Borneo Breezes

Christmas in Nain

2011-12-11T14:01:00.000-08:00

In 1981, just having finished my MPH at Johns Hopkins in Baltimore, I took on the job of travelling doctor for the Northern Labrador Coast for Grenfell Regional Health Services.

The six aboriginal communities were scattered along the sea edge like a necklace stretching from Rigolet west of the base hospital at Northwest River on Melville Inlet, to Postville, Makkovik, Hopedale, Davis Inlet, the one Innu or Indian community with Nain, at the northern tip.

At that time Nain was a six-nurse nursing station, looking after about 2000 souls, half Inuit and half Settlers. Settlers claimed links to fisherman who came and stayed, marrying into the Inuit population and living lives much like that Inuit to the extent they had been included in the aboriginal land claims in the area. The other communities were a similar mix with Settlers predominating and were smaller with from 1-3 nurses.

As the first resident doctor, I travelled up and down the Labrador Coast, in touch with the six Grenfell nursing stations through visits and phone calls as well as through a regular schedule radio telephone. Grenfell's bright red, single-engine Beaver, CF-OEL usually overnighted in Northwest River. Early each morning the nurses and I would finalize which patients would go where during the "sched" broadcast, based on urgency. The Radio "boys" based at the hospital at Northwest River then loaded up supplies and people.

Most of the nurses were experienced nurse practitioners, who delivered babies, managed emergencies and provided excellent care for a wide range of medical conditions. Newly trained nurses usually spent their first stint of field experience in Nain, where there would be other more experienced nurses. A few of the nurses, had, over the years, married into the community, partnering with men who were from the local community.

The whole of the North Labrador coast was magical but Nain was particularly so. The Moravian Church had brought Christianity in the 1750s. The Moravians were a German religious/missionary group who had first gone to Greenland and also landed in Winston-Salem and Bethlehem in Pennsylvania, where they still are today.

The Moravians introduced brass bands to the Labrador Inuit. Still today at Easter and Xmas, the Inuit dutifully bundle their brass instruments in massive covers made of woolen duffel so they could play them outdoors in the Arctic winter. A group of men, would start at one end of the community, moving from door to door playing at Christmas and Easter. Sometimes chilly gust of wind would sweep their sound off into the hills so you couldn't hear them if you were standing beside them. Other times, the sound cut with clarity from one end of the community to the other, the winds seeming to amplifying their procession through the community.

The band members take turns playing, stopping in homes where they are warmly welcomed and fed as they warm their hands and instruments removing the ice that has formed on them. This merry brass band with the enthusiastic mob of children chasing after them is the best possible tonic for the arctic cold of a Nain winter.

The Moravian services at Easter and Xmas are called Love Feasts, a time when all those attending are given a candle in a red apple base to hold. The Moravians relied on the annual visit of their boat, The Harmony, during the barely three-month long, ice-free period in the summer to provide all their provisions for the year. It's perhaps an even greater stretch than that required to contemplate outdoor brass bands in the depth of an arctic winter, to imagine how the Moravians kept the custom of candles housed in bright red apples alive, but as you can see in the pictures, they most assuredly did.

The women and female children who have them, continue to wear the decorated white knitted head muffs, favoured by the Moravians and the men sport white duck parkas without zippers trimmed with red or green braid, their Sunday best, pulled over their thick woolen parkas. Christmas is a time of serious house cleaning. The housekeeper at the nursing station has turned the place upside down, scrubbing the walls, floors, curtains and windows and she assures us the same is happening all over the hamlet. Everything must to spiffy clean.

A huge Moravian star with multiple conical points hangs in the middle of the church and decorated Xmas trees adorn each side of the church, even though trees can no longer be cut within down and must be found and brought from quite a distance.

The white missionaries have long since left the coast but many of the customs are continued by the Inuit. Many homes sport Xmas trees, some with the original glass ornaments brought by the Moravians. Others have added pink scallop shells, cotton grass, caribou moss and sea shells as ornaments. Almost every home these days sports the shiny streamers stretched around the walls.

On January 6^th, the Inuit celebrate Nalliuk Day, a time local youth disguised as fur covered beasts, who look much like the mummers of southern Newfoundland, chase after young children or anyone who unwarily happens in the streets of the town that night. Like many of the Holiday customs, this too has roots in a pagan past.

Young children come to your door with their hats or toques at the ready to claim gifts of pencils, crayons, toothbrushes, candies or cookies. Mostly because Nain is a small place, one recognizes the children who turn up at your door. Often as it is cold outside, they stay for a while to warm up before continuing to other homes dodging the Nalliyak.

During the Xmas season, the local kids build miniature igloos on the hills surrounding the hamlet. On Xmas Eve and other evenings if weather permits, the children, scamper to the igloos, light the candles in them as darkness falls and the population in Nain is transported to a magical place.

Photos: Nain Moravian Church on Xmas Eve; Nain Brass Band;cover of Inuktitut Magazine,1978; Grenfell Xmas card

Lion-less Trees

2011-11-29T01:45:00.000-08:00

An Irish neonatologist and I, who have been sharing a flat in Mbarara, have cleared our calendars for the weekend and are heading for the southern part of Queen Elizabeth National Park to see the famous Tree-Climbing Lions of Ishasha. We have engaged a 4-wheel drive and driver and arranged a pick up for noon on Friday.

The southern part of the park is remote and isolated, the safari lodges expensive at several hundreds of dollars a night, so I try to book us a spot in one of the park bandas. I try all the phone numbers listed in the tourist magazines and brochures. I try searching blogs of overlanders who have visited the park but none of those numbers work either. Then I try one of the ranger posts in another park which I find to see if they can help.

I find a fellow, who with typical Uganda courtesy, tells me that if I call back in five minutes, he will try to find the number. He has the number when I call back. I thank him profusely and can almost hear his smile across the line.

It isn’t really clear what we will find in the bandas, so we decide to take sheets, mosquito nets, towels, blankets and drinking water. We have lots of space in our rented 4WD.

The bandas are outfitted and even have chairs. The rangers cook a basic dinner for us and our driver and then offer to build a fire outside our banda after dinner. The only item from our stash of camping gear we needed at all is our drinking water for brushing our teeth and for mixing with the pint bottle of waragi (local gin) and orange squash we have brought for our sundowners.

We have reached the seventh empty fig tree, when my colleague sighs, another lion-less tree! I start to keep count. By noon we have covered almost the whole southern park and have reached lionless fig tree number 37. Even the vultures, who are thick in the tree tops in this area of the park, seem to have given up for the day.

We head off at 7:30 am to find the Tree-roosting lions. When you see the huge fig trees, you understand completely why they took to tree climbing in this local. The fig trees provide voluminous shade and have mammoth, smooth limbs but gnarly branches a lion can drape himself over while he waits in comfort for his wife to bring him his daily catch. The limbs extend horizontally for long stretches and provide a great view.

We decide the lions are off in the Congo on a family celebration and tell the driver we should head north to Mweya Lodge, the flag ship tourist hotel in Queen Elizabeth National Park for our planned lunch and swim.

Almost as soon as we seriously abandon hope of seeing the tree-climbing lions, we begin to see other magical sights. First there is an unusual yellow flower in the savannah.

Then we catch the Crested Eagle in silhouette above a brace of Colobus monkeys, distinguishable only by the long white tails hanging in parallel in a group of Euphobia trees.

A flash of brilliant blue brings us to a stop by the side of the road where we spot a pair of rare Giant Blue Turacos.

The following day is Eid on a Sunday so we see both Christians and Muslims making their way to prayer in the morning.

Sure enough we head off shortly after breakfast to follow a group of other vehicles to We cross Kazinga Channel and see a large group of fishing boats out, plying along the reeds in the

Our driver is determined to redeem himself and has been communing with his ranger colleague to find us lions before we leave the park the next morning. Sure enough we locate two male lions, outside the park, so we even save our park fees, devouring a waterbuck their spouses have provided. We think heading home we have got more than we could possibly have hoped for.ir dugout with heart-shaped paddles as one fisher casts the net and the other maneuvers the craft.
Photos: Tree-climbing lions; Great Blue Turaco; yellow savannah flower; Muslims at Eid; Crested Eagle;fishermen at work.

