Refresher Training

Clotilda comes by at 4pm to tell me there is a two day CORPs (Community Owned Resource Person) Refresher course in Kitunguru, next morning. These refresher courses are held for volunteers two years after they were originally trained. Clotilda has been facilitating community work for the university for years and is one of our most gifted and stalwart trainers. One of the two other trainers took violently ill and has been in hospital for the past week while the other has to to tend to urgent family matters. So Clotilde is not only running out of time but has 4 new trainee trainers to deal with alone in this workshop. Even our project staff are caught off guard and have to scramble to obtain funds at the last minute.

“What things do you need? What can I do to help,” I ask.

"Let me see what there is," says Clotilda.

Everything from the previous workshop has been left in a big bag, unsorted, so I show her to the cupboard.

“What is on the program,” I inquire, hoping to get some clue of what training materials are needed.

“I’m not sure”, she says. “We organized the timetable at the planning workshop three weeks ago.

If I didn’t know her better, I would panic. But she is a natural and gifted trainer so I start pulling things out that we have done before or talked about lately. We start a check list and come up with about 8 sessions, starters and some energizers.

We were going to introduce the puppets, so I haul out a bag, count them and add them to the pile. I toss in copies of a handout I prepared for the trainers on how to make puppets more effective.

The Family Planning counseling cards and the board games we want to introduce have not been translated or put on heavy card. More felt characters are needed for the flannel board display on contaminated water. By now, the project staff have joined us and we are all scrambling. I suggest an introduction using a banana fibre ball toss around the circle which Clotilda has done before. We add the Tippy Tap to the training bag. It’s a wonderful gadget the CORPs can introduce to their villages to conserve precious water. We have a couple of pictures that can be used for starters in Malaria and Growth Monitoring if we can just find them. For the session on special children we need blindfolds, ear plugs and long ties to bind arms and legs so participants can experience what it is like to be disabled. We tear up short cloths to use as blindfolds but come up with only 3 pairs of ear plugs. The power is out again so I am unable to download and print the pictures we need or to laminate the ones we have located. It is shaping up to be a trainer’s worst nightmare.

By this time we have found the outline program of what was originally planned. Most of what we have pulled together will fit. We weren’t planning to do Family Planning but we think we probably will include it anyway. The training method we use is a double circle counseling. Half of the group act as clients and half as counselors. Each client with a specific situation hears from 11 different counselors. And then they switch and clients become counselors, counselors become clients. Although each “session” is only 2 minutes, the exercise is very effective in bringing home the necessary components of counseling---listening, asking open questions, rephrasing, not judging, showing interest, addressing people by name and knowing where to refer people for appropriate help. The Family Planning session is thus more about effective listening and carries over into other areas well.

The project secretary goes off to translate the cases into Runyankole. The driver stays up all night translating the board games and drawing the snakes and ladders. At midnight I finish cutting out felt silhouettes of a water pump, a newborn baby, a grave marker and a small child. In the morning the power is back on so I get up early, heat up the laminator and cover some of the pictures and cards we will need.

We drop by the health center before heading into the field. Clotilda shows me the new, brightly painted walls on the ward. I am surprised and gratified that most of them are versions of the pictures in our new training manuals.

We greet Sarah, a CORP who works as a cleaner at the health center and thank her again. When Joseph, one of our trainers, was taken as an emergency to hospital Sarah offered to stay with him and cook until his family arrived.

Families are often split up here, with one spouse working in one part of the country and the other spouse far away. So getting Joseph’s family here takes a couple of days. In Africa when you are admitted to hospital you have to take family with you. They cook and care for you while sleeping on the floor under your bed. Joseph had his young son living with him, but the boy was too young to be able to take care of him, so Sarah jumped in to fill the need.

Organizing Joseph's stay has taken a whole group of us. We contributed food, dishes, sheets, mats, milk, transport and blankets. All of us are grateful to Sarah for dropping everything to take care of Joseph and his son.

