Friday, July 25, 2008

Trip up the Mountain

One evening as it is cooling down, a group of us from the STI workshop for physicians take a trip up the mountain, heading for a dry river bed where locals picnic.

The road clings to the side of the mountain. We stop in the sun to top up our water supply with clean, clear, cold artesian water pouring out of plastic pipes along the road. Young boys sell fresh bright yellow plums, roasted corn and small black mountain figs. The figs look like plums as they are fresh. Everyone knows what they are called in Pashtoo, Urdu and Farsi but not in English.

When I inquire if they are figs, I am met with bewilderment.

Finally, I ask, “Are they are used to break the fast in Arab countries?”

“That’s it," the kids reply gleefully.

“Ah, then they are figs!”

Our second workshop in STIs has gone much smoother than the first even though there are more non-English speakers, because we have made a concerted effort to translate everything into Pushtoo. We noticed in the first workshop that although everyone understood some English, many did not have a great deal of facility in English and some points were not being sorted out until they were in small groups speaking Pushtoo.

Many of the Afghan physicians attending the workshops are not fluent in English so they sit at the back with a colleague beside them translating. Amazingly to me, they follow closely and are active in the discussions which are mainly in Pushtoo. The wonderful thing about participatory training is that so much of the learning takes part in small groups and discussion.

Since everyone speaks Pushtoo fluently, I assumed all the translating was being done in Pushtoo. But then when I asked for some of the written feedback at the end of each day which was not in English to be translated, I was told it was Urdu. I t seems that a number of the educated Pushtoo-speakers, such as doctors, do not write Pushtoo,. They write and speak Urdu. So unbeknownst to me, the workshop has been moving along in three languages, Pushtoo, Urdu and English. Make that four, it seems the Afghan physicians are using Farsi some of the time especially for the more complex concepts.

With all these languages being used, the draft flow charts needed to be available so everyone had a copy of them. I was concentrating on having everyone memorize the flow charts and not planning to print them until after the workshops. But with all these language challenges, the core material needed to be more accessible so I sat down with my marker pens and drew up the flowcharts


At the base of the mountain, the area of the dry river bed is huge and given the number and height of the mountains that surround it, one can imagine how quickly it would fill up in a downpour. But right now there are small trickles only and trucks, buses and taxis have wound there way down. Kids are dangling their feet in the small streams. Colourful carts move about selling gum, sweets, roast corn and chips. The woman are dressed in colourful, holiday attire, which seems out of keeping with the flat gray stone and gravel-covered dry stream bed. But there is generally a festive atmosphere. Our large van crunches slowly down the slope, and it is a slope and not a road, so we too can be part of it. But even with care it is clear this is not the best vehicle for such a spot and we carefully maneuver with some difficulty up the slope.

Down in the dry river bed there are a whole slew of beehives and some beekeepers, in their net and gloves moving supers around. I can’t quite make out what they are doing from up on the road but it seems a strange place for so many hives as it is a long way from any flowers. Later, higher up the mountain in Nathiangali I find young fellows selling their mountain honey. They have collected in buckets a number of actual bee hives wrapped around branches in a teardrop formation. They pour the honey into a plastic kilogram jar for me for 200 R (about $3.50). It is exquisitely flavoured with a light, clear consistency. There seem to be a lot of flowers similar to our jewelweed, with its long pouch full of nectrar growing on the mountain sides. I think I might have acquired some jewelweed honey.

Shortly after we have made our way out of the dry gravel river bed, it starts to rain. Not just rain, but it pours. It comes down in sheets so thick you can’t see across the road. It is monsoon season, which I had no idea reached this far inland, having only experienced it in South East Asia. There is a rapid exodus of the formerly dry river bed as bikes, carts, buses and trucks lurch up the slope. I catch this fellow in his cart with his feet drawn up as he cowers under the small shade of his cart waiting out the rain.

The most surprising aspect for me at the STI workshops has been the response of participants to the gender training. There was initially resistance as in why are we talking about gender. In the clinical sessions we had delineated the biological issues which make women more vulnerable to STIs - the increased area of genital mucosa, cervical ectropy in young women, the lowered immunity to infection in pregnancy, the high rate of assymptomatic STI disease in women and the exposure before during and after pregnancy as well as during breast feeding of the infant.

Gender issues everywhere are of concern. Women experience higher levels of poverty, illiteracy and violence but more especially in this area of rigorous purdah there are added burdens of poor access to health care, lack of mobility and shame. It would seem that without a framework for analyzing issues such as gender, the current situation becomes the norm even for a group of reasonably enlightened physicians.

At the end of the workshop, one of the doctors, who had recited a number of moving Pushtoo poems for us as energizers during the workshop, confided to me that he had three sons and one daughter who at 15 was the eldest. His daughter was brilliant at school but recently had complained to her parents that she felt they favoured the boys and neglected her. He said that since learning about gender at our workshop, he understood her concerns and had to agreed he had favoured his sons. He was going to start to listen more carefully to and support his daughter more actively.