Stalking the Orange Potato II

2011-11-19T05:03:00.001-08:00

After seeing the fine nursery of Orange Sweet Potato vines that Juliette had managed to maintain in her front yard under the overhanging matoke trees, we moved down the road closer to the swamp, to see if her friend and fellow community based health worker, Dovinia was home. Dovinia was there and happily greeted us, answering all my questions about Orange Sweet Potatoes.

Dovinia suggests laughingly that we call them Orange Potatoes rather than Orange Sweet Potatoes. This is the first time I heard that the potatoes were not sweet enough. In various tests , as the OSP has been shown to contain high amounts of sugar, so we are left wondering if the sweet potato here is somewhat different or if the taste itself is somewhat different. Certainly some people complain that there is a “different” smell to the OSP but then they tell you it is not too strange and one gets used to it. I wonder how much can be attributed to just being slightly different.She expressively told us how big the tubers were and what a fine crop she obtained. Then she told us how she waited for us to return to collect her Orange Potatoes because she had not been able to sell them. She had eaten some but many more had rotted because the people said they weren’t as sweet as the local variety. This was at a time when a debbe tin was selling for 7000-10,000 UgS.

But whatever the difference, both Juliette and Dovinia were inspired sufficiently to continue with them, without any outside encouragement, based on the fact that our project, which they trust an appreciate arranged for them to get the vines. It seems there are many different forces at work here and we could be better using, perhaps even exploiting, our influence as change agents

Dovinia tells us she knows they are better for people than the local variety but she didn’t know how to convince people. She felt they had to be special because our project had brought them to her. She was surprised it had taken so long for members of our project to come and check on them. I sense a big communication gulf that attaches itself to many of our best intentions. There was a community development coordinator for a short time who had introduced the Sweet Potatoes but after he left it seems no one even inquired as to how the farmers were making out. Dovinia, like Juliette, has provided vines to her neighbours and friends. She doesn’t know of anyone who kept on with them.

Dovinia is a tall, good looking woman who shines with vitality. Could this be the Orange Sweet Potato? She had managed to keep a ready supply of vines going by moving them into the edge of the swamp near her home.

When I asked to take Dovinia’s picture, she whips her head scarf off and stands proudly erect on the road still in her gardening clothes. Neither Dovinia nor Juliette speak English, so the conversation has to be translated, back and forth, with the help of both the driver and the senior facilitator, both of whom have excellent translation skills. It is tricky at times for them to understand my questions and for her to grasp what we are asking. But there is no impatience with the interruptions and explanations.

Dovinia laughs along with us as we stuggle to understand. Are the vines kept in the water or on the edge of the swamp? She seems to understand and appreciate that we are in awe of her dedication to the Orange Potato and listens carefully to our questions. We feel we have had a rich day.

On top of interviewing our Orange Sweet Potato adopters in detail we have also arranged for the field visits of our Community Facilitation Course to the community based health workers and communities in this area the following week. A lot of ground has been covered. As we are heading off I see a large group of Gloriosa Lilies, stunning on the side of the road. We stop to take pictures. The driver is learning how to do Macro shots as he is the only one who can scale the huge lip on the side of the road.

We are heading home out of the swamp when we come across one of our volunteers distilling waragi in the steam leading into the swamp. Waragi is local gin-like alcoholic drink made from bananas.

Angella points out the stills all around the outside of the swamp when the tiny streams flow into the papyrus swamp. The running water is needed to cool the vapours and convert them into liquid. there is a drum being heated with fire wood and a plastic jerry can with tube running into it to collect the distillate after it passes through the copper coils sitting in the water.

The whole apparatus is held together with banana fibre with the tube funnelling water onto the copper coils made from what looks like matoke outer casing of the stem. I am in awe at the ingenuity of the inhabitants and the productivity in the swamp.

We have passed a couple of “banana boats”, hollowed out logs which are used for brewing “tonto, or local beer, what is called “pombe” in Swahili. Waragi is distilled from the local beer it seems.

Photos: Dovinia; Gloriosa Lily; waragi still; connections.

Stalking the Orange Potato I

2011-11-18T23:53:00.000-08:00

Two or three years ago I asked my friend, Anna-Maria, who is introducing Orange Sweet Potatoes into Uganda to provide some to the community based health workers that I help to train in Mbarara. Only I hadn’t a clue what “some” consisted of. Really, to my mind “some” were tubers or sections of potatoes with the eyes, like the ones that appear in my potato bin when I have been away from home too long. What I had not understood was that Orange Sweet Potatoes begin each planting season as a seedling. To have a sustainable crop one needs to have an annual supply of seedlings. This I probably should have known as seedlings are used to plant the regular sweet potato crops in these parts and I have noticed women carrying loads of vines around during planting time. Swamps are also found in certain parts and during the dry season it might be possible to keep the seedling alive by moving them to the swamps.

Anna-Maria was generous and provided a number of seedlings, advising us that she could not support the farmers and they would need to figure out a way to keep them going to have future crops. A number of people associated with the project began to grow Orange Sweet Potatoes. The project director put in a crop on her land which is somewhat distant from her home. The potatoes were huge, the crop which survived was bountiful but the majority were consumed by a herd of her neighbour’s cows who were unfenced as they are in many parts of the country. She and her family loved the taste of the potatoes.

One trainer put a crop into her small plot. The potatoes were large and many and everyone enjoyed them especially knowing they had increased Vit A levels and were very nutritious. But her vines did not survive the drought that came after the rains, so no second crop. It didn’t seem to me that I would not find any sustainable harvesting of Orange Sweet Potatoes in our area.

Recently I began hearing whispers about volunteers who had managed to keep the Orange Sweet Potatoes going. We have one vehicle for our project so our driver knows everyone and every place. I asked him to track down anyone who still had Orange Sweet Potatoes.

When I told Anna-Maria that I had learned of a couple of our volunteers who still had crops, she was interested. We have both been reading Malcolm Gladwell’s The Tipping Point and Chip and Dan Heath’s Sticky and about how ideas spread. So I went out last week to interview those whom I could find. Certainly the unplanned spread of innovations is something we all could use more information about.

I located with the help of our driver, Nasser, and a senior trainer, Angella, who acted as interpreter, two wonderful ladies. Juliette is one of our original community based health workers. These CBHWs were originally trained more than 6 years ago and have had regular supervision and annual refresher training. They are committed, confident, skillful and knowledgeable about child health and they are motivated and enthusiastic. Juliette is a leader in her group and was chosen to be a trainer by her peers. This past year she was chosen for the whole sub-district of Rwampara as the Model Volunteer.

Her home is immaculate with a Tippy Tap in place, chicken pen woven from papyrus, an energy efficient stove and clear pit latrine. There is a stand of matoke (cooking banana) in her front garden and in the shade of the matoke there is a nursery of Orange Sweet Potato seedlings. She insists on digging one up when I ask her how she keeps it going. She tells me how she has given seedlings to a number of farmers in this parish but none have managed to keep their own crop going. When relatives have visited and noticed the size of the potatoes and the volume produced from a small plot, they also wanted to carry some to their homes in other parishes. So from this one energetic woman has flowed a small but important stream of innovative potatoes to the surrounding area.

As we leave Juliette’s home, heading for her friend’s place close to the swamp, she offers handfuls of seedlings to Nasser and Angella, who are inspired by her description of how she has kept her Orange Sweet Potatoes going. In Stalking the Orange Potato part 2 I will tell you why I call it the Orange Potato and what else is going on in the swamp.

Photos: Juliette with OSP; Juliette's OSP nursery; Chicken Coop; Handing seedling to Guests

Tour of Student Field Placements- II

2011-07-27T16:07:00.001-07:00

For the students the field placements are a challenge. They have to work as a team to ensure their accommodation is clean, adequate and protected from mosquitoes. They need to organize for meals to be prepared and water provided as it is not always nearby. Often they have to clear and clean the rooms they will use. Ways to visit schools and homes in the neighbourhood need to be planned carefully as often the students do not speak the local language.