Restituta, our project manager, who organized Joseph’s transport to hospital and called his family says, “It’s like we are one big family.”

And indeed it is. It takes a whole extended family to care for you in Africa.

On the way to the village site where we will have our training, we stop to collect morning tea. Because there wasn’t time to make the arrangements, tea will be sodas and mandazi, a deep fried type of donut. We catch the morning migration of milk cans being taken on the back of bicycles to the dairy collection site. It is a reminder that we won't be having any milk tea today.

I have printed up a draft timetable in English for the trainers. We have relegated those sessions that need additional preparation to the second day. Two of our trainee trainers have arrived by the time we get there so Clotilda and I fill them in on what needs to be done. They are eager to gain experience and agree to try out some new sessions. Then off we go..

Understandably, there are a fair number of glitches, but the participants don’t seem concerned. The trainee trainers are confident and spirited. There is lots of laughter. There is however, one session when everything comes to a halt as the whole group watches one person in each group laboriously writing down questions. About half of the CORPs are illiterate so reading and writing even in their own language doesn’t come easily. As trainers, we had agreed we would stop using writing on paper as a technique, but somehow this has been forgotten. I feel I must intervene and do. I wish there was a nice way to do it but I haven’t found it.

So I say, “Let’s try it without writing.”

There is silence.

“Well”, I add, “I noticed that the discussion in the group has all stopped. This is supposed to be a group discussion, so I wonder if we could put down the pen and paper and just talk.”

“They are writing down the question,” says the trainee trainer.

“We want to get the questions down”, the group adds.

All of this takes more time because of the need to translate back and forth. Then I take the paper and sit on it.

“Now what are you going to do?” I ask.

Another silence and what seems to be confusion. I am given a lot of deference here and so am expected to behave in a certain way. Sometimes when we show pictures of health practices, people will state that the people were smart and therefore their behaviour is healthy, even if it isn't. So appearances are highly regarded here. By behaving out of character, I have upset the applecart. Even, I reflect later, I may have obscured the message entirely.

“Well, let’s do the questions one at a time, then,” I continue. Finally, the discussion starts.

I might do this at a workshop at home and people would get the point, but such an approach can come across as interference here. I am lucky because the trainers are used to me and they take it well. Later at our debriefing they mention that they are going to cut out the writing completely. I cheer and everyone laughs.

I put these slips in process down to lack of preparation. You really need to walk through your whole session and have everything in order so that you can make it look as if you are winging it. The trainers understand that it is supposed to look seamless but sometimes they are caught out when they haven’t prepared. At least that is what I think happens.

North Americans trainers might have all the content, sequence and materials in order but hardly ever are able to make a session flow the first couple of times. Africans seem to catch the essence right off. Sometimes I am bowled over with what they come up with in roleplays, poems, songs and drama. It all comes together so seamlessly. Then, at times like this, I begin to doubt whether they have understood the whole point of experiental learning and whether they are keeping an eye on what's happening in the groups.

Clotilda wants to do a flannel board story about contaminated water. We made up a story after a visit to a remote site where the whole community, including animals, were using a pond for drinking water. The local chairman was sure at least one child was dying every two weeks and half the community had diarrhea.

The story, told with felt cutout figures on a flannel boad, brought the room to stunned silence. For the rest of the day, people referred to the situation and what could be done to improve it. Clotilda wants to do her own version slightly differently, which makes me very proud, so I make the extra pieces she wants. Attention is riveted on her while she tells her story. Afterwards they want us to leave it up, “so they can think about it more.” The flannel board seems to work best when it portrays a real, local situation which the figures reinforce visually. Clotilda’s addition of a sick baby, followed by the grave not only reflects reality here but is dramatic and brings tears to my eyes.

