Anatomy of a Meeting

For several weeks now I have tried to set up a meeting with two colleagues. Both of them, like me, spend much of their time in the field and it has proved hard to arrange a get-together. I have been anticipating our meeting today but wake up realizing I don't know where we are to meet at 9 am. I call Zack and find he is already on the road. He hadn't read his email. He says he will be back at midday so I agree to call our colleague, Ephraim, and change the meeting.

When I reach Ephraim, he is perplexed, saying it was Zack who suggested this time. He indicates that he is likely to be in the field but I should go ahead with meeting Zack as he is in agreement with us on designing community modules.

"But", I protest,"We were going to brainstorm some possible ideas, we need your input!"

I cancel my trip to the field with the research assistants who are going to one of the communities where refresher courses for community health workers are being held. Then I call Zack and tell him to let me know when he gets back. I come back from the office at noon to wait for him. Zack calls about 1 pm to say he has been delayed but is starting back and should be here in a half an hour. I notify Ephraim.

Ephraim is now out near Queen Elizabeth Park where he is making pre-vists to field sites for the student placements. He won't be back until late tonight. He wants me to go ahead.

"We have talked at length about these things," says Ephraim. "We are on exactly the same page, on the same team. I am with you on whatever you decide."

I have to laugh, as we have certainly talked a lot about our ideas although we have been less adept at moving them forward into action, but I enjoy his support and enthusiasm. I determine I am going to make an effort to have some idea next time that he will totally disagree with. Then I wonder if that is even possible.

At 5 pm Zack arrives. He looks exhausted. His car broke down up in the mountains to the east of Mbarara after he called me to say he was coming and he was out of cell phone contact. The driver had to go by boda-boda (motorbike) down to the highway to collect the part needed. I am stunned that given such a rough day, he still kept this appointment with me about developing interactive training modules. I ask him about his day.

He tells me about the long lines of very sick children he finds at the remote health centers when he visits. Many have only a Nursing Aid, giving out tetracycline or ciprofloxacin. He feels obligated in such a situation to assist in the long lines as well as to teach the Nursing Aids how to better use the drugs.

He talks about the new research project in which he is engaged, about the supervisory visits he makes to the surrounding rural health units and his efforts in putting a Family Medicine curriculum in place at the university. Listening to him, as he recounts his day spent in the field, is like hearing case studies told as traditional stories.

He concludes with the comment that we need to teach the students about how to handle medical mistakes and how to do it as part of a team. He digs into his briefcase to locate the list of 15 possible topics he has prepared for our interactive modules. I jot them down, recognizing many are similar to the ones Ephraim and I came up with. But best of all, I have got some made-to-measure case studies and practical approaches for our interactive training modules from Zack.

Photos: school room; milk depot, sawing logs.

Preparing for a Bicycle Ambulance

The more remote the communities we work in are, the further off the main road and the more difficult access is for them, the better partners they make, it seems. And pretty much all of the communities we work in are remote. Remote in this part of Uganda usually means deep poverty. It also means people are hardy and work cooperatively to tame the steep slopes into plantations.

BBC radio, Have Your Say, had a program about the African middle class last week. Middle class was defined as having $1-2 to spend per day! The other day I was shown a photo of children supposedly from our area. At first glance I could tell they were not. Later we were able to make out the name on their uniforms, a private school in Mbarara. In Uganda where education is highly valued, the middle class send their children to private schools.

Many of the Health Center II and Health Center III in Mbarara and Bushenyi District have at present a single health worker, although I have heard they are going to get a second health worker soon. The majority of the health workers are Nursing Assistants, a cadre that has only 3 months formal training. For many of them it was a long time ago. When they are away or sick, the health center is closed.

Often in the community they are referred to as doctor. In the health center in Namiyonga, it is clearly evident why Agnes is referred to as doctor. She sees all the sick children, provides family planning advice, organizes immunizations, makes home visits, trains the community health workers (CHW) and holds community meetings to discuss and advocate for clean water. The walls of her small tidy but sparsely furnished health center are covered with bright posters and charts of the monthly cases of malaria. Even when she is presiding over a drama competition with her CHWs providing humorous health education, after it is finished, a line of mothers and children forms at her clinic door.

In Agnes' community, they have done some health planning and decided that their priority is a transportation plan, a way to ensure pregnant women in distress and sick children needing referral can be taken to the Health Center IV on the main highway for treatment.

A couple of groups who design bike ambulances, came to our area last year. One fellow, supposedly with vast experience in the developing world, took one look at the roads and headed back to Kampala the very next day. But the idea was planted. Huge loads of 5-7 bunches of matooke (banana) are ferried to the market by bicycle in this area, even if it means they have to walk the bicycle through the rough spots. Even I have been scouring the net for possible designs.