When I shared this story with my fellow trainer Emel, he replied that he had always thought he treated men and women equally but after his first basic gender training he realized he was running the health programs of his organization differently, taking extra care to reach women.

That is the ultimate test of any training workshop, that we transform the way we see the world and are motivated to make personal changes. I feel as if I had my hands briefly on the golden ring.

Photos: boy on edge of mountain road; mountain figs, dry river bed picnics; beehives in river bed; Mountain honey; monsoon rain on cart


Tuesday, July 22, 2008

Trip to Nathiagali

During the week at the appointed times, the men unfold prayer mats. Occasionally a large blue rug is spread on the lawn so a group of them can pray. As ablutions are done before prayer it puts a lot of pressure on the one public bathroom but the hotel staff are accommodating and open unoccupied rooms for our participants when asked. Emel has opened his room for the 6 female participants so they can wash and pray. When I learn several days into the workshop about the lack of washrooms, I offer my room, even tidied it up somewhat but no one takes me up on my offer.

In many Muslim countries, Friday is a half day. We have planned additional time for prayer on Friday so the men can go to the mosque but when participants ask for extra time so they can visit Nathiagali, we shift around the timetable. Along with Murree, Nathiagali is a very popular tourist place not only because it is accessible to Islamabad..

Nathiagali is at the top of the mountain close to Abbottabad. Our participants have been so keen, hardworking and dedicated, we feel they deserve a chance to get out and see the sights. But not personally being one for tourist places in general, I don’t appreciate why they want to see a tourist town. So when I do visit it on the weekend, I am charmed of Nathiagali.

First, in its favour, I seem to be the only non-Pakistani tourist. The mountain is stunning. Curving roads, stupendous scenery and clear vistas. This is also the site of a massive earthquake several years ago. My friends point out the incredible difficulty of reaching people in this area, many of whom were stranded for weeks on these steep inaccessible peaks. There are still people living in the tents supplied at the time. Much of the aid, we are told, has yet to reach most of them.

Nathiagali means street and that is what it is at the top, a narrow crowded street. There are young boys selling circlets of daisies and floss candy, shops with precious stones and gems from China, pashmina shawls so soft they practically lift off your hands when you hold them and sandlewood boxes from Kashmir. Kids clamour on gaily decorated donkeys and mango milkshakes are prepared while you wait.

We meander down the street along with all the other gaily dressed families. There is not much tourist trade in Pakistan right now and I am the only foreigner around. One young fellow stands close to me and asks his friend to take my picture on his cellphone camera. I ask him if he is going to tell people I am his girlfriend or his aunt. He smiles and laughs but doesn’t understand English. My friends tell me I might be on YouTube now.

We stop in at a wonderful eating place, that just hangs over the edge of a ravine, where I get the photos of these chickens on spits that are being turned by hand. About half the time we are in Nathiagali, the town is shrouded in mist or perhaps it should be more rightly called low hanging clouds. The men go off on the mountain trails to have a look at the monkeys while we women move in and out of all the jewelry stalls.

Photos: view on Kashmir Hwy; Nathiagali; Boy selling circlets; Chicken Roasts on Spit


Monday, July 21, 2008

The Fascinating Art of Truck Back Panels

It is true. I love the truck art here in Pakistan.

Look at these two winged cenotaurs with female heads. Where else would you see this? All of it is hand painted. It doesn't look to me like it is even silkscreened but I could be wrong. Occassionally I notice that many of the trucks at a single truck stop appear to have similar styles or choice of symbols but that could be a result of hanging out together or going to the same places.

I wonder if anyone has studied this folk art? Maybe, I think it could be a way to connect with the truck drivers, who are very pleased when you want to take pictures of their vehicles.

How about this glorious eagle?

And this free white horse?

I was having such fun taking these pictures that they gave me a toy truck all decorated, a very large toy truck.


Oh, Ye of Little Faith

After a lovely drive through the hills we arrive at Abbottabad about one o’clock. The first road signs I see make it obvious that I have been misspelling it. I thought it was a local name and it is just a Pustoon/Pashtun version of an English name.

I am placed in the Royal Suite (royal because it has air con) in Jan’s Continental Guest House. Only Emel and I will stay here as it is deemed too expensive by others who will stay together or with friends. Emel has brought his three lovely children who are on summer break. We look over the front lobby of the guest house which will serve as our meeting room. It has a wall we can use for projecting the slides and is currently full of overstuffed sofas chairs. It seems to function as the dining room part of the time but it will do. He assures me it is much cleaner than other places he scouted. And it certainly has wonderful gardens full of pomegranate and apple trees.

