Thursday, November 29, 2007

Twilight Trip to Buddha Park

Our tuk- tuk drivers, tuk-tuks are motorized rickshaws, are assigned to our street and spend most of their time between rides hanging out near the guest house since we are their main customers. They often come with us into the shops and return to pick us up when we are done.

The other night they were having a barbeque beside the road with some people on the street which is so quiet it doesn’t need to be shut off for the neigbhorhood to have a block party. The lady who does our laundry across the street comes running over with it late at night when we return. We go to a yoga demonstration in which her young daughters perform. Her husband drops us off at the bus depot for our trip out of town, making sure we get on the right bus. It feels like we have been dropped into a family in our month here.

A friend has recommended we visit Buddha Park outside the city. We hit the morning market in the afternoon, when it a little cooler, and took longer than we planned. We spent all our time in the Lao textile section. Lao textiles are so lovely and there are so many varieties old and new to fondle and admire. On my last visit I took many back home, planning to make clothes from them but when I got home, I was unable to cut them up, so I hung them up and admired them. This time I get an antique piece, made on a very narrow loom about 8 inches wide, but it is a fine weave and one of the traditional patterns that are so intricate. On the faded red border there is a simple, effective but worn patch. This is a piece to cherish.

So when we finally leave for Buddha Park it is 5 pm. The breeze is wonderful but by 5:30 pm we are still not there. What we don’t realize until later is that it is 25 km out of town. Where is it? we wonder and then we hit the rural area and potholed dirt roads. It is getting dark. Finally we arrive.
Buddha Park is not what we imagined and my Buddhist friend is at first a tad annoyed. It is thoroughly bizarre and wonderful, I think, a wild combination of Hindu and Buddhist statues and images, all massive, ornate and cast in ferro-concrete. The whole thing we find out was designed by a self-styled holy man, Louang Pou Bounleua Soulilat, who felt a sculpture garden would be a way to spread his philosophy, which is it seems a blend of a number of religions. It is an idea with some merit, the architectural base, I mean.

So I rush around anyway taking pictures since it took us so long to get there. Only the first picture of the lying Buddha turns out, for all the others only the flash works. Well we say we didn’t have to pay an entrance fee because everyone went home. We wondered why the tuk-tuk driver didn’t warn us it was too late it get there in time to see the statues, but then we realize this was the longest trip we are likely to make, the trip costs $30.00 and is our biggest transportation cost in Loas, even the bus trip to Van Vieng only cost $4.00 and then it all falls into place. The ride back is cold with the wind whipping around us but we agree the experience is something we will dine out on.

Photos: Lying Buddha; Art from Buddha Park


Friday, November 23, 2007

Post Conference Visit

One of our project sites has been chosen for the post conference visit of the TUGH Conference in Kampala. Staff and volunteers have been creating displays of our interactive teaching material to mount on walls and local women’s groups have been preparing Ankole millet baskets for sale--sun hats from reeds, bags from papyrus, and placemats from banana fibres. Entertainment has been organized including drumming, dramas, songs puppet shows using locally-made puppets as well as village tours of model homes.

We are in the rainy season now, so a canvas tarp has been erected outside the health center for the crafts. Our trainers have donned fancy hats and serve as interpreters and escorts. More than 70 people arrive from Kampala to stay overnight at the Lakeview Hotel in Mbarara. For the trip the following morning we have someone on the bus with a portable megaphone to provide an introduction to the project and area.

The day is sunny and glorious. We drive past the tea plantations in shimmering green and crater lakes where everyone wants to get out and take pictures. Our trainers, who are drawn from local health center staff, move around among the people explaining the various techniques. We have also involved some of the elective students who worked with the project during their holidays to assist. Several groups move out to see the villages, check the pit latrines and Tippy Taps, observe the drying racks in use and the kitchen gardens. The villagers are proud their homes have been selected and at the same time staggered to see so many white folks at one time.

The number of flash bulbs going off is daunting even for those of us used to it. For many of the visitors this is the real, the rural Africa they were hoping to see. For the puppet show, dancing and dramas the whole group is crowded, African-style into one small room, but everyone is tolerant and kids are poking their heads in through every window and door.