As I am leaving Uganda in a week a quick visit has been arranged for me to the student placement sites a week after they have settled in. I will travel with Clotilda, a skilled community facilitator whom I work with in training health workers. She also works for the university assisting in the field placements and is a skilled linguist. For the last month we have been launching our initial training on community facilitation. None of the facilitators have university education, while the participants do, yet they have managed to pull this off with aplomb, earning gratitude and praise from the participants.

We are taking with us on our tour, four hour-long sessions I have prepared for the students that are based on the interactive training we have done with health workers. We will have 1- 2 hours at each site as the sites are widely scattered on a route that takes us beyond Kabale on the road to Rwanda from our base in Mbarara. We hope to visit three sites each day and overnight in a hotel in Kabale, the Switzerland of Uganda.

As the site supervisors have little time to spend with the students, my hope is to package the material so someone like Clotilda can facilitate them. Clotilda trained a long time ago in a three month course as a nursing assistant but she is very bright and has great depth and breadth of practical PHC experience from her years as a university facilitator.

Clotilda and I take turns being the lead facilitator. We use the same training techniques and tools as we have used for our health workers. We ask somewhat different questions and we respond with connections to examples related to the student's clinical work.. Clotilda easily picks up the additional material I am adding for the students, only occasionally referring questions to me to respond or give an example. We try all four of the sessions, mix and match them after asking the students what they would like to do. Originally we planned to leave out teamwork but as one of the groups identified that they were having trouble, we felt it was a teachable moment.

The only thing limiting us at each site is the time. The enthusiasm of the students prompts us to overstay at every site. We are able to do two full hours in all but one site. We leave additional handouts for them from all the modules at their request. Clearly we have sparked their interest.

Our first stop is Kinoni, about an hour from Mbarara, where there is a large group of students including four German medical students. It takes a while for them to gather as they have to turn their clinical duties over. It would be better if Clotilda and I arrived in the afternoon as patients would have returned home by then, but we have little control over this on our short tour. We then head on to Rubanda where the students are waiting in their lab coats for us. Although all groups have not received their kerosene for cooking, both the first groups are settled in and close to water and markets.

Our next stop is Rubaare, a faith-based health unit. The grounds are well kept, the equipment is rudimentary but available. As it is Uganda Martyrs Day and a national holiday, their preceptor joins us for our session. We spend some time at each site listening to their problems and helping them to solve some of them. From here we head directly south to Kabale. Just before reaching we drop in on the group at Bukindi. It is late in the day and they are far from the market so after our session, several of them grab a lift to the market. We find a hotel in Kabale and have a late supper. The next day we visit a small but dedicated group at Humurwa.

We arrive first thing in the morning so are able to have a short chat with their preceptor. An experienced rural clinician, he is enthusiastic and has helped the students to settle in and get organized, but outside his door ranges a long line of patients. We do get to talk about record keeping and he shows us the largest register I have ever set eyes on. This is surely a place for computerized records! We head south of Kabale to reach the farthest site at Muko. Here the students have no electricity and some of the windows are broken so it is cold at night. Clotilda negotiates with the administrators for them and we get promises to make needed improvements to their accommodation. As we leave, four of them jump into our vehicle so they can recharge their computers about 10 km. down the road.

On our way back to Mbarara we pick up the DVD Outbreak that I left overnight with one group. We had hoped to discuss it with them, but they have copied it but not viewed it yet. We arrive back in Mbarara at 11 pm after two full days on the road. We make a final stop just outside Mbarara to drop off some onions, carrots, and potatoes we purchased at greatly reduced prices by the roadside in Kabale. The project secretary meets us on the road after a short cell phone call. We need to haul out the flashlight to separate the various bundles of vegetables. A couple more phone calls and a detour down a side road to a deserted building, locates a bunch of matooke set aside for Clotilda to take home.

Even the short time with the students has been useful. they tell us. Their written evaluations of the sessions are very positive. Mainly, our visits serve as a reminder that they and their education are important to all of us. At each site they have requested a photo of the group and our visit.

Clotilda and I discuss the possibility of spending a week based in Kabale and going out to visit a couple of different groups each day. We think it would work and give us more time at each site. I am convinced a set of reading materials for each session could be arranged using print and internet material if we could solve the problem of electricity. We need to continue to work out ways to make it happen.

Photos: Kinoni students; Rubanda students, Aids Register; Muko students

Tour of Student Field Placements- I

2011-07-26T02:25:00.000-07:00

Some of my best times in Uganda have been with medical students during their rural field placements. They spend about 6 weeks in remote health centers following a short orientation. Over the years the program has grown and improved. Recently field supervisors drawn from the health centers were recruited and attended a week-long leadership training workshop. I attended for one day and found the facilitators excellent and the group energetic. Although as busy managers and clinicians in rural centers they have little time to spend with the students, they were interested and committed. Involving them as field preceptors seems a great way to strengthen the service in rural centers.

For the past several years, the university has made the field placements multidisciplinary so the medical students have been joined by laboratory science, nursing and most recently pharmacy students.

I started staying for days and even weeks at a time with students at one of the sites where the health workers for our project are also trained as there is accommodation for trainers. When we were doing interactive training in Child Health, we would include the students in some of the sessions. Three of the Level IV health centers used as field sites for students had groups of the community health workers I help to train attached, so I was able to spend some time at each of the three sites. It helped that our child health project had an interest in developing a way for students to learn about and to appreciate the work of community health workers. Some of us also felt that involvement with the student teaching at the health center was a way to improve the quality of service provided in rural health centers.

The Dean, Associate Dean and the Head of Community Medical Education have been actively involved in and committed to improving the field experience and using as a way to influence future practitioners, coming up with the idea of involving field preceptors, providing leadership training and revising the curriculum.

It isn’t always possible to combine my visits to Uganda at the same time as the field placements but when it has proved possible, it is always a highlight. Over the years I have been pulling together a number of interactive training sessions related to community health in Uganda that can be delivered on site. Topics include specific areas students request such as Community Entry as well as topics the Coordinators ask for such as Community Participation and even issues I feel need more of a community and preventive approach such as Motor Vehicle Accidents.

The response from the students has been very positive. One group said they all wanted to do community medicine after the week. I had to assure them that that wasn’t my intent and I would be happy if in whatever field they chose, they took a more preventive and community approach. Some of the success of these interactive sessions is likely due to the contrast it provides to their past exposure to rote learning and to the isolation they often feel in the field. Even a modicum of the mild amalgam of challenge and direction that is provided by participatory training seems to combine to light nascent flames of interest and excitement. But whatever the reason for their enthusiasm, it is a delight to work with them.

To be continued in the next blog.

Photos: the line up at the Rubanda water pump; student groups at Rubanda work on action steps of development; participation ladder with Bukindi students; Muko group in front of the new building.

Open Hearts & Surgery

2011-07-24T02:18:00.000-07:00

She is almost two years old when I finally meet her. A sturdy toddler, inquisitive and like most African children, Isabel is interested in other people. She wanders around around the Agip Motor Hotel in Mbarara where her parents and I have gone to dine out.

She plunks herself down in my lap but soon is off to explore the verandah. A Chinese business group notice her watching them and give her a cellophane-wrapped sweet which she brings back to us. Something new for her, she shows it around to us all. At first we don’t know where she got it but as they are the only Chinese group eating on the porch and the writing is in Chinese, we soon figure it out. When she sets off again, her brother, Timothy is delegated to keep an eye on her, but she is clearly a handful.

When she reached six months, she began to have difficulty breathing and took on a blue tinge. She was taken to Kampala where she was diagnosed as having a small hole in her heart. This is bad news in Uganda where the doctors may be able to diagnose it correctly but have no access to cardiac surgery, not even for fairly simple manoeuvres such as fixing a patent ductus. The news quickly spread and people offered to locate a place where surgery could be done, to review the diagnosis and to contribute air miles and cash. A search was made of sites, advice was sought, but in Uganda, time was running out.