We have been unable to find or purchase flannel board pieces. So I have been cutting and sewing bits of felt together. I am not an artist so I use silhouettes. Some of my trainers wanted to make a malaria story on the flannel board, but were unable to do it despite cutting up a fair amount of felt. Children here do not have a lot of exposure to crafts so those skills seem to be vestigal in many. However it seems simply a matter of exposure because in other parts of Africa it is part of the culture and beautiful applique cloth is created and stamps are carved to use for printing cloth.

I agree to make some figures for malaria but warn them that we can’t always scare people with death and destruction in our health messages. Once again, I may be wrong. Here, health prevention messages often do make the difference between life and death.

I have also been thinking about how nothing ever gets stolen at our workshops. People don’t help themselves to even pens, markers or paper. Yesterday I lost a bag full of four lengths of Zaire cotton at the market. I was purchasing them for gifts before I leave. Some fourth year medical students dropped over and when I told them about my loss, they immediately responded that I might have left them somewhere, not that they were stolen. My mind set was such that I could only imagine that they had been stolen.

So todayI retraced my steps of yesterday and at the stall where I bought the carved Ankole spoons, the trader had my bag intact with the material. She said she knew one of her customers must have left it, just not which one.

It’s a big lesson. I need to trust people more. I’m the klutz who keeps misplacing things. Nobody is out to steal my things. They are doing their best to assist me. Including the trainers at the workshops.

When we started training, lots of poster paper, marking pens and words were used. We were a bit short on interactive learning. This is how we run North Americans workshops. We are very word focused and highly literate. The Ugandans trainees reproduced what they saw. At one point, in our villages where the majority of people are barely literate, our volunteers were using up reams of paper and marking pens. Ever since we noticed that this was happening we have made a conscious effort to do more experiential learning. As they say, if the student hasn't learned then the teacher hasn't taught. So I have to own some of the responsibility. There are probably many things I could be doing differently that might make it happen sooner.

Puppets are one of the interactive ways we are introducing. It has turned out better than I had hoped. Several of the senior and junior trainers are very adept and can already move the mouth in the shape of words. All of the CORPs at our workshops have practiced making health messages with puppets. CORPs who are learning to be trainers and all the senior CORPs being retrained will receive a puppet to use in the community and schools.

The CORPs have made up funny voices, great dialogue and dramatic events with brilliant climaxes. They are delighted when they find they can move the legs, arms and mouths of puppets. They are getting used to watching their puppet instead of the other person and to holding the puppet so that it can be seen. We are in for some great puppet shows.

Another teaching approach we have successfully introduced is the making board games with health messages. Our trainers have created snakes and ladder games for malaria, hygiene and immunization in Runyankole. Answering questions correctly can prevent your slip down the snake or let you climb the ladders. The first six games were drawn on the back a large calendar made of firm quality paper. I think it was a Toyota calendar. We couldn’t find a single dice here so someone is going to try carving them out of wood. Styrofoam versions were used for the time being along with bright fluorescent erasers as markers for the players.

It is said if you teach you need to keep learning from your students otherwise your messages become hackneyed, your work uninspired and you become bored. So I always wondered, if that was true, why the most eminent professors in medical school seem to enjoy teaching the introductory classes or as often happens nowadays facilitating problem based tutorials in fields other than their own specialty. I would hazard a guess, at this point in my career, that it is precisely because working with beginners you can be caught off-guard, can be surprised and can see things from a different perspective. It is with the beginner's mind that we can make quantum leaps in understanding that allow us to drop deep into areas we thought we understood and yet were only up till now, merely skimming the surface. What started out as a slap-dash, last minute workshop has proved to be refreshingly full of insights for me.

We all go home reinvigorated with a Tippy Tap that we have made by ourselves from a plastic jerry can, some string and a couple of sticks. It is a wonderful device that saves precious water by only letting a small amount out for each person. The Mbarara version of this invention by Canadian Jim Watts, has a foot pedal so you don't touch anything with your hands. Our CORPs, by example, will help to spread it to their communities.