The whole thing has been planned by our volunteers. After the ethnic dancing they soon have everyone up dancing. One of the volunteers pulls me to the front of the room and tells me to watch how the Ankole dancers, furiously wiggling their bottoms get the drummers to stop. I have seen it many times but never realized what I was watching, a ritualized approach and rebuff of the dancers to the drums until finally by increasing the frenzy of their dance they are able to silence the drums. It is as if the drummers are talking to them, “Are you sure you have had enough? “No, well try harder”

During one of the two dramas put on by the volunteers, a woman jerks erratically on the floor, simulating an epileptic fit and is ignored by the other players. She continues to jerk and writhe. A small child sitting at the front nearby the woman, collects a piece of cloth and unseen by the actors, gently places it over the woman. There is a poignant indrawing of breath from the audience at this touching display of mercy.

Well into the field visit, one of the medical students visiting is feeling unwell and admits to have been bitten on the hand two days earlier by a dog in Kampala while she was walking. Rabies immune globulin wasn’t available at the clinic she attended and the doctor told her to get it from another clinic. Several suggestions were provided. She decided to come on the Post Conference tour instead.

We have a gazillion physicians on the tour—well at least 20 --including infectious disease, microbiology, public health and internal medicine specialists, so there is plenty of free advice. However our field site is about 8 or 9 hours out of Kampala and those of us who work in the area think there is probably not any rabies immune globulin locally available. People requiring it are usually sent to Kampala or Kigali, Rwanda from here.

When we return to the regional hospital on Sunday, we sheepishly ask the internist, who has access to some inaccessible drugs, if he can assist. He is pretty sure there is none but agrees to go and check. He also contacts a local VSO doctor who has a couple of possible contacts in Kampala where rabies immune globulin might be available. Further questioning reveals that the bite was not provoked so the dog is unlikely to be rabid and the RIg is not indicated.

Numerous phone calls are made by many people in attempts to find RIg. Being Sunday doesn’t help. Several of the visiting specialists who were convinced they could locate some immune globulin because of their contact with local researchers or professors, have had to admit failure. Indeed it appears rabies immune globulin may not be available, not even in Kampala.

The RIg episode is a circus, a potentially serious one, with no one in control and too many experts. It reminds me that if you get seriously ill in a foreign country you need to have a good, local physician, no amount of “experts” is a substitute for one who knows the local system and how to connect with it.

For lunch the group is taken to a local safari lodge on the escarpment above Queen Elizabeth Park where we can see elephants as tiny dots moving across the plains. A tired but satisfied group returns to the hotel at the end of the day. Hosting the visit has made our staff and trainers more aware of how unique and exceptional the project is.

Photos: Trainers in hats; Explain to visitors; Puppet Show; drama


Thursday, November 22, 2007

Participatory is Fun

Our Uganda project has another workshop on Participatory is Fun to be presented by Clotilda and Restituta, two of our skilled facilitators. Training methods that we use in the field will be shown focusing on how they can be adapted for use with health professional training. The meeting room we have been assigned is located at the back of the hotel, around several corners. As we prepare the room, I comment to Clotilda that given the location, we should not expect good attendance. As an experienced and creative mobilizer, Clotilda responds immediately that we need to mobilize.

This is her first conference but she has noticed that hoards of people congregate around the coffee in the center outside the main hall between workshops.

“Let’s put up one of our rice bags on the wall,” she suggests.

We use new plastic bags for rice for displaying messages and making board games etc. so we quickly prepare one with large photos advertising our workshop and put it strategically in the main lobby. I comment that a sandwich board would be better as we could move around so everyone saw the message. She asks me what a sandwich board is and I explain it is like a human poster.

People have been telling Clotilda how good she looks in the fancy hats we use for drama. As the time for the workshop draws near, she hands one to me and says, “OK, it’s time now to mobilize”

She hands me a fancy hat and I follow her out into the now-crowded lobby. As we move through the crowd, up and down the aisles, we invite people to our workshop. Laughter follows us. Someone offers to buy our hats. Groups gather around us to find out what is happening. Our glittering head gear can be seen for a mile. I don’t think they have ever seen anything like this. We miss our coffee but when we start the workshop, the room is packed to overflowing. After the introductory energizer, which she has had to alter to accommodate the increased numbers, Clotilda chortles in my ear, “We have mobilized!”