Her parents are dear friends, among the first people I met at the university in Mbarara when I arrived in 2002. We share an interest in community health. They are hardworking and resourceful. They quickly located a surgeon and hospital in India which accepted children from Africa and they committed to making it happen. This proves difficult as time is running out. Also although colleagues were generous, the cost of sending mother and child to India and getting the operation done are nothing short of prohibitive.

Still colleagues at the university in Uganda managed to raise $1000 in cash, a phenomenal feat in such a cash-strapped economy. This nest egg and some donated air miles were not enough to ensure it will be done but it was enough for Isabel and her mother to set off on the plane before she was severely compromised.

Some of us were still trying to process the info and help to locate an appropriate place where the operation could be done, when we heard they had headed for India, one step ahead of the Grim Reaper. It was clear that at this point, cash was needed, not advice. Through donations wired to the Kampala branch of her bank account, which her mother was able to access in India,enough money was realized. The whole thing was touch and go for most of the time, but thanks to modern banking transfers, the internet and generous friends, one very sick, young gal was able to get the life-saving operation she needed.

It is such a thrill to see her clamouring over the chairs in the hotel. She is a testament to Open Hearts and Surgery in a place where one doesn't deserve to find them.

Photos: Isabel and mom, Brother Timothy

Nutrition Training in Bushwere

2011-06-28T02:49:00.000-07:00

A short course on nutrition had been piloted in a few communities near Mbarara. Numerous studies have been done which show malnutrition to be a major problem here with as many as 40% of children under five years being identified as malnourished. This is despite the fact or maybe because of the fact, that south western Uganda is the producer of matooke, a form of cooking banana, which is the main staple food for much of Uganda,.

Matooke has little nutritional value other than calories. Men ride and push bicycles loaded with as many as 6 huge bunches of matooke long distances to reach the main pickup points on the highway for trucks carting matooke to Kampala.

Matooke is much beloved by Ugandans, well southern Ugandans. If you have a dinner with corn, potatoes, salad, chicken, rice, fruit, cake, cassava, meat and ground nut sauce and you don’t have matooke, your Ugandan guests will inquire, “Where is the food?”

You think I am joking? Well think again.

The nutrition workshop involves one or two of the community volunteers from each parish cooking the noon meal together. They bring their own food and prepare the meal together one day in the traditional way.

The following day the trainers help them with the same food but make a number of changes. They mix various food together; leave the pumpkin seeds in to be steamed for added zinc and add more local greens. In the workshop they talk about the added nutrient value and food groups. But it is the delicious taste that convinces the volunteers. That and the fact that they have assisted in the preparation so are able to replicate it at home.

I have been asked to attend the training and give them feedback. I haven’t been actively involved in the training but some of the training exercises and pictures used in our child health manual have been incorporated.

Both the male and female trainers are doing an excellent job. While cooking largely falls to women at home, the male trainers are demonstrating some wonderful skills. Doudi peels a pineapple holding the green leaves with one hand and wielding a machete in the other, leaving a totally clean pineapple. Oscar shows how quick he is at peeling matooke, which unlike the yellow banana, had a hard, thick, sticky skin.

I watch a group of women make short work of cassava, which I have never before seen being peeled. They skilfully remove the thick skins and center piece, breaking it into smaller pieces sometimes with a knife and sometimes not. A huge pot is filled with matooke, then layers of other food placed on top and the whole thing covered with banana leaves so it can steam on an open fire. Because some people prefer roasted matooke, unpeeled matooke is also placed in the fire to roast.

I ask them, as they prepare the food, about the manual they are using. It is confusing and not much help, almost all the trainers tell me. Someone points out it is unclear and goes from one topic to another. The issues are mixed up says another trainer.

This surprises me, not for the usual reason, for I also have found the manual disorganized. What surprised me is that they are reading and relying on the manuals. Almost all trainers appear to pick up what they need to know about a topic and about how to facilitate it from watching other trainers. I have come to this conclusion by noticing that certain ways of facilitating sessions and certain messages that do not appear in the manual are being circulated whether they were right or wrong.

If trainers were referring to the manuals regularly, I thought, these deviations would be identified and corrected. But it seems I have been jumping to conclusions and some of the trainers are using the manuals and what is more are able to identify a well-written one from one that is not. Remembering that many of the trainers have just basic schooling, I wonder if what I am seeing is that they are getting more used to using manuals.

I praise the trainers for their facilitation, for how they incorporate the new cooking skills and techniques into the training and for using labelled rice bags representing the three food groups.

I suggest that the trainers identify a couple more interactive nutrition exercises for the classroom work, maybe some pictures of the appropriate size of staple food for different ages and collect more colour photos of food used in the area to add to their collection. They agree with me that they could cover the same material in two days rather than 3 or 4. I concur that the manual needs work but as they are doing a good job with the training at present, think it can be postponed for now.

Photos: rice bags used for identifying food group; laminated food photos; pumpkin put on top of matoke; more greens added; covering with banana leaves for steaming.

More from Mpigi Marsh

2011-06-17T11:01:00.000-07:00

Mpigi marsh is magical and not just because of the shoebills. There is plenty more to see. I am sure you want to see more of the marsh. There are lots of birds moving around the marsh, settling on the papyrus or taking up residency in a tree. The pelican is especially majestic as she floats around taking lunch.

Then I also have some more of the Shoebill as she flaps her wings to take flight. She looks a bit like the dinosaur she is, as she mobilizes all her energy and intention to take flight. A flurry of effort and determination after hours patiently and silently watching for eels moving slowly among the reed on the marsh bottom.

Here is a closeup of the eel, so enjoyed by the Shoebill. The eel is lying in the middle of bottom of the dugout. We didn't realize it was not a fish until the fellows hauled it up to show us that it had no gills and looked more like a snake than a fish. I suspect the presence of the eels is one of the main reasons for this grouping of Shoebills in the Mpigi Marsh.

The people of Mpigi Marsh are hardworking, frugal and resourceful. They have to be. The repairs on this dugout are a testament to all three qualities, showing how they use plastic jerry cans to repair their canoes.

Life is also hard. The morning we spent with them in the Marsh, we found them at a communal dinner, part of the funeral for a young child who died from malaria, a scourge of this swampy area, but something that can be prevented with bednets and access to early treatment. It isn't an easy life, for people or for shoebills. Many of the "fisherfolk" are children, likely bringin in extra food and extra cash for their family.

Community Facilitation CE Launched

2011-06-16T01:59:00.000-07:00

Our trainers are drawn from local health centers in SW Uganda. Many of them are the only health worker at the Health Center II or III level. The majority are nursing assistants with three months of formal training. Often they have been stationed in the same place for more than ten years.

Our training, first in child health and more recently in community development, has given them additional health information, more confidence and provided motivation as well as social stimulation. They also appreciate the certificate of attendance we provide at the Training of Trainers courses.

For several years they have been asking if they could receive more formal recognition for their training from the university, which would mean for us to make the training a regular continuing education course. After much to and fro with the university, including development of a detailed curriculum, course description, outline, objectives etc. our training has been accepted as a Continuing Education course, perhaps the first to be provided at Mbarara University of Science and Technology.

The first Training of Trainers course was provided during my recent visit and included a number of university faculty as well as our field-based facilitators. Now with our trainers prepared to provide a university continuing education course, we have offered the first Continuing Education course in Community Facilitation facilitated by three of our own trainers.

Much to my surprise we had ten applicants sign up for the course, all of them university graduates and willing to pay for it. By the second day several more people, who had heard about the course from their friends who were attending, came to say this was exactly what they needed and they wanted to join us. We are now hearing from others eagerly inquiring as to when our next course will be held. The trainees come from local and international NGOs, faith-based institutions and recent graduates from developement studies. I am amazed how, with minimal advertisement there are so many people interested. The trainees are exceedingly enthusiastic, so already a second course is being organized for later in the year.

