire country. He postulated that most patients were walking to health units and 5 km. was the distance most patients were willing to walk. Mothers carrying one child and leading another were unlikely to be able to cover much more than 3 km.

I have searched in vain for a decent, informative link about Dr. Maurice King and regret I have been unable to find one. I did find one BMJ article that gives you some sense of what he is up to in his 8th decade.

It took a while and much discussion around the world before some of the ideas first launched in Makerere could be fleshed out and shared in all regions. By 1978 in Alma Ata, the capital of what now is Kazahkstan, the principles and practices of Primary Health Care were discussed, hammered out and agreement reached. This created a global committment to achieve Health for All. Primary Health Care (PHC) was identified as essential health care, scientifically sound, socially acceptable, universality accessible, with full community participation, while encouraging self reliance, social and economic development. It was to be provided at a cost that was affordable.

It was recognized that the greatest challenge would be to provide primary health care for the poorest, those in fact who were the least expensive consumers. The initial goal was to complete this mammoth task by the Year 2000. This proved overly ambitious but by 2000 significant progess had been made, lessons had been learned and efforts were pointing in the right direction so there was substantial regrouping and efforts since 2000 have been much more focused.

Mohammed Yunus had a similar epiphany to the one experienced by Maurice King, but his was an economic epiphany that occurred during the Bangladesh famine of 1974. He saw how rural women were trapped in a vicious cycle of poverty by the demands of moneylenders. He began providing what he called "seed grants" for corn seed at reasonable rates to enable the women to repay their loans. Later groups of women pooled their small amounts of cash in order to be able to provide small loans to one or two women at a time.

Over time guidelines for ensuring the process of providing credit to the rural poor were worked out. Many of the loans were for as little as 5 USD, which could be enough to buy a goat or a couple of chickens in order to get started. When a woman, because of illness or family problems, was unable to repay her loan, others in her group gathered round to assist her. As soon as the first loans were repaid, the next women in the group received their loans.

One of the most startling results of these small loans was the repayment rate, which even early on reached 90 - 95%. This far exceeded the results of financial institutions lending to much bigger enterprises. In fact it was unheard of in the loan business.

Today micro credit clients are estimated to be as high as 92 million world wide. In Uganda, our community health volunteers have been greatly interested in such schemes and have thus adapted some of the same principles in order to purchase bed nets. After learning how useful bednets aree for preventing malaria, a group of 8 volunteers in one parish decided they should all get one. Each month they pooled 1000 Uganda Shillings (approx. $1) to a fund to purchase bed nets which cost 12,000 UShs. Once they had their plan, the health worker who supervised them approached the store and was able to get a reduction to 8000 UShs for bulk purchase. Within 8 months, all of the volunteers in the group were able to purchase their own bed net.

If one practices community health in the developing world nowadays one needs to know about microcredit and income generating. It is a steep learning curve for many of us, but the successes and the impact such efforts have on health of people make it an eminently worthwhile task.

Bangladeshi are pretty excited about the Grameen Bank winning the Nobel Peace Prize and have been even more excited about Mohammed Yunus' ideas. You can see a wonderful set of pictures of what is possible in Bangladesh at Drishtipat Group blog. Microcredit schemes in other parts of the world have not been around as long but micro credit functions exuberantly throughout Africa, South America and South East Asia as well as in Bangladesh and has now been extended to men as well.

As a health worker, I would like to extend congratulations and thanks to Mohammed Yunus and the Grameen Bank. His efforts have helped us move Primary Health Care forward and push poverty back.

Photo: M.Yunus credit AP


Thursday, October 19, 2006

Nasi Lemak

Packing for several months travel, is like studying for exams. I find a multitude of ways to put it off. I did my best housecleaning just before exams, anything to delay the inevitable. These days I am tidying and filing things I forgot to do or misplaced after I returned from Sarawalk. If I don’t deal with them now, they will surely be lost. So it is that I find some Malaysian recipes I need to file and am flung full force into culinary nostalgia.

Time is running out so shortcuts are needed. Maybe I can do without these specific recipes. I have a couple of Malaysian cookbooks. Nasi Lemak, or Coconut Rice, is one of the commonest of dishes, surely I already have this recipe? One of my books, a truly Malaysian cookbook, has no index, so I am unable to determine quickly if it has this version. Another is the Australian Women’s Weekly version. Australians do a wonderful job in all their South East Asian cookbooks, beautiful pictures, authentic dishes and easy recipes, but when I check out their Nasi Lemak recipe, it really misses the boat as far as I am concerned.