The workshop is a great success. We have participants practice doing health dramas, puppet shows, flannel boards and songs. We show them our 3 card sort on weaning, pictures sequences for malaria and snakes and ladders board game on immunization. It is a great surprise for our facilitators to find that Europeans and North Americas are not very good at making up songs and dramas on health topics. The Europeans and North Americans need to be encouraged and given more time and even then the results are no where near what our village volunteers can produce which include all the key points and are funny to boot.

Song, poems and dramas are incredibly effective for teaching in Africa. We often have participants provide a short summary of a session with a song or poem and are amazed by what is produced with very little preparation. For some reason these skills are not as well developed by non-Africans. The contrast of what our workshop participants produce here compared with village volunteers is dramatic and has us all wondering if it can simply be a result of "professionals" being overly self-conscious. It is not all that clear.
Photos: Clotilda in hat; WS participants


Saturday, November 17, 2007

Latrines & Things

Vasco Pyjama has an interesting reaction about her agency building a fancy multiple-seat latrine for a school that had a severely compromised, dilapidated latrine. She was upset to find the fancy latrine was locked by the teachers.
This has got my friend Liz and I, with much, too much time on our hands, reminiscing about latrines.

Liz remembers travelling with AMREF’s flying doctor to one Masai community in Kenya. They found the Masai women were making use of the flush toilets by washing their sheets in the porcelain bowl. It resulted in a number of sheets being flushed down the toilet and jamming up the works, until they realized these strange white porcelain fixtures were not washing machines.

We may laugh, but how would they know? When would they have seen either? And sadly, given the choice, I am sure they would rather have had a washing tub than a toilet.

In a new compound in Uganda where I worked, we had male and female toilets in the main building for use of the whole staff. When I found mud and gravel on the toilet seat a couple of times, I just wondered to myself but when I found footprints on the seat, I was truly perplexed and had to ask what was happening. It turned out that some of our workers were unfamiliar with sit-down toilets so were standing on the seat and squatting. For this, one needs wonderful balance! We thought lots about what to do and in the end decided we needed to build pit latrines on the compound as well.

A doctor Liz knew lost his glasses down a latrine built on a mountain in Bhutan. When he asked the monks how he could retrieve them, he was told the pit was so deep it had never been emptied and he should just give up on his glasses.

The difficulty of retrieving things from a latrine reminds us of a retired doctor we know who is so concerned about babies dropped down latrines (a not-uncommon way to dispose of unwanted babies in Africa since nobody wants to go down after them) and children who fall into latrines (a not uncommon toddler injury) who are reported in the Kenyan newspapers, that he has devised a knotted rope which can be stored in a latrine to allow older children to be pulled up and someone skinny to be lowered to rescue an unwanted baby.

Pictures are used a lot for health education in our project. One of our pictures shows a woman sweeping up a child’s feces and putting them in a brick walled pit latrine with a wash area attached. When we tested the picture in the villages, people interpreted the pit latrine as a cooking kitchen and could not understand why the mother would put the feces in a kitchen. So we had to draw banana leaves over the pit latrine look more like those that are familiar to them.

Ventilated Improved Pit (VIP) latrines which limit odors and flies are one of the major contributions to improved health in the developing world, especially when combined with hand washing provided by Tippy Taps. They are in the same category, in terms of impact, as Oral Rehydration Salts (ORS) and access to potable water. So issues related to latrines are important to understand.

What do these stories have to tell us? I am not sure, except that we shouldn’t jump to conclusions about behaviour related to defecation. We probably should always assume we just haven’t understood.

Photos: model home latrine in village; design of VIP latrine; confusing picture


Wednesday, November 14, 2007

Grand Rounds 4.08

Dr. Anonymous, a versatile fellow who does radio casts, podcasts, mounts videos on his blog and writes a wonderful blog in addition to all the pyrotechnics, is hosting Grand Rounds this week. If accessing all these is difficult, you can be well satisfied just to read his blog.
I am pleased to be included at all and feel so pleased to be one of his five editor's picks. You can check out the entire 43 posts by clicking on his picture.