During the first week of classes, which were held in the Red Cross offices, a number of students visiting the Red Cross from a college in Kampala as part of the field work of an adult learning course, ask if they can sit in. It seems they get the theory of adult learning but not the coaching or practical skills needed to put it in practice. Looks like this could be a growth industry here.

The facilitators for this first certificate course, could not be better. Bernadette, Charles, Theresa and Clotilde are sensitive and supportive to participants, providing just the right amount of encouragement and direction, giving helpful feedback and jumping in when needed. Each of them has selected specific new skills they want to develop themselves and new sessions they want to try out. I think I have produced facilitators who are not only superb but who are better at this than I am.

Photos: Consulting with Charles; Food groups with Bernadette; Problem Tree for Domestic Violence; circle counselling; Richard creates his own flannel pictures.

Shoebills in Mpigi Marsh

2011-06-15T04:55:00.000-07:00

We are out the door at 7:30 am Sunday, a thermos of tea, hats and sunblock in hand. We have warm shirts because the day is still cool and its looks like it is going to rain. We head south from Kampala on the main highway to Mpigi on the lookout for a sign indicating St. George's School. Schools in Uganda are better marked than cities or highways.

Traffic in Kampala, usually clogged with vehicles, is light at this hour. as we head out to see one of the remaining groups of Shoebills in Uganda. Shoebills, also known as Whale-headed storks, are found in Sudan mainly but there are two groups in Uganda, one group of seven in Mpigi Marsh and another group of about the same size in Murchison Falls.

The Shoebill looks a bit like a dinosaur would if it were a medium-sized bird. The cover of Brandt's Uganda travel book provided my first exposure to them. Since then I have taken a photo of a shoebill through the chain link fence at Entebbe Zoo so it would not appear to be in captivity. Now I am going to have the chance to see it in the wild.

We have a cell phone number for a guide called Hannington and have let him know we are on our way. Mpigi exits are spread out along the Kampala-Masaka Road for miles so we have been told to keep an eye out for the sign for St. George's School. We reach one large crossroad with numerous signs-- for St. Joseph's, St. Henry's Girls, St. Theresa and St. James, but no St. George's. We call Hannington on the cell phone. He tells us to keep going. The rain is starting to pelt down. We drive about 10 km further south. Now when we contact Hannington he tells us we have gone too far.

The rain is coming down fast and furious. Abby, our driver, is beginning to think it is not such a great day to be out in an open canoe in Mpigi Marsh. I am still hopeful as rain in Uganda usually clears up quickly bringing the sun, but I can see her point, especially given the trouble we are having locating the turnoff and Hannington.

We turn back along the highway, still no St. George's. Another U turn and just as we are about to give up in exasperation, we return to the original crossroad with multiple signs, locating Hannington in a red shirt, black pants with binoculars strung around his neck.

If our guide's name was James or Richard, we would have likely given up long ago, but the very name Hannington has us going, as we run through all we can remember about John Hannington Speke, one of the early British explorers in Uganda. At this point we are speculating that maybe Speke died going back and forth looking for the source of the Nile.

We head down a murram road, slippery from the rain, several stalled trucks skewed on the uphill slope. Hannington takes the wheel and maneuvers the vehicle around the trucks. It is at least a half hour off the main highway to the edge of the marsh, thick with papyrus, with hand-built raft in various states of disrepair littering the edge, men returning with the morning fish and hand-hewn canoes bearing motorbikes from the off shore islands. As Hannington arranges for our dugout and paddler we settle into the dugout.

The sun is coming out and beginning to dry out the area, birds are twittering, a black and white hornbill takes off over the papyrus as hand-hewn paddles.

A perfect day to be out on the marsh propelled forward with paddles shaped like heart-shaped leaves, similar in shape to those found in early drawings and photos of the Lake Victoria region. Fishermen are bringing their catch, including an eel, the preferred lunch of the shoebill. At first we don't discern between the fish and the eel so they hold it up for us to see it is more like a snake, lacks fins and has long feelers.

Two young boys are sent out to push a larger raft to the side of the narrow channel and off we go. Purple water lilies line the edges as we scoot along the water way silently, manuevering in and out. The marshy edge looks as if it goes on for miles without breaking into the open water.Not long out we come to a female shoebill standing in the marsh intently watching one spot. We sit and watch as she patiently waits, then quickly grasps an eel, bites it with the sharp end of her bill and swallows it. I can hardly see in the bright sunlight but my camera does its work and I have several lovely photos. It is a female we note from the tuft of hair at the back of her head.

Photos: Mpigi Marsh in the dugout; Shoebill on alert; Shoebill snags an eel; Shoebill waits; Pelican; African Jacana- the Jesus bird that walks on water

Selling Snake Oil in Uganda

2011-06-05T04:39:00.000-07:00

I took the Swift Safari bus back on Monday from Kampala to Mbarara- a 5 hour journey with capable driving. My friend's driver dropped me off at the bus park early in the morning when the bus was almost fully loaded so I only had to wait about 15 minutes for the bus to be full.

The gals in the seats beside me were negotiating for jean jackets out the window. Several jackets were passed back and forth through the open window as the bus edged closer to the bus park gate. They haggled with the vendor until the deal was concluded. The imminent departure of the bus just seemed to add spice to the bargaining as they tried each jacket on until they both had the jacket and the price they wanted at 15000 UgS., about $6. Nice looking jean jackets too and they fit.

A woman was moving back and forth in the aisle as we headed out of the bus park selling cold drinks and snacks, oblivious to concerns she might end up in the next town. Outside people were buying maize and other edibles. I had brought water and a few guavas with me so was content.

As we headed out of Kampala, a man standing in the aisle opened a briefcase stored in the rack in the middle of the bus and began loudly hawking items throughout the bus. He worked the bus for about 10 minutes, then he got off the bus at a bus stop. Quiet reigned in the bus with his departure. Some dozed. Some talked quietly. Some read newspapers. Long distance buses have been improved significantly so now you don't have to share your seat with one or two others.

About the half way point of our trip after a short pit stop in Masaka, a young fellow boarded, and as all the seats were full, he stool in the middle of the bus. After five minutes he too proceeded to open a briefcase that was strategically located in the middle of the bus. He introduced himself in a loud voice, that was heard throughout the bus, using the vernacular interspersed with English.

He began by flogging herbal soap that could treat syphilis, impotence and sadness. He kept up a continuous chatter and had people laughing and asking questions. Distributing bars of blue soap, he invited people to smell it, continuing to extol its virtues. He followed up with blue, scented candles said to reveal the secrets under your bed.

"What don't you know that you should know about?” he asked.

Of course we could all think of many things and again the laughter and chatter broke out. Candles were passed over the tops of seats for people to hold and soon bills were coming back to him. After a surprising large number of people had purchased these blue, tell-all-the secrets, candles, he moved on to a very special cream to get rid of hookworm.

"Just rub it on your belly," he invited everyone. People clamoured for them. Transactions were made. He was clearly entertaining. He also hollered the whole time and spent much of the time right beside me.

As the only mzungu, (white person) on board, I felt I had to keep quiet but I wanted desperately to challenge him and even to throw him off.

But for pure entertainment, I hadn't seen such a show since as a kid I had attended the local circus and heard the carney's spiel about the bearded woman and 3-headed calf. It certainly takes you back.

Photos: Views from the Window: Selecting the best roasted maize; Crested Crane Pair grazing.

A Matter of Faith

2011-06-04T07:42:00.000-07:00

At first you don't notice them. They move in small bands, rarely more than 6 or 8, on the wrong side of the road. The roads in Africa are lined by pedestrians moving to and fro, but these walkers along Mbarara-Kampala highway are making the annual pilgrimage to Namagongo Church in Kampala, the site of the Uganda Martyrs

Pilgrims come from across Uganda and even beyond the borders. Groups stream along the roads from Gulu, Soroti and Arua in the north; from Kisoro, Mbarara and Masaka in the south; from Kasese, Fort Portal and Masindi in the West and Mbale, Jinja and Tororo in the East. This year groups from Sudan have been dropped inside the borders to begin their pilgrimage while Tanzanian groups move their way up from Bukoba.