Photos: 3 Card Sort, Using Ball, Painted walls of HC, Milk cans on bicycle, Snakes and Ladders,Flannel Board,Puppets, Puppets, Tippy Taps made from gourds and plastic jerry can

Grand Rounds is Up and Getting Higher

Medical Grand Rounds is up and definitely getting higher at Rumors Were True. Just click on the Holy Grail and it will take you there. Topher has not only selected 26 fine pieces from over 60 submitted but it seems he did one better and went looking for new talent. He displays it all with music, art and humour based on Monty Python's Legend of the Holy Grail. Makes you wonder if the rumors are true and the sunshine, music and laidback approach in the Caribbean does bring out creativity. I am pleased to have How Children Play included.

Emergency Doc Wins Giller Prize

Congratulations Vincent!

Vincent Lam, an emergency physician at Toronto East General, where I once worked in the histology lab during a med school summer, has recently won Canada's most prestigious literary award, the Giller Prize. In an excellent Canadian tradition, he won it for a collection of short stories called Bloodletting & Miraculous Cures.

In presenting the award, Margaret Atwood, who met him when he was the ship physician on a cruise boat doing an arctic nature tour and assisted him to find a publisher said, "Medicine is a narrative art, just like fiction. Both have their fingers on life and death."

She also described his book as "subtle in emotion and occasionally gruesome in humour."

The Giller comes with a $40,000 cheque. There is already talk of a TV series based on the book. Well done, Vincent!

My sister, bless her, says I just need to find a mentor like Atwood.

I claim a sort-of connection with Maggie, who eschews use of this nickname except by close friends. In a wonderful book club I started a while back, I made a rule that we would not discuss Atwood. I had my reasons and over time, others in the group developed other reasons. They were, if nothing else, creative and humorous.

It was our only rule, so every time someone visited, joined or asked about our book club, we had to review our one and only rule. Of course this involved a lot of discussion about Atwood with examples drawn from her life and writing and over time covered every book she ever wrote, in detail. Canadians know such a lot about Margaret Atwood!

Some discussions would start, "There is a new book out by the author we don't discuss...".

So we ended up talking about her way more than any other author, just exactly what I was hoping to avoid. In fact it almost became the Margaret Atwood Book Club. This is a phenomenum known well by people who seek to ban books. And I too have learned my lesson.

Photo: Doubleday

Entebbe Arrival

One of my bags is missing when I arrive in Entebbe airport. As I am heading upcountry, it seems best to wait a day to see if it arrives, as promised, the following a day. It gives me a day at My Favourite Guest House, a restful stop where I may run across biologists doing chimpanzee research on the Sese Islands or mission pilots. Trumpet flowers cascade over the wall and a pair of turacos adorn the trees. It is also an opportunity to reverse some jet lag so I head to what used to be the flagship of the Uganda Hotels for a swim.

The Lake Victoria, since renamed the Windsor Victoria, has been renovated. I lived here for three months in 1985 after a couple of coups which almost destroyed it. It was so decrepit that long term guests painted their own rooms and bought their own curtains. We also supplied our own “extras”, such as butter, milk and sugar, for meals. But when the electricity worked, wall sockets still accepted dual voltage plugs. Water had to be hauled and plugs were missing but you could use the spacious bathtub and sink if you had a drain stopper. It felt a bit like living in an embassy after all the services were cut off.

I wander around the buildings lost in reverie. I kept a piece of bright patterned African jinja cloth, the sturdy local cotton used for school uniforms, from that period for years and wonder where it is now. Recalling this vibrant piece of colourful material tugs out of hiding other visual memories and I am able to reconstruct the room and people of that time in great detail. If memories are lodged in muscle, I wonder what mechanism it is that sets loose such a cascading sequence from a single strong visual image.

Later I head to the zoo which has also been renovated, restored and updated to focus on preservation of threatened and endangered species such as the whale-headed stork and white rhino.