"Borneo Breezes tells the tale of a medical student cholera workshop in Uganda. (Great pictures!)As a result of their visit they learned that people in the fishing village were collecting drinking water from the Kazinga Channel frequented by hippos, water buffalo, elephants and a multitude of birds. Boiling was not regularly done because wood and money for fuel was in short supply. Oral rehydration packets in the health unit had all been used up. Juices were being made from unboiled water. Handwashing was not doine regularly and latrines were available in only one-third of the homes. So there were many possible sources for spread of cholera and much need of health education."


Returning to Laos

Monks in orange robes whitewash the crenellated stone fence of the wat across from the hotel where I am staying in Vientiane. The Mekong River, outlined by bright lights on the Thailand side, watches sluggishly as the city gussies itself up in preparation for the That Luang festival at the end of November.

I am visiting with a friend, who will be honoured later in the month, both of us former volunteers and much to our combined delight we are being treated royally by the health project staff here in Vientiane. We don’t want to be medical tourists, gawking at tropical pathology but are enjoying the opportunity to participate in and observe aspects of health care from the sidelines.

Laos remains a poor country its edges softened by the graciousness of the people and the luxurious flora, hanging vines, bright flowers and luscious orchids. At a restaurant last night, an American sitting by himself, catches my eye as he leans over to ask if we are medical. I detect a barely visible slumping of my companions deeper into their seats and am on my way to serious obfuscation on behalf of my friends when he mentions mutual friends who had worked previously with some of those at the table and is invited to join us.

Today we visited Mahoset, the national referral hospital, and made rounds on the pediatric ward. An 8 month old breast-fed infant with congestive heart failure secondary to beriberi was blue and breathing rapidly when first seen but as the condition is not uncommon, he was quickly diagnosed and dramatically reverse by an infection of Vit B6. Beriberi is wholly preventable, caused by his mother eating a diet consisting almost solely of polished rice.

We also met Godiva and Godfrey, two goats munching quietly in the grass beside the laboratory building. Godiva and Godfrey provide the blood each week for the blood agar plates used in the microbiology lab. Business in microbiology is picking up so they may soon need three goats. The goats are tethered sufficiently apart so that pregnancy does not disturb this agreeable and functional relationship.

There isn’t a lot for the children on the pediatric ward or their sibs who are often brought with them to do on the wards, so some enthusiastic university students volunteer on the weekend to hold play time on the ward. There are puzzles, crayons and books for the kids, which seem to be as much a treat for the parents as for the kids. In general there seem to be a lack of toys, educational toys, for kids but the students have had some basic training and are committed in helping to change that.

At a local café where we have Lao coffee and mango sticky rice pancakes each morning, we meet up with a local child life educator who tells us how they are trying to establish social work as a profession in Lao. Many of the required courses were offered at first only under Women’s Studies, which proved a problem for interested Lao men to explain to their families.

There are some new finds in Laos including a wonderful new writer, Colin Cotterill, who uses Laos as a setting for an irascible, irreverent, charming Lao physician who comes out of retirement after a career with the Pathet Lao at 70 to be the national and only coroner. The books combine Alexander McCall Smith, Tony Hillerman and Mrs. Pollifax with a cast of well-drawn, equally engaging colleagues and friends who struggle against almost unmanageable odds with a delightful sense of humour. The Coroner’s Lunch, Thirty-Three Teeth and Disco for the Departed are the first three in the series. They are the kind of books that make you want to know more about Laos and Laotians.

Photos: Monks whitewash fence; orchids; Mahoset pediatric ward; Godfrey & Godiva; Main Wat


Sunday, November 11, 2007

Presenting a Cholera Workshop

A No GUNS sign, a revolver with a red slash thru it sits directly beneath the No SMOKING sign in the fancy hotel where we have come for the international health conference. Good idea, I think to myself, I wonder if that sign is also sponsored by the WHO!

A couple of my students are presenting a workshop about cholera at the conference. The workshop is based on their visit to a fishing village with a medical health officer. As often happens, they had about 15 minutes to prepare for the visit before hopping into the back of the health center truck. The cholera outbreak provided a wonderful opportunity for them to try out what they had learned from a case study we had just completed on responding to a meningitis outbreak in Ethiopia.