Nasi Lemak started out as Malay cuisine but has been adopted and adapted by all the races of Malaysia. It now passes as the unofficial national dish of Malaysia. The Australian Women’s Weekly version is plain and simple coconut rice, as you would find it steamed in a hollow bamboo tube. So I really do need to file and save this version.

Nasi Lemak

Cook one cup of rice in 2 cups of coconut milk with 3 screwpine leaves. Add sliced shallots and ginger. Serve with sliced hard-boiled eggs, chopped cucumber, fried ground nuts, anchovies on the side. Top with Sambal Ikan Bilis recipe follows.

Fry ½ cup of dried ikan bilis (anchovies) in 2 Tbsp of oil until fragrant.
Grind dollop of prawn paste, 1 garlic clove and 4 chopped shallots Add one Bombay onion sliced in rings, 2 Tbsp of tamarind paste, 8 dried chillies with seeds removed and salt and sugar to taste. Cook, stiring occasionally until the gravy thickens. Now add in the fried anchovies and mix well.

You have to admit the Bombay onion is a nice touch. I am not sure what a Bombay onion is but it sure sounds authentic. And what about screwpine leaves? In Malaysia, people often have several different names for herbs and trees, so someone showed me what they looked like, but am I going to find any over here? Nasi Lamak can be wrapped in banana leaves and taken on picnic.

You can order Nasi Lemak almost anywhere in Kuching including my favourite stall, Gerai No. 9 which is located in the center of town near one of the larger mosques. This collection of stalls makes a wonderful visit on a Friday evening. Men dressed in longyis and prayer caps are coming and going to mosque. The call from the muezzin cuts through the bussle of traffic and shopping. An evening coolness has set in. But if you get there, it would not be wise to order Nasi Lemak. The first clue would be that it isn't on the menu. They would, of course, make it for you, if you asked.

But at Gerai No.9 you really should take note of their number one offering, Nasi Kerabu, or Rice Mixture. You see, the owners of this food stall are from Kelantan state in the north of Malaysia. Nasi Kerabu is also made everywhere in Malaysia but the very best Nasi Kerabu comes from Kelantan and the best Kelantanese Nasi Kerabu outside of Kelantan is found at Gerai No.9. It includes chopped greens, hard boiled eggs, meat, fish, sambal, ground nuts, onions and….. Now, I should be able to provide their special recipe for you. I have it somewhere but I really must go and pack now.

Photo and recipe: Imagine, Getting There, Malaysian Airways magazine


Tuesday, October 10, 2006

Grand Rounds 3.3 is Up

Jon Mikel at Unbounded Medicine has posted the 3.3 edition of Grand Rounds in the medical blogosphere. An interesting bit of reading, easy to access. click on the illustration to go there from here.


Puppets for Health

I have been on the outlook for puppets. I have been assisting in a child health project in Uganda for a couple of years. In collaboration with our partners, the Mbarara University of Science and Technology, a new medical school in Uganda, we have recently finalized Child Health training manuals for our community volunteers and trainers. The training manuals integrate the knowledge the community volunteers need with the techniques they can use to inform and educate people in the community. (I have a pdf version of both the trainer and CORPS manual I would be pleased to share with anyone interested but don’t know how to embed it on the post, so you will have to email me.)

The manual draws upon our experiences with the first volunteers, or Community Owned Resouce Persons (CORPs) as they are called. As you can see from the picture on the cover of our CORPs manual, the volunteers, in blue T shirts, are very adept in drama, even attracting audiences of children when they are practicing.

We have managed to implement all the various training techniques such as role playing, drama, story telling, demonstration, flannel boards and small group discussion. But we have yet to introduce puppets effectively. This was mainly because we didn’t have puppets to demonstrate how to do it.

The thing about public health messages -- wash your hands, immunize your child before one year of age and boil your water—is that they are boring. Important, of course! But soporific! We need puppets as well as drama, humour and storytelling to make them more interesting and to increase their impact and adoption. Hence the search for puppets.

Now, I am a great lover of thrift shops. So I began my search for puppets in thrift shops. This choice also fits nicely with our project budget. But over the course of a couple of months, I located but a few puppets. When I lamented about the dearth of puppets in thrift shops in my area to my sisters, they offered to help. On my recent trip back to the prairies they overwhelmed me with their success. In six short months between the two of them they had located more than 250 puppets.