We pick up the delayed bag at 9 pm the next night and head for Kampala so we can start off in the morrow, 20 miles closer to our destination. Availability of less expensive hotels in Kampala also factors into the decision. I stay in the Rubaga Guest House. The car also sleeps here, as Ugandans say, because there is a locked metal gate and guard.

We drive by Rubaga Cathedral on our way out of town. Huge crowds streaming up the hill to the cathedral remind me it is Sunday. Kampala is surrounded by seven hills, well, seven larger hills. Missionaries claimed the best views, so Rubaga, the Roman Catholic cathedral is on one, Namirembe, the Church of Uganda protestant cathedral, is on another and the Kisubi Mosque sits atop a third. All lovely buildings with grand views.

It is a four hour drive to Mbarara through the lush countryside adjacent to Lake Victoria with lots to see. Once we have left the congestion of city traffic in Kampala behind, I am suffused with gladness to be here. Although wiped out by jetlag, I cannot close my eyes.

Just outside of Kampala, on the way to Masaka, the capital of the Baganda tribe, the Kiganda drum makers are clustered in small jerry-built structures near the road. Pleased to show you their wares and the process of making them, they specialize in Kiganda drums, a tall one called engalabi covered on the top with monitor lizard skin and the elegant engoma made from cow hide. Engoma come in all sizes, some of the biggest reside in the cathedrals in Kampala. Tiny souvenir drums are available but their business here is making the real McCoy with full-bodied sound.

We pass the wayside markets with matooke (cooking banana), charcoal, tomatoes, papaya, onions, beans, watermelon, avocados, potatoes and sweet bananas. At first glance to an outsider like me, the markets all seem similar, some bigger, some smaller but all seem full of the same stuff. The drivers know better. We get a phone call enroute from one of our colleagues asking us to pick up yams. I quickly agree.

But the driver says, "Yams, not possible. We have passed the place where we can get good yams."

There are several Muslim towns enroute to Mbarara. I wouldn’t ordinarily notice that they were predominantly Muslim but today is the day before Eid il Fitre, the big celebration at the end of Ramadan. In Malaysia it is celebrated with elaborate sweets and freshly-squeezed juices and here in Uganda with meat. So the Muslim towns along our route all have busy meat markets with plenty of business today.

It begins briefly to rain. Ugandans say there is a wet season and a rainy season or short rains and long rains. This ensures plenty of rain and several excellent growing seasons here along the edge of Lake Victoria. The wonderful thing about the rain is that it usually doesn’t hang around for long. It soon stops and the sun comes out. Although Uganda straddles the equator, because it is about 3500 feet above sea level with the moderating influence of Lake Victoria, the weather is like an English country garden most of the time.

"Kulika yo. Naway kulika" Welcome back, the driver and I greet each other when we arrive at the Guest House. It feels great to be here in what Winston Churchill called, the Pearl of Africa.

Photos: flowers, turaco, whaleheaded stock, white rhino,Rubaga Cathedral, drum maker in shop, meat market before Eid, and lad with banana leaf rain hat.

How Children Play

I believe we need to take risks, all of us, otherwise things remain the same. Some of the risks are personal. Even if you mean well you can do harm. In fact, meaning well has been a terrible thing in some cases and some places. Take the incarceration of aboriginal children in missionary schools for instance. Who knew it would result in such abuse? Who even suspected? So one must always tread lightly when one thinks one is doing good for someone else.

Thinking that what you do is more important than it actually is also constitutes a real risk when you work in the developing world.

A friend of mine, who was an acknowledged friend and supporter of aboriginal people and their aspirations, was told by an articulate and observant aboriginal friend, that he was the real problem.

“Pompous bureaucrats influence no one,” his friend George said.

“Because you are sympathetic and caring, you are the one having an impact. You are changing things in the communities where you work in unknown and unwanted ways.”