I return to my room to collate the clinical material, simplify the flow charts and begin to develop the counseling sessions. I sort out what needs to be photocopied and what needs to be printed the next morning. I hope we will have a computer and printer but if we don’t it will be taken to a copy shop. Either way I need to be organized. Power seems to cut out frequently here too, so I continue with putting the info on flip charts.

At 10 pm, I finally hear from the project staff. They confirm that they have brought the pretest, handouts, timetable, certificates and all the case studies I have sent ahead for them to copy. All of it is stored somewhere for now so I won’t be able to check it till tomorrow. As it is late, we agree to meet at 7:30 am the next morning.

I assume they have prepared the room but I am getting anxious about organizing the material according to when they will be needed. I wonder if they removed the answers from the pretest before copying it for the participants and I fret about when we are going to have time to put the role plays on cards. Pre-workshop jitters, I assure myself. There are a lot of ways for this to unravel but I seem to be the only one worried so I go to sleep.

When I go down next morning for breakfast at 7 am, the workshop room is shrouded in darkness, still jammed with overstuffed chairs while three inert forms, bundled in capacious white wraps, lie asleep on the floor between the sofas I notice more white wrapped bodies in the spacious hallways upstairs. There is a biblical quality to the scene of a fancy hotel with people asleep all over the floor.

Now I am convinced we won’t be ready for the workshop. Of course it’s not the end of the world to be delayed a day. But at 7:30 on the dot, the place is swarming with project and hotel staff. Sofas and chairs are pushed back. Tables removed. Banners are erected outside and inside. A printer and computer are set up. A tidy pile of what needs to be photocopied today is sent off with the driver when the shops open at 8:30am. Role plays are glued onto cardboard and the backup generator put in place. The answers, it is true, have been printed on the pre test and have to be manually removed but that is easy work with many hands. That is the thing. It is all easy when there are many hands. I hardly know what to do with all the help I have now.

The workshop opens right on the dot. Usually when the syndromic approach is presented to physicians in the developing world there has been considerable opposition and resistance. What doctors want and do not have is laboratories to improve their clinical management. The syndromic approach which is strongly supported by the World Health Organization, has been around for a while now and has proven itself effective in not only the management of STI but in decreasing the spread of HIV. It is not without challenges but it helps practitioners to provide early, effective treatment even in rural areas where there are no doctors. These physicians from North West Frontier Province would also like laboratories but they seem much more aware of the drastic lack of access to health services within their own rural and urban areas and most of them immediately realize the necessity for using it here. So we are off and running.

Photos: Jan Continental GuestHouse, Abbottabad; Flow Charts; Infection Control Demo


Sunday, July 06, 2008

Alive and Well in Pakistan

Preparations for the workshop are going well. The flow charts for 5 STI syndromes have been made into posters. I have been working on the coffee table in the lobby because there is no space in my room.

There is a bit of a glitch though. The only information about the Ministry of Health STI syndromes used in Pakistan has been obtained from the reproductive manual. It doesn’t seem flow charts have been used much because the flow charts don’t flow well. Rather than a streamlined approach to the drug of choice for each syndrome, with alternatives for pregnant women or penicillin allergy, as is supposed to happen in the syndromic approach, there are ten different drugs suggested for urethral discharge.
This, I am advised, is b
ecause there are no drugs in the government basic health units so patients are given prescriptions which they take to the local pharmacy. So what the doctor prescribes depends what the pharmacy has. Oh, this is something that needs to be fixed. Frontier has done what the government should have done and purchased bulk drugs for their units. So I guess part of what we will be doing at the workshop is sorting out which drugs are currently being used. Not the best approach, but who knows?

We have decided, given the high incidence of Hepatitis B and C in the North West Frontier Province to include sessions on infection control as well as Hepatitis in the workshop. Dr. Wagma is going to assist us with some gender sensitivity. We worked out a format during her visit yesterday which will serve to emphasis the importance of gender issues in sexually transmitted diseases including HIV/AIDS.

There are several wonderful bookshops here in Islamabad. I noticed in one, a mammoth pile of Naomi Kline’s recent book, Shock Doctrine. I read a not very laudatory review, but gather that it would make eminent sense to educated Pakistanis. Naomi lives on the Sunshine Coast, or at least has a house there, which makes her a sort of neighbour of mine, I suppose, and it is a wonderful feeling to see a big pile of her books for sale here, on Canada Day if you please!