My youngest sister had made colourful sturdy cotton bags brightly decorated with cut-out fabric stencils spelling, Puppets Bag, which will be given to the health centers. And I returned home, the proud possessor of five large sacks stuffed to the brim with freshly washed, recycled hand puppets.

The puppets include homemade versions sewn from hopsacking, classic versions of Punch and Judy with plastic heads and long flowing dresses, rubber dinosaur heads, plush dogs of all breeds, fleecy rabbits, Shari Lewis’ Lambchops and The Cat in the Hat. There are crocheted animals, felt finger puppets and renovated pajama sacs. A number of the puppets fit over all five finger including a banana with three monkeys, Noah’s Arc with four animals, and an octopus with tentacles. There are a number of African animals, lions with ferocious manes, zebra with prancing hooves, crocodiles with sharp teeth, a giraffe with a long neck, elephants with long trucks and pink ears and a whole carnival of monkeys. The safari animals will be especially suitable since our project in southwestern Uganda lies adjacent to a number of game parks.

There is a single gorilla. I have plans for him. While our project is near the famous gorilla sanctuary, close to the Rwandan border, few if any of the kids will have seen a gorilla. It is time we started talking about them.

Puppets will create an opportunity for our CORPs to take their messages to schools. It will help them to engage children in assisting us to get the message to the community. In Africa, children are often the caretakers of younger children. This observation led David Morley, a British pediatrician who authored the classic text, Pediatric Priorities in the Developing World, to develop a program called Child to Child. Based in the Institute of Child Health that he founded in London, the Child to Child program produces simple training material related to health that can be used to reach children of school age as well as a newsletter. It has been a revolutionary idea and one with sizeable impact in Africa.

Besides the hand puppets, we have also collected a few masks. Our manuals have a number of exquisite illustrations of puppets done but unfortunately Blogger can't handle them.

There is a challenge for us regarding the puppets. Our project is very concerned about being sustainable. International funding in such ventures follows its own directions. We have been lucky so far and have managed to secure five year funding to extend our project to several new areas. The Ugandans recognize that what we do needs to be carried forward by the people themselves. Lugging five sacks of fleecy children’s toys into Uganda is the antithesis of sustainable.

I have, however, a plan. I am proposing that the project hold a puppet making workshop. I have done this once before in eastern Uganda. We involved a local puppeteer who brought along his creations and was very interested in creating stories related to health. The puppets that people constructed at the workshop were exquisite in design and made from local materials such as the clay from anthills, dyes from local plants, brushes made from the sisal plant. I have an artist friend who may be able to help with this. This way the puppets would reflect African tales and local realities.

Having African puppets made by Africans will also help me to deal with another odd problem. I know the kids are going to laugh at the cow puppets I have found, all of which have short, stubby horns. Ankole cattle, which are much prized in southwestern Uganda, have elegant long horns that extend like a lyre above their head. The solution is to make African puppets drawn from their own world.

Now that I think of it, Ankole cows are all individually named. People not only talk about them frequently but they talk to them. I could see a wonderful drama of two cow puppets talking about how well cared for they are. Yes indeed. In even more grandiose moments, I see making puppets as one of the much needed income generating activities in the region. That would make them truly Puppets for Health. This is bound to be fun.

Photos: Puppet bag by 1st Sister;Cover of CORPS training manual; Puppet stash of 2nd Sister; Puppet Man; Ankole cow.


Saturday, October 07, 2006

Responding to the Pakistani Earthquake

On October 8, 2005 a devastating earthquake hit northern Pakistan killing tens of thousands and injuring an even greater number. International and Pakistani relief and rescue operations were mounted. The affected area was remote and difficult to reach. Many days passed before rescue workers had dug out all those pinned under building debris.

Such catastrophic events often result in an outpouring of aid, but such assistance, in the developing world, is rarely adequate to meet all needs. Much of what needs to be done, falls to local people who have few resources. Yet they have great resiliency.

Frontier Primary Health Care (FPHC)is a small NGO struggling to make ends meet in North Western Frontier province. They work in communities located not far from the area affected by the quake, felt the shock and aftershocks, heard about the quake and sprang into action. Staff and volunteers collected clothes, bedding, shoes and food items from the villagers in their area. Dais, the local trained midwives present in all FPHC villages and camps, went from home to home in their own areas to gather donations. Some people actually gave the clothing and footwear they were wearing at the time. A widow contributed clothes recently purchased for her children to celebrate the end of Ramadan. Health units and clinics packed up as many bandages and medicine as they could spare.