We need to be glad of such friends and also wary when we feel most sympathetic and justified in our stance. A group of us before coming to Africa were addressed by Ivan Illich. I can hardly credit now that he was there in person. His words certainly were, so maybe they were delivered by someone else. They were, very definitely, his words. If you have read his "Medical Nemisis" or "Deschooling Society" you will recognize his message.

Ivan Illich said, "Don't come to change us or help us. Come because you are getting something out of it. Take pictures of our wild flowers, study the animals, climb the mountains if you like, but leave us alone. We want to make our own mistakes."

Half of us had a crisis of committment right then and there. I nearly turned around and headed home. He wasn't angry but he was forceful. I held his words close to my heart and read his books. His ideas proved very useful to me in medicine. He takes an extreme position, but he has a point. So, early on, I admitted to myself that I was in the developing world to learn what I needed to know.

Or as Gloria Steinem says, "We write what we need to read."

I like to take pictures and collect baskets. It has been my fall back position. As I go on, I continue to add things that I am getting out of being here. The list has become very long. Some of my best learning, most poignant insights and finest hours are in these so-called tangential pursuits. Here is really where I connect with the people and place and see my own input in perspective.

Most of the pictures here were taken in the sheer exhilaration of seeing children at play, appreciating it and celebrating it. Some are from the southwestern part of Uganda where I am now. The vehicles made from sorghum stems come from Lira and Gulu, in northern Uganda. I have also seen elaborate churches made of sorghum stems in Ethiopia so they are probably to be found wherever there is lots of sorghum.

I am currently joined in the Guest House at the university by two Swedish plastic surgeons and their wives for a week. One of the surgeons has been coming for five years.

We share details of our days. They arrived from Entebbe yesterday evening, left for the OR at 8 am this morning and returned at 5 pm having repaired four cleft palates.

I have been supervising repairs on the house, meeting with one of our facilitators about how to record data during the upcoming Mass Measles Immunization, pulling together our Training of Trainers report and discussing with my boss how to set up a transparent process for selection of a Micro Project Manager because he is being inundated with candidates wanting special consideration.

None of this I share with the Swedes. Instead, I tell them about the three under-five deaths in a single village, one a child of a volunteer, that occurred this week. As if to show that the work I am engaged in is also useful. Then I am overwhelmed with sadness that our project isn't doing enough, or moving fast enough so we continue to have such deaths. We are having trouble even getting an accurate count of what goes on in the villages. I would be deluded to think I was here changing things. Days like this I don't even feel like a physician.

So for a brief moment today, I wish I was a plastic surgeon and could fix things like cleft palates and leave. I know it doesn't make sense but I start to recall the time I spent on plastics with nostalgia.

Thankfully it doesn't last long. Today is a day I need to remember Ivan Illich's words. None of us, who "come from away" as Newfoundlanders say, are here to change things. I can just plod along, do the best I can and remember that I enjoy taking pictures of kids at play.

Being in and of the community I get lots of exposure to the varied and multitudinous ways in which children play. Kids are creative, maybe especially in Africa. Look what they do with so little. They deserve so much more. Imagine a larger world where they too have a recognized place and opportunity.

Here in their creative play, we have children in their glory. Wonderful hats, dolls and skipping ropes made from banana fibre, tire rims rolling along under the control of a stick, clay birds shaped from anthills by hand, land rovers, buses, tanks and ambulances all made from sorghum stems pierced and held together by splinters of bamboo thin as toothpicks.

The wives of the surgeons want to know where to find the Ankole millet baskets with covers, the finely woven lids of wooden milk containers and children's toys. The search for what is unique and fine, interesting and exciting in a culture always leads us back to community. I can link them up with our women's groups who are looking for markets. This might be helpful.

Photos: child on wooden bike; rolling a tire rim; soccer player with ball made of plastic bags and banana fibre; bird made from anthill clay; skipping with a twisted banana fibre rope; hat made of banana fibres;3 lads in banana fibre hats; four sorghum stem vehicles.