Following their visit to the fishing village, they wrote up their insights and from this we have developed a workshop. When the network of community-oriented medical schools, now called Towards Unity for Global Health (TUGH ) or The Network held their conference in Kampala in September this year, we submitted our workshop.

The medical students involved in the cholera outbreak are now interns based in various sites around Uganda, but Simon, working in Kigezi, a couple of hours south of Mbarara, is able to come up on a weekend so we could refine the workshop and practice the presentation. Denis, the other student, can't get away early so will be coached when we get to Kampala.

Universities in the Network are encouraged to send students to TUGH meetings and many students attend from all around the world. African students especially have been encouraged to come to this workshop by having local doctors billet them, so many were able to attend. This mixing of students and teachers creates a very vibrant atmosphere for the conference.
For several days Denis and Simon polish their presentation on the laptop in my hotel room. We know we are in the big city because when they first come up to my room, we are told they need a special pass. But after the first visit, the staff seem to know who they are.

The day before the workshop, the students try to arrange for a projector and learn to their chagrin that they should have booked it months in advance. This is an eye-opener as well as a great disappointment since the slide show was pertinent to the case study as well as providing an introduction to Uganda. The conference organizers have no other projectors available, can offer no suggestions and indeed seemed stumped by the ongoing difficulties of keeping things running smoothly.

We were beginning to organize the workshop without a projector the next morning when one of our faculty suggest that we check with our computer technician who was doing some tapeing at the conference. He just happens to have a projector stored at his friend’s place in Kampala. We now have just one and a half hours till the workshop. As time was short and Kampala traffic dreadful, it is decided that the friend will bring the projector on a motorbike or boda boda, which will be faster as it can weave in and out of traffic and avoid the noonday traffic jams. Participants are just fileing into the room as the projector is being set up.

We like to complain about what can’t be done in Uganda but often, as has happened this time, we are able to accomplish the impossible with no time to spare under the most adverse of conditions. I would love to tell you that everything went smoothly but unfortunately for my story, the bulb was partially burnt out—maybe because of the hectic race through town and the colours of the slides are a tad muted.

The cholera workshop attracts more than 45 participants, all possible seats are taken and we don’t have enough handouts for everyone. Simon and Denis succeed in getting full and active participation of the whole room, as they take turns alternating between presenting and recording responses seamlessly while making effectively use of the rich details of their own experience to embellish the case study.

At the time they visited the village, the outbreak had been going on for several months. A number of children had died previously but what had brought the issue to the medical health officer was a complaint to the local authorities about the death of an older man on the weekend.

As a result of their visit they learned that people in the fishing village were collecting drinking water from the Kazinga Channel frequented by hippos, water buffalo, elephants and a multitude of birds. Boiling was not regularly done because wood and money for fuel were in short supply. Oral rehydration packets in the health unit had all been used up. Juices were being made from unboiled water. Handwashing was not done regularly and latrines were available in only one-third of the homes. So there were many possible sources for spread of cholera and much need of health education.

The need for autocratic leadership during disasters was dramatically demonstrated by a former military leader who lived in the village. He decreed that everyone should build latrines and much to the student’s surprise, villagers, many of whom were without latrines, followed his instruction. The importance of listening to people’s concerns in a disaster was brought home during a village meeting when the people agreed to provide the health worker with food to ensure she stayed in the village until the epidemic stopped. Such stories stay with people much longer than lists of what to do in an outbreak and helped to make this case study memorable.

After the workshop an American medical student tells me how impressed he was that the African students were able even given the lack of information available to take effective action. In his small group the Europeans and North Americans had been stunned that no laboratory confirmations were possible and little in the way of supplies were available. Many in the group had wanted to give up, but were spurred on by the African students who felt something useful could still be done despite the difficulties.

He is also impressed that the students presenting are so confident facilitating a complex interactive case study. I think it has to do with all the preparation they have been doing but I am prepared to admit that confidence also comes from competence in handling a cholera outbreak well with scarce resources. Whatever, I am bursting with pride.
Photos: Signs in Africana Hotel lobby; Interns facilitate workshop at TUGH; Animals in Kazinga Channel


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