Then during a visit from a friend from UNICEF, she mentioned they were going to try some out. When she learned we had two communities that had developed transportation plans and were seeking solutions, we struck up a partnership. The bikes as yet are still in the pipeline, but the community recently brought down to the project office, 300,000 UgS (more than $100) in cash, their contribution to the bike ambulance. We require community contributions to our efforts and while this is a community that has little, they always prepare lunch for us and provide volunteer labour. But this is a sizable amount of cash for the community. As the bicycle when it comes will be a donation, the money was put in the safe to be used for maintenance. Recently they sent a message inquiring as to progress on the bike and indicated they had collected a further 200,000 UgS but would wait until bike was delivered.

Photos: Recently painted clinic; young boys; training session; coop work in field.

We Don't Do Roads

We have travelled half way up the mountain behind Mbarara to visit Kibera parish, in Kinoni subdistrict. Here Keneth, one of our enthusiastic Trainers works as a nursing assistant in the very village where he grew up. Keneth meets us in another more remote village in his parish where the "road" has shrunk to little more than a cow path. He is combining today's agenda of community engagement with a clinic for the under 5 year olds. He sits his chair in the shade and a long line of women and children line up for their mebendazole, (worm medicine) Vit A and to have their Child Health Cards checked to see if they are up to date with their immunizations.

I leave Keneth to do his clinic and have the volunteer health workers show me around. One mother is giving her young infant a bath. A number of goats are tied up outside the home, indicating they are somewhat better off. We are taken next to the woman who won the model home competition. She also has goats as well as an energy efficient stove which she proudly shows us. Even though we have come unannounced there is a functioning Tippy Tap to provide for hand washing and the yard and the compound area is sweep. In the corner is a treadle sewing machine holding pride of place, a testament to her industriousness.

Election posters are plastered over the mud walls of one house. Elections in Uganda have just taken place. We both notice that the posters cover the whole range of candidates and parties and are exceedingly colourful.

The clinic seems to have been a good idea as we have accumulated a large group of the community for health education. I have come with a reporter from the local government newspaper, The New Vision. Ostensibly, he is there to report on our Child Health project and the work we are doing in the area.

He takes pictures and talks to people and even translates for me when the Local Chairman comes to ask if we can build a road for him. The Local Chairman has prepared well and recounts the story of how all the men in the village came out to help create a road and collect stones. But the heavy machinery never arrived and the road was never built. I sympathize with him, acknowledging that the lack of a road has contributed to the lack of schools and teachers in his area. Also that it prevents them from easily getting their produce to the market and from materials and people reaching them in this remote spot.

After a wonderful community meal of matoke (banana), ground nuts and local produce, the discussion about the lack of a road continues. I have no trouble agreeing that the lack of progress, access and development in this community affects their health. The Chairman is engaging and concerned and shares with us that until recently they had no supply of clean water and had to draw their water from the swamp. While other communities around them were assisted by ACTS, a Canadian NGO working in water in this area, his community did without because ACTS couldn't get to them. But, he goes on, just recently they have provided the community with a spring fed well. I have no doubt that it was largely due to his perseverance that this happened.

He seems convinced that because our project has strong vehicles that we can help him with his road. We have only one 4WD because many of our communities are far off the road. I explain again, that we are a child health project. We train and support the village health volunteers in his village so that mothers and their children are healthier, stronger and live longer.

Finally I say, wondering at the same time how it will translate, "We don't DO roads."

I soften it by adding that when communities are active, people are more likely to pay attention to them and that we all sympathize with him and agreed roads would make a big difference to this community. Then I point out that we have brought a reporter with us.

Keneth has prepared the volunteer health workers to do several of the new community development exercises. They stand in front of the group and lead a group discussion about development and what it means to them. They agree that they need more schools in the area so all the children can attend. The chairman notes that at present there is only the primary school established by Sacred Heart in the sixties.

The volunteer HW follow the discussion with a short version of the Development Game which demonstrates how even well-meaning projects for the poor can inadvertently favour those who are better off. They conclude with an energizer called the Knotty Problem which highlights the fact that those who create a problem know best how to solve it.

The volunteers have done a wonderful job of health educating. I am thrilled that they have done so well on their own and congratulate Keneth. Faces shine with the praise heaped on them. Even their volunteer leader who has come from another village is thrilled with their facilitating.

It has been a long but a satisfying day if somewhat unsettling seeing first hand how much the lack of a road can affect a community, its health and development.

Three days later an article appears in The New Vision. Our project gets a brief mention but better still, a fair amount is said about the lack of a road in this remote community and the need for it.

A couple of days later we learn that the district has sent out graders and heavy equipment to start work on the road.

Hallelujah, I think. Maybe we have a role to play when it comes to roads. Maybe we do DO roads after all.

Photos: Chairman & I talking to women in Keneth's line; mother washes babe; election posters; the chairman & New Vision reporter; kids watching.