But my best find in the book shop was a book called Alive and Well in Pakistan by Ethan Casey. He includes a quote written by Joan Didion in the New York Review of Books on the anniversary of the attack on the World Trade Center. Her article is called Fixed Opinions or The Hinge of History. My bookclub just finished her book, The Year of Magical Thinking, when she mentions writing the article, but I haven’t seen the article. Here is Ethan Casey’s quote that has me wanting to read the whole article:

“repeated pieties that would come to seem in some ways as destructive as the event itself…The final allowable word on those who attacked us was to be that they were evildoers or wrongdoers, peculiar constructions which seem to suggest that those who used them were transmitting messages from some final authority…We have come in this country to tolerate many such fixed opinions, or national pieties each with its own baffles of invective and counterinvective, of euphemism and downright misstatement."

Lots of links and lots to think about. And some photos of various kinds of transportation in Pakistan, a couple by my friend Dale.

Photos: Decorated lorry, donkey being feed on roadside; QingQi driver with Kung Fu art; Ox with load.


Tuesday, July 01, 2008

Lying Low in Pakistan

My brother, recently returned from a tour in Kandahar where he has been with the Canadian military, sent a message when he heard I was heading for Pakistan. He said that I should be careful, that Pakistan isn't safe!

“What,” I asked my sister, when she conveyed the message, “about Afghanistan? He thinks that is safer? Did he forget there is a war being waged in Afghanistan?.”

Our two year Strengthening STI Management project is drawing to a close. My visit to assist with the physician training has been postponed several times in the past two years. Finally, on advice, the workshop was shifted from rural Mardan to Peshawar. This would be more expensive but was deemed more secure. The day I arrived in Islamabad, US planes were bombing at least three tribal areas close to Peshawar. So my brother was right and war is being waged here too.

Headlines in newspaper the following day declare "Militants Lie Low in Bloodless Operation". Side bars in the newspaper indicate a number of civilian deaths.

If this is lying low, I wonder what would flying high be like?

So I am settled in a guest house in Islamabad which is deemed secure for now and has wonderful food and staff. Unfortunately it has regular power blackouts. My only casualty is a broken toe when I was attacked by my suitcase in the dark, so I am limping around. As well my computer batteries were fried during one of the power surges, but switching my two batteries around seems to have stimulated one of them to function so I now get about an hour and a half , rather than the almost 4 hours of battery time I was getting before. On the other hand maybe both of them are at half mast! I had a moment of brilliance in the duty free in Heathrow on the way over here and purchased a portable hard drive but it seems I should have been thinking voltage stabalizer.

Meanwhile, my colleague, Emel is scrambling. After a lot of calls it looks like we are going to be able to go ahead with the training in Abbatabad, a quiet place north and west of Islamabad. The security staff at the Canadian High Commission agree that this area has been calm. More calls and a site is booked and physicians notified. When I point out to Emel that if I were not here, the whole thing would be postponed, he quickly agrees and then graciously adds, “But thanks goodness you are here and we will go ahead with it, enshallah.”

The situation in Mardan is worrisome so I suppose this is a useful distraction. Our drivers who have been in and out of Islamabad, tell me that the health work still goes on and they are able to move to all of Frontier's twelve health units,.

It has been a long while since I have run a STI training workshop. A Canadian colleague was originally supposed to come to assist in running this workshop as well as adapting it to Pakistan but security has forestalled that. More recently several possible Pakistani physician trainers were approached to assit but the most recent possibility is not able to come to the first workshop. So it looks like I am going to be facilitating alone. Not quite alone, as I do have the assistance of the Master Trainers who are excellent in Pushto but not so fluent in English and my colleague, Emel, who is a master organizer and keeps reminding me that he is not a trainer!

My first task has been to assemble a slide show on genital ulcers that includes all the patter and comments and possible questions. This is needed because I didn’t think I would be allowed, as a woman, to show and discuss genital ulcers. I run my slide show by Emel since it looks like the total cast of facilitators is going to be him and I. He doesn’t look comfortable even with all the notes I have attached. The upshot is that he feels that as a foreign female doctor I can discuss the slides of genitals although he agrees a local female doctor would not be allowed to do so.

I think about this for a while, a very long while.

Now I have to get on with making most of the training material, since I am here in Islamabad and the rest of the team are in Mardan. But then today a whiff of fresh air, just like a Borneo breeze, came wafting through my door bearing a local artist. We have been correspondidng on the internet about him drawing the illustrations for the training manual we hope to produce so that they will reflect the local situation and customs. He is an incredibly gifted and much in-demand illustrator and after some negotiation, it is apparent that on our limited budget we can not afford him.

Today he has come to tell me that he will do all 50 illustrations and is going to produce some of them almost immediately. So I am close to euphoric, at least as close as I can allow myself to be given all the preparation needed for our workshop.

It is a wonderful tonic to help counteract all the awful things I am reading about the Taliban. As are these evocative photos of rural Pathans in our project area, a wonderful, hospitable albeit conservative group of people.

Photos: PM residence in Islamabad, rural Pathans gather sugar cane, Literacy training for women, health poster competition for young girls, making gur (brown sugar from cane)


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