They come with their requests, prayers, intercessions and hopes, seeking absolution and bringing their gratitude.

Most groups cover about 40 km. a day.They travel lightly over the land--a rag- tag group bearing small plastic bags glimpsed from the vehicle as we pass. Babies still on the breast, youth with their exuberance, a 73 year old woman coming all the way from Kabale, about 400 km. to the south who started off a month early because she knew she would need frequent rest stops.

The pilgrimage looks on the surface haphazard. If you aren't paying attention you might not even notice it. We are speeding by on the road for an hour or more before I notice them. Only when I recall that it is getting close to June 3 does it dawn on me that these are the Uganda Martyr Pilgrims.

There are no hiking boots, or fancy, over-stuffed backpacks, no signposts along the way or special way side stops. There are few hats and only one umbrella. Everyone carries some sort of sack or bag with many of them slung over the shoulder as Huckleberry Finn might do. No refreshment stops or sculptures adorn the route. I spot one wooden cross and a small banner carried by the Mbarara group. This pilgrimage bears little resemblance to the popular Spanish pilgrimage of Camino del Santiago! But if anything, it is even more touching in its simplicity.

Behind the scenes each group has a daily route between two churches where they will be fed and provided with somewhere to sleep. Churches are kept informed of the progress of the pilgrims by Radio Maria, the Catholic station. In the noonday heat, here at the equator, groups often pause along the way. Each year when they arrive at Namagongo Church a different diocese is responsible for hosting them. Last year it was the Karamajong Diocese, and I am told the entertainment and dancing were fabulous. It is almost impossible if you don't have a special invite to get even close to the church on June 3rd.

In many ways this pilgrimage reminds me of the pilgrimage held each year in northern Alberta at Lac Ste. Anne which draws aboriginal people from many tribes and from as far away as BC, Saskatchewan, Manitoba, Yukon, NWT and Ontario. From hundreds and even thousands of miles, many aboriginal groups including the Cree, Blackfoot, Dene, Sioux and Metis peoples have gathered for spiritual renewal and social and cultural rejuvenation at the end of July.

Although I worked up North with aboriginal people for many years, I only stumbled across Lac. St. Anne pilgrimage on a canoe trip on the Clearwater River years ago. Relatively unknown in the rest of Canada, Lac Ste. Anne is an important traditional summer gathering that almost certainly predates contact. It has been recently designated a National Historic site in Canada hosting more than 30,000 each year for the annual pilgrimage.

People don't talk about it a lot and don't seem to spend a lot of time planning, but whole families make their way to the site every year. Lac Ste. Anne for me captures the same sense as the Ugandan Martyrs pilgrimage. It is about a people's focus on what is truly essential, on their spiritual center. As they said on the TV here, it is a matter of faith

Photos: Uganda Martyr Pilgrims on Mbarara Kampala highway

Pair-Wise Ranking

2011-06-04T00:35:00.000-07:00

We began introducing community development ideas and exercises into our child health project fairly early. In the beginning, our funding was short term. In order to continue, when funding came to an end, our volunteers had to be prepared for even their meager transport allowances (one dollar) to enable them to attend monthly meetings, to come to an end. Our volunteers thought because international partners were involved, that funding was limitless.

To explain sustainability and dependency we introduced picture codes: one based on Teach a Man to Fish, the other an adaptation of the Pit of Ignorance. The exercises and discussions that followed proved useful, even illuminating for the volunteers. A sense of commitment and a greater understanding of the importance of their role in improving health in their communities took root.

The change in attitude was most noticeable when our original volunteers were incorporated into the larger groups of volunteers being established by the Ministry of Health in Uganda as Village Health Volunteers (VHV). When VHVs began asking for allowances, gum boots and umbrellas, it was our original community volunteers, not the government or project staff who would explain to the new recruits the importance of sustainability and volunteerism. To sustain themselves many of the groups began income generating activities (IGA) and "cash rounds" to pool the small money they had to enable them to start IGA as a group.

As volunteers started income generating projects, additional sessions on community development were introduced. Finally, last year we had enough interactive exercises that had been adapted and piloted that I began to compile a manual and short workshops for both trainers and village volunteers.

Training of Trainer workshops in community development were done with our senior trainers last November as well as the first two pilot workshops with our village volunteers in development we could identify and iron out the difficulties. They were enormously successful, even more so than our child health training. Now with a small grant from a UK organization, groups of our trainers are taking the community development workshops to all the VHV teams in Kinoni sub-district.

I have been able to watch them in action. I miss the fine points of discussion without an interpreter but am able to follow the facilitation skills they are using and the flow of the sessions. One of my greatest delights happened in Ryaminyonga, one of our most remote communities this past week.

Kevin was training of group of 37 VHVs with three other trainers. Kevin had attempted a Pair Wise Ranking exercise at the TOT which hadn't worked. As a result, I was thinking of letting the exercise drop completely and hadn't used it since that time. When I saw it on the timetable at Ryaminyonga, I was a tad worried. I wasn't sure why it hadn't worked and hadn't been able to figure out what we needed to change in order to make it work. It had been a new idea to everyone and somewhat complicated.

Then I watched in amazement as Kevin, who had organized all the bits and pieces that are part of Pairwise Ranking, execute it flawlessly with a colleague assisting him. I was beside myself. A little more preparation and presto, it worked.

But an even better aspect to the exercise was that Kevin was ranking the six items the VHVs had identified as their prime motivation for volunteering. The items included: T-shirts, allowances, confidence, training, improvement in child health in their village and community respect. For his example he used one volunteer from the community. For this volunteer, training and confidence scored highest with 4 each; child health improvement and respect were next, with 3 each; T-shirt only 1 and allowance scored 0. Training, of course, is the what produces the confidence, the child health improvement and the community respect so I was doubly thrilled.

A shot indicating that training scores highest, of course, makes for a good photo! Another challenge for me is to convince the trainers of the importance of having our visual aids written in the local language, and not just translated verbally by them at the time, as few of our volunteers are proficient in English. But that is for another time, today I am still savouring the thrill of having seen Pair Wise Ranking done perfectly.

Photos: Keneth does Pair wise ranking; Ryaminyonga VHVs, Oscar facilitating; Training wins!

Anatomy of a Meeting

2011-05-18T21:57:00.000-07:00

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

2011-05-13T23:10:00.001-07:00

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

2011-05-12T03:47:00.000-07:00

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.

There Be Dragons

2011-03-05T09:41:00.000-08:00

Ancient geographers recognized that maps were things of beauty, a testament not only to what was known about the physical geography of a journey but to the heights to be scaled by human dreams. Mapmakers documented journeys that were both magical and mythical. Maps contained what was already known about an area as well as all the possibilities. In recognition that one never knows all there is to know about a region, they placed in the four corners of maps, wondrous breasts and birds, such as were said to guard the entrances to heaven and hell. They said about the edges of ancient maps, There Be Dragons.

I have been engaged in a journey that requires this kind of map making. We have set off for a destination yet to determined. We have lost sight of the safe harbour from which we set sail and are headed for a shoreline that remains remote. We are unsure of where we will pitch up or when. And lately the journey appears to be as much about the dreams and possibilities inherent in the process as well as the actual territory to be covered.

For 5 days last week, I was closeted with four people who talk as fast and as much as I do. I got a good dose of what it is like to have to listen to me! We were finalizing a 2 year grant we received from the Canadian Institutes of Health Research (CIHR) to meet together and plan how to implement Participatory Research in Pakistan. Our meeting was to have been held in Pakistan but as we were unable to travel there in the past two years due to insecurity, we organized to meet in Vancouver.

I was the only person who knew any of the others before the week began. One had been to Pakistan with me and one I had only ever talked to on the phone. So we had some team building to do. We have a medical anthropologist working in health promotion from Manitoba; a nursing professor from SFU in MCH; the head of Physicians for Global Survival and the head of the International Institute of Child Health at UBC whom I had worked with 25 years ago in Ethiopia.