With winter coming on, it became clear, that the people who had been displaced needed blankets, quilts and mattresses, so staff members collected old clothes and linens and had them converted into blankets in local cotton mills. Within a few days, by mobilizing and informing the people in their area, Frontier PHC staff had collected massive mounds of supplied. Staff set to organizing and packing the all the material. More than eight vans and trucks were filled the donated supplies and driven to the affected area. They were among the first local groups to arrive at the scene of the quakes.

Their arrival in the Batagram area was greeted enthusiastically. The donated articles were greatly appreciated and put to immediate use. Teams from UNICEF and the Ministry of Health were already on site. Using quick upper arm survey, they had determined that malnutrition was a major problem among the children under five. This is something that was likely to be quickly exacerbated during the post quake period, causing high death rates in children. The problem was that not only had the quake destroyed homes but crops and stored food supplies had been lost, as well as cooking utensils, making it difficult for families to prepare food for already compromised children.

Consultations were held with Frontier Primary Health Care on the spot. With their extensive experience in nutritional rehabilitation and establishment of demonstration kitchens, FPHC was requested by the UNICEF and Ministry of Health officials to assist in establishing nutritional rehabilitation in several of the affected areas.

In the meantime, friends of FPHC, especially a former FPHC administrator from Scotland, had been successful in raising funds from groups such as Quakers, Scottish Executives and the Cadbury Trust in UK. These funds were used for purchasing equipment for the demonstrations kitchens and stoves for dislocated families to enable them to prepare food for their children. Quantities of edible food items such as rice, beans, lentils, oil and sugar were provided to enable the nutritional rehabilitation program to continue over the winter.

Three of FPHC’s Master Trainers were loaned to quake-affected regions of Shangla and Batagram districts. They set up a curriculum and timetable for training staff in running a nutritional rehab program. In collaboration with locals, they identified appropriate sites for demonstration kitchens in the camps and quake-affected areas. This initial planning was followed by training workshops for the health workers. Preparation of supplementary foods for malnourished children, implementation of nutritional monitoring and operation of demonstration kitchens were covered in the training programs.

FPHC staff has never been formally trained to respond to humanitarian crises. They don’t have an emergency response plan for their health units or for their organization. Their own facilities are strapped for medical supplies, frequently running out before month end. They are never sure if they will be able to pay staff salaries for more than a year ahead. Compared to health organizations in North America they are woefully unprepared for a disaster of this magnitude.

What they do have is a large and compassionate heart for their fellow humans, a vision of how a health organization needs to operate and the skills and experience that come from operating within the ever present constraints of scarce resources. It seems to be more than enough. Indeed, they are constantly demonstrating what is possible with very little at all.

There is a development exercise used with people interested in international work. In a group, people are asked to write down one word for the first image that comes to them when they think of a developing country such as Pakistan. Then they are asked to say the word. The words are all written on poster paper. When they have responded, the resource people, who have worked or lived in the country, give their word. Almost without exception, those who have not been to the country come up with negative, dark and depressing words while the resource people provide positive, hopeful and happy images.

I think our negative images of poorer countries come from applying the facts we know about the country to our own lives. For example, in Pakistan the Gross National Income is $410 per annum, 38% of under-fives are moderately or severely malnourished and 19% of newborns are underweight, suggesting malnutrition of their mothers. (UNICEF 2002 data) . Such figures argue for the existence of a humanitarian crisis even before any earthquake arrives to add injury to insult.

But while such numbers are real and represent an oppressive material poverty, they fail to capture the social cohesion that exists, the cultural richness that abounds and the vitality and strength of the people.

For an epidemiologist, numbers are important. The response of FPHC staff, volunteers and community to the earthquake like the statistics that describe Pakistanis’ health are however, better reflected in the following quote.

Everything that counts can not be counted.
Everything that can be counted, may not count.
Chas Garfield

Photos: from FPHC Annual Report,2005


Tuesday, October 03, 2006

Singing for the Angels

Preparing a winterized cottage retreat for sale involves painting trim, staining walkways, cleaning windows, replacing fixtures, washing the siding, vacuuming the inside and clearing brush from the lot. When friends offer to help, I am ecstatic.

At the end of the first day it looks better. At least the cobwebs have been removed from both the inside and outside now. Some of the brush has been burned in the pit at the back and the garbage has been lugged out to the Nuisiance Grounds. Those who have read Margaret Lawrence will know that garbage dumps in Manitoba have been known as Nuisance Grounds for ages and even in these days of EcoCenter recycling, some still are.

I comment that the place would look a lot better if the trim were painted.