At the last minute, likely due to the current turmoil in the Middle East, our Pakistani colleagues did not get their visas. So we used Google docs and email and long telephone calls to connect with them. We accomplished the objectives of our meeting; beginning to work together as a team; analyzing the data from an environmental scan done by our Pakistani partners in local villages and planning 3 research proposals from the data obtained from the scan. By the end of 6 days we had also drafted an outline and made a good start on a project to train midwives. And we all had headaches.

After delivering the last person to the airport, I returned home, picking up my mail enroute. In the parcel from my sister there was a card with the colour drawing that heads this post, of Abyssinian Long Claws by the artist Jill Last. I thought it was a birthday card from my sister, but inside was a note addressed to me on leaving Ethiopia 25 years earlier. At first I didn't recognize it although the artist was well known to me. Then I realized it was from Charles, the physician I had just spent 5 days with, who had been in charge of the project in Ethiopia when I left 25 years ago.

I called my sister in Winnipeg to ask where she had found the card.

"Was it yours?" she asked. "It is your name and about Ethiopia, so I wondered. I found it in the back of the frame I bought at the Goodwill Store."

I was gob-smacked and got prickles on the back of my neck.

What are the chances of this? My sister finds a card I received in Ethiopia 25 years ago when she purchases an old frame at a thrift shop. And if that is not enough, it arrives the day after we have been meeting about the Pakistani project. That was when I realized that this team I had pulled together, this journey we were on it was both magical and mythical. When I illustrate this journey, one of the wondrous beasts in the corner of my map will be Abyssinian long claws.

What Jack Taught Us

2010-12-10T13:17:00.001-08:00

Professor Arnold Naimark has referred to Jack Hildes' definition of the silent language of medicine as the non-verbal means by which values and standards find their way to those places in our hearts that words alone cannot reach. Most of Jack Hildes’ lessons were of this non-verbal variety.

Jack was the kind of fellow you watched carefully, attempting to determine how he made it all come together. I went to Churchill with the Northern Medical Unit as a student first in 1972 when Wally Temple, John Russell and Mike Gonzales were doing burr holes for subdurals and emergency abdominal operations. I saw Churchill and the kind of supportive supervision one could get from the university connection and visiting specialists as a good way to prepare myself to return to Africa. I was so green, I did not realize you were in trouble when flames started to leap out of one of the engines in a Twin Otter. I would probably still be there in Arviat except for a curious Inuk who came by on skidoo to see why we had landed so far from the air strip! I travelled on to Chesterfield Inlet with Jack, fell asleep while he played bridge with Sister Isabel until the wee hours of the morning. I was astounded when he started his clinic at 7 the next morning. I felt that I would need to train as SuperDoc to work in the North.

So when Sharon Macdonald, Eddie Berinstein and I went to Churchill to practice as the first group of U of M graduates in 1974, we were in the beginning, all very clinically focused. We had to be. We took turns doing surgery and anaesthesia. Bill Sutherland, who later went to practice in Rankin Inlet, helped to ease us in to our new roles. Jack would come up to Churchill 4 or 5 times a year to wrestle the hospital board into shape; getting them to agree to having an Inuit representative, Ollie Ittinuar, by offering to provide an interpreter; forging a strong connection with Keewatin Medical Services with visits to the Inuit hamlets and teaching nurse practitioners for us; and making links with the province with regular visits to the Cree communities down the Bayline and to the Tadoule Lake Chipewyan community. In short, he was transforming, bit by bit, what had been a white hospital enclave at the old army base in Fort Churchill into an flourishing aboriginal Community Health Center.

At the end of our first year, Sharon, Eddie and I were invited by Jack to negotiate for our second year. He was surprised we didn’t ask for more money and increased our salaries anyway. But by then we had started to get a broader picture of aboriginal health. So we said we wanted to get more involved in northern health, attend conferences, do research and assist with the community health center. Jack readily agreed.

" Whoa", we countered, "we don’t even know where to start or what to do. We need your help. "

We were asking even at that early date to be mentored.

Around about then, Lorna Medd came on board as co-director of the NMU, although she used to joke that she was the only co-director, Jack always remained the director! But we began to get more creative. We held several of our own health conferences in Churchill. The first conference was broadcast over CBC North. Soon CBC was swamped with phone-in calls from the Keewatin communities and Josie Kusugak was invited down as their spokesman. We approached Jackson Beardy about using his art as a basis for a cross cultural sensitivity workshop for medical students who were spending the summer on northern reserves. When we first asked him, Jackson said “You might be barking up the wrong Cree.”

But he agreed and it was a rousing success. The family medicine residents asked us to do one for them as well. Social scientists such as Mary Morison were doing research on the relationships between the GPs and the specialists, social workers and dentists were engaged and along with a wonderful group of itinerant specialists whom we referred affectionately to as Uncle Jack’s Old Boys Network, a functional health team was being shaped.

Two of Jack’s tips have followed me in my career. The first is: Start with what you have. I had started to track the high number of meningitis cases we were seeing in Churchill but before long I was ready to toss in the towel. The laboratory was a hodge podge of antiquated laboratory tests such as Pandy’s test and medical records were a dysfunctional labyrinth you could enter but might never emerge from. Jack was adamant that we had to start with what we had. Only then would the lab and medical records improve, he claimed. Start with what you have has travelled with me thru mental health issues in Labrador to motor vehicle accidents in Africa.

The second tip from Jack that I continue to use frequently is she who writes the minutes controls the meeting. The early Northern Medical Unit days were peppered with meetings: meetings with the province, with medical services, with communities and with doctors. Jack always went in with a clear idea of what he wanted out of each meeting. He would brief us in advance and debrief with us afterward. He often had one of us take minutes but he always edited them carefully. He wasn’t interested in what he called purple prose, but he tracked forward progress. His approach to meetings made him an effective negotiator.

He was also known to occasionally fall asleep in the middle of a meeting. One could actually hear the Zizzes. But he would come to quickly and leap right back into the fray. I think it was Jack’s way of signaling that he was bored by posturing and rhetoric.

She who writes the minutes controls the meeting has been extremely useful to me. I can point to a number of times when concise minute taking has made a real difference in not only meetings but in forward progress in projects and steering committees.

Jack not only established community medicine training at the University of Manitoba but was a true founder of community medicine in Canada. There are many wonderful stories of how he related to and interacted with communities, but my favourite occurred during a visit to introduce the Northern Medical Unit to the communities on the East side of Lake Winnipeg. A group of us had dropped in with Jack to Berens River, Popular River and Paugaussi in a single engine Cesna one fine summer day to talk about what a link with the university might mean to these isolated reserves. This, as you can imagine, was not an easy idea to put into words, never mind to sell to remote reserves. No sooner had the community gathered in Little Grand Rapids than we realized we had walked into an active hornet’s nest. The nurse was threatening the chief and councilors. Everyone was hurling abuse at the nurse. Accusations and intimidation filled the air. And in the middle of the controversy was a sick, disabled child.

This was not the time to point out that the NMU had played no role in this particular fiasco, nor to point out that the university and Medical Services were completely different organizations. Most of us with him thought that Jack could walk on water but we figured he was about to meet his Armageddon in Little Grand Rapids that day.

As the shouting escalated, the rest of us physically and mentally backed off. In contrast, Jack became totally engaged. He listened carefully, teasing out what had happened. He probed skillfully and rephrased appropriately until the sequence of events was clear. It wasn’t a pretty situation or even a defensible one. But finally when tempers had cooled, Jack got everyone to agree that mistakes had been made; that pressures on everyone had been excessive and that humans are fallible. A meeting about what the addition of the university could add to the current health mix in Little Grand Rapids was no longer necessary. Jack had provided the best possible demonstration.

He could certainly dance and dance he did that day as the rest of us watched spell bound. I think now what made Jack so effective in so many similar high pressure situations was his strong belief in our human connectedness and our fallibility.