My friend Doug says confidently, “Well if you want it done, we could probably finish the outside trim in a day. At most, maybe a day and a half.”
I am quick to take him up on the offer. Our next day starts late because we don’t get to the cottage until 3 pm. Doug’s partner, Melody, arrives a couple of hours later to cook supper for us but even she is put to work with priming. Even so, we only manage to complete three windows and prime four more before dark.

It is true, that what we have managed to paint, looks great. But there are still about 20 more windows to complete, some of which haven’t been primed and four of them can only be reached on full extension of the two-story ladder.

This is not looking good. Even another full day isn’t going to make a dint in painting the trim. On top of which, neither of us wants to go up to the very top on the extension ladder. I don’t even like washing first floor windows from a sloping roof. We have planned to stay overnight at the cottage. Over dinner, we talk about everything except about painting the window trim. All three of us avoid the fact that this is a five day job at the rate we are going. None of us wants to acknowledge that this task is way beyond our skills. We busy ourselves reading sections of the Saturday Globe and Mail newspaper and making a foray to the local store for ice-cream. We slice fresh peaches over the ice cream and speculate on whether melted chocolate drizzled over the top would augment or detract from the flavour. We talk about everything and anything rather than think about the job in front of us.

I dream that night about houses built into hills with no windows at all and whole tribes of gypsies washing and polishing their caravans. It is pretty clear my unconscious would like an easy way out. I try to glean the gold from these dream messages. Should I become a cave dweller? Who are the gypsies in my life? Is the solution to this a motorized home? But although confusing, my dreams do not distress me. I feel optimistic about spending a golden fall day with friends close beside the river painting the trim on a favourite haunt.

This residence has housed whole weekend meetings of book clubs complete with kids. Paths have been created for cross country skis and snowshoes in the Crown Land behind. Friends have been married, fishing trips launched and Xmas celebrated. From 400 year old white oak trees, which sprang from the acorns that early voyageurs carried with them for food from southern Ontario as they explored western Canada, the site of this tiny community has been established as an important portage or river crossing site. White oak is indigenous in southern Ontario and Quebec where the voyageurs originated but not here at the edge of the boreal forest.

Today the house sits only 1000 meters from a float plane base which ferries hunters and fishers north to exclusive private lodges. Five kilometers east on the other side lies the site of a still-functioning winter road, created each year across the river as soon as the ice thickens. Winter roads are used to move supplies into northern communities that are inaccessible by regular roads.

My dreams and memories of the place have lulled me into going with the flow today and seeing how far we get. I am aware that there aren’t many facts that would support such an attitude. One part of me is fully aware that this is a dicey situation for someone who hopes to have the house on the market and head back to the coast within a couple of days.

We resume painting early the next morning. Neither Doug nor I want to actually put into words that this isn’t looking all that hopeful at this point. Or that the house might actually look even worse if only half of the window trim is painted. We focus ourselves with the ongoing business of painting the trim, window by window.

With the extension ladder poised beside one of the high front windows, Doug is about three-quarters of the way up, swaying slightly, not looking very comfortable. I decide I better hold the ladder at the bottom for him. It takes him a long time to prime the window trim. Just as he is finishing, my neighbour, Stan, drives by in his platinum grey sports car. He reverses and jumps out in his leather jacket. I have been away for more than a year, so we have some catching up to do. I introduce him to Doug who is clinging to the ladder, looking as if he is afraid to go up and afraid to go down.

Stan doesn’t ask obvious questions, but I feel embarrassed to be caught in such a disastrous situation and proceed to explain that we seem to have bitten off more than we can chew. I try to make light of such a blatant display of abysmal judgment.

He looks around, taking in the whole scene, and asks, “Do you need some help?”

“Oh,” I sputter, “Is it possible? Are you serious? Would you help us?” Stan is a professional painter and has helped out in the past when my nephew and I couldn’t figure out how to reach the ceiling over the stairs behind the fireplace. Cathedral ceilings pose some interesting challenges.

“Sure, he says, “I’ll just get on my paint clothes and be right back.”

“If you could do the high windows, that would be wonderful”, I say. “I would be eternally grateful.”

He laughs, “Sure, no problem.”

I go into the house to collect more cans and brushes. The house, almost devoid of furniture, has an open floor plan, loft, central granite fireplace and cantilevered walls in the right loft and back wall. It is an exotic design for here in Cottage Country, which I may have cause to regret, since I am told buyers want bedrooms and bathrooms. But I am holding on tight to the belief that I only need one buyer and it is going to be an artist, writer, or weaver with no kids and a love for open spaces and the outdoors.

As I enter, the entire house reverberates with harmonious chanting. It is as if a whole choir of angels is performing. Not just any choir but the Cambridge Boy Choir with Charlotte Church and Anthony Way as soloists. As Eckists, Melody and Doug often sing the HU, so I think at first Melody must be using a tape recorder or IPod recording of the HU. I glance into the loft and see her all alone singing. HU is the Eckankar Song to God that can be chanted as long as 20 minutes at a time. The quality of the HU chant is similar to that created by throat singing, when the deep chest voice resonates throughout the whole body.

At the Rainforest Musical Festival in Sarawak this past year, a group of Mongolian throat singers performed for us. Several of the men in the group were able to produce two different musical notes simultaneously. The audience, many of whom would never have heard throat singing before, was mesmerized. They received a standing ovation. The sound that they created was eerie and profound at the same time. And it was utterly bone tingling.

Melody, whose speaking voice is quiet, has seemingly produced a HU that resonates throughout the empty house. After listening in silence for five minutes, I stumble back outside, having forgotten why I went in originally. By this time Doug is on the ground priming the front windows. Stan has returned in his painting clothes and is setting up his ladder under the eaves. I stare at them in bewilderment until I recall that we are painting the house trim and Stan has come to assist.

“Melody must have brought you here by singing the HU,” I blurt out.

Stan and Doug continue painting.

I endeavour to explain. “Melody is chanting a HU all by herself in the loft. It resonates through the whole house. It’s magnificent, like the song of the angels. That must be what drew you here to help us,” I tell Stan, who is now high up the wall.
“It’s like the Sirens in Ulysses. Even if you aren’t aware that you hear them, you are inexorably drawn to them. Melody’s singing must have brought you to us.”

Doug sees that I am serious. At least he knows what the HU song is, so he goes to the door to listen.

He comes back, shaking his head in disbelief, saying, “It’s true. It’s amazing. What a magnificent sound.”

Stan doesn’t know what we are talking about. I inform him that the HU is a love song to God for people, like Doug and Melody, who follow the Eckankar religion. I tell him about Mongolian and Inuit throat singing. I explain how Buddhists monks chant OM to achieve a heightened awareness. I speculate on how the empty house appears to provide additional resonance as if it were an instrument itself.

While Stan is not as captivated by the experience as Doug and I, he appreciates that for us, his assistance with the painting has been miraculous, even God-sent. We view his showing up to paint as nothing less than divine intervention. He just laughs and keeps painting.
After finishing the primer on the five highest, least accessible windows, he heads home to deal with a skunk his mother-in-law has caught in a live trap. Later in the day he returns to apply the final paint coat. Again he works quickly and efficiently, looking secure and comfortable on the highest rungs of the ladder. Doug and I are just finishing up on the lower windows as Stan puts the final touches on the high ones. We thank him and the HU song that brought him to us, profusely. He smiles and refuses payment.

Later Doug, Melody and I discuss the day’s events.

“Do you think, because we were so desperate, that we were in an altered state to start with?” I wonder out loud.

Melody is not convinced. She was aware of some additional resonance while she was singing the HU, and thought it was likely due to the empty house. But to Doug and I, it has the attributes of an out of body experience. I equate it to the dance of the whirling dervishes which reportedly produces ecstasy. The altered state they achieve is created by a combination of heightened receptivity to start which is augmented by repetitive actions such as dancing, chanting and whirling.

“But we were passively listening,” protests Doug. “We weren’t doing anything to shift us to a heightened state.”

“There are different ways to become more receptive,” I protest. “We were stressed to the max and not saying anything about it at all. It was weird. We have been in high stress situations during our wilderness canoe trips. How do we react? Our usual behaviour is to holler at each other and curse the elements. We talk non-stop. Since when have we ever used the technique of blithely ignoring something as a coping mechanism?”

‘You’re right about that,” acknowledges Doug.

“This is like the types of situations William James mentions in Varieties of Religious Experience,” Melody adds, “But being William James, while he may have reported it, it isn’t likely he worked out why it was happening.”

“Whatever,” Doug responds in an awed voice, “It was a very special blessing that delivered Stan to us.”

“Amen to that,” the three of us agree in harmony.

Photos: mountain ash in fall, Bear paw snowshoes, Ojibway/Cree snowshoes, most inaccessible windows, Nuisance grounds sign and sunset as we leave.


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