Jack loved details and he was a big picture thinker. It was this paradoxical mix that made him so influential. He influenced those of us who mentored under him not just to address the ill health of people but to notice and appreciate what kept them whole, vibrant and unique. He might have been measuring the temperature in the leg veins of arctic shore birds when he first went to the Arctic as a physiologist but what captured the places in his heart that words alone can not reach was how, despite the adversity, the scarcity of resources, the poverty and the attempts at assimilation, northern aboriginal people not only had managed to survive but did so with so much of their culture and center intact. His legacy to all of us has been a NMU that could address with sensitivity not just the ill health of aboriginal people but could celebrate with them their culture, strength and aliveness.

Photos: Jack on Jackhead dock; Charlie Ferguson at Rankin Inlet; HBC at Repulse Bay; John Crispin at Norway House; aerial view of Norway House by George Hunter & Norway House Baby Contest, 1977.

Community Development Training in Kitunguru

2010-11-09T08:19:00.000-08:00

We have taken our Community Development training on the road, about 30 km. down the road to a couple of places called Kitunguru and Nyarygonga, both rural areas that are part of Kinoni Health Center IV outreach. Each day enroute we see several pairs of crested cranes, Uganda's national bird, by the side of the road. I think they must have taken up residence in this area. This morning as we were heading out I saw an Abyssinian lilac breasted roller flitting form tree to tree outside our door. He was here last year but this is the first I have seen of him this year.

The workshop training aids are not yet all translated, at least the posters aren’t, so I mistakenly assumed the trainers would do without posters and just teach in the vernacular. Not so, as I quickly find out with presentations heavily laced with English. I have been provided with a translator so I can now track everything that is said by participants and facilitators, theoretically at least. More about that later, but what I do hear, is not reassuring, so I request my translator, Evelyn, do some translations of the English posters into Lunyankole. It quickly becomes a group effort, as the phrases are eased in Lunyankole. Why didn’t I pick up on the need for them to do it collaboratively earlier? I wonder later. One of the trainers who appeared to be avoiding doing it earlier, is now the one who seems to be doing most of the refinement of phrase. As a result, the translations seems to go quickly and we have not one but two posters translated. One for the points of Active Listening and one for the key parts of Feedback.

With the vernacular posters in place, the air is peppered with a whole lot fewer English words. this seems particularly important since very few of the community based health workers speak any English. We have never been able to manage any back translations of the Lunyankole for reasons I have been unable to penetrate. I suspect I have not yet convinced anyone of how important back translations are. Yesterday when we were using cards for an exercise with both languages, several trainers said they couldn’t understand what one or two cards meant. So clarity of translations is a real, ongoing issue. I have asked for the whole exercise to be checked so the discrepancies can be identified. And I wonder how often it happens. Again and again, I suspect.

By noon the tin roof of the room where we are holding the workshop has heated up and it is stifling inside so we take the Action Steps of Development session outside. We have difficultyin attaching the rice bags to the rough surface of the wall but finally get it up. The session is about half way thru when dark clouds bring in a tropical storm which lashes down with fury on the tin roof. The cacophony that results makes it impossible to hear someone sitting beside you. The whole group sits quietly on the wooden benches waiting for the storm to subside.

I notice the trainers seem more energized at these community workshops than they were at the Training of Trainers workshop. They have a real gift for drawing out responses and tapping into the energy of the volunteers. They recognize when participants haven’t quite got the message. I am more concerned that they include lots of interactive exercises and eye-opener moments, as they call them, while they are in a sort of turned-on performance mode. The Action Steps rice bags also need to be translated. But for this, I have a handout in both languages prepared for now.

We have a couple of small prizes for the best group report and the best feedback. There is animated competition for them and great delight in the winning of them, although some of the items, such as a cloth, fold-up version of a Frisbee, need to be explained. Delight, that indeed is the appropriate word.

This group of government volunteer health teams includes all of our previous community based health workers in the area, most of whom have been with our project for more than five years. We have a retention rate of 85% over the five years among our volunteers and perhaps more surprisingly, they all continue to spend considerable time doing their volunteer health education work. Training, which we have provided annually for them, has been a potent motivator. They take it seriously and enjoy it. It has done a lot for their confidence and skills. I like to think it is because the training is relevant, useful and empowering. I can’t be sure this is so, but I notice attendance at the workshop has been increasing each day and I suspect it has something to do with the training provided.

Photos: Action Steps outside; lilac breasted roller; under the mbati roof; using pictures

Drama Competition at Rymiyonga

2010-10-30T21:19:00.000-07:00

For weeks the Volunteer Health Teams have been practicing for the drama competition. The first round winners were three and with their Trainers they have been hard at work including role plays, songs, traditional dances with drumming and even making their own scenary. HIV/AIDS features in the presentation as does traditional medicine.

There is one member of the large Vesico-Vaginal Fistula team, a O & G resident, from the US staying at the flat to guide the last cases though their convalescene. They have spent all their time at the hospital,getting a rather trucated version of life here in Uganda, so I have invited her to join us. One of the groups has arranged for a mammoth community feast.

Friends, relatives and well-wishers will be attending. Cash prizes will be provided for the winners. Save the Children personnel have come to make the presentations.

The groups have done so many different songs and plays that each presentation goes on for at least a half an hour. The church is huge with walls stretching high into the ceiling, likely meant to be a cathedral when complete. The floor is mud and the windows without casings or glass but the idea is definitely grand. Chairs and benches have been brought in for us. The light is poor inside so I ask the puppeteers to bring their puppets outside where I can better photograph them. They seem proud to be asked as they have made the puppets themselves.

It is a joyous celebration. The groups well prepared and shining with delight. Wonderful really to see all the VHTs in their T shirts filling the place. This brings all the kids over to watch again, they can't get enough. I love the big foam faces and their matching curtains for the box.

Photos: Traditional healer drama; VHVs in their T shirts; kids watch; puppet show.

Ruhungu Volunteer Health Team Training

2010-10-29T07:44:00.000-07:00

At 8 a.m. when we set off for Ruhungu parish in SW Uganda for the Volunteer Health Team training workshop, the roads are already full of traffic. In the road to the village, we pass the milkmen on their bicycles carrying cans lashed on the back with strips of rubber inner tires selling the days milk along the way. Heading out from the community we pass bicycles heavily laden with huge bunches of matooke, a green cooking banana which forms the basic staple in the area. For people in Ruhungu, matooke is not only their staple food but also a source of income. The fields are bright green, glistening from the recent rains.

We are the first to arrive. I am travelling with an interpreter these days which is helpful for following in detail the training and also with a pediatrician on a short visit to the area as part of her London School of Tropical Medicine course. She is Portuguese and makes a connection between what we are trying to do here with what is needed for African migrant populations in Lisbon.

Surprisingly enough, she was, prior to coming here, totally unaware of community-based child health program and their potential for getting health education and prevention efforts mobilized in rural areas. Her enthusiasm is contagious allows me to see it with fresh eyes.

Once again we are training without manuals. This doesn't seem to diminish the effort that participants put into training however. To put across the health messages and make them more memorable and thus more easily recalled, participants are encouraged to report back using drama, songs and poems. The whole group so likes the immunization song that it is repeated several times until I too am able to catch the Runyankole words.

After the session about diseases, the whole class moves to the front of the darkened room, to copy into their scribblers, the key points the facilitator has written on the newsprint posted at the front of the room. Electrification, which was such a game-changer in rural Canada in the Fifities, has not yet reached these rural parts of Africa, more than 60 years later.

During small group work after tea, huge thunderheads unload a torrent of wind and rain on the tin mbati roof of the small hall. The cacophonous hammering makes it impossible to hear a person yelling in your ear, yet through it all, the participants stuggle to hear and make themselves heard. There are very few places left where one still sees such dedication to learning.

The pediatrician is amazed at this. I realize I am no longer even surprised. Such is the desire for learning here in the rural areas that training is almost always given as a top motivator for the volunteer health workers.

The dense rains has been expected so the mid day meal preparation has already begun indoors when we arrive. The woman organizing the huge sikiri (tin pot) full of banana leaf-wrapped matooke can hardly be seen thru the smoke eminating from her fire atop three stones inside the small room. She sits happily on her small stool with groundnut stew in one corner and the huge mound of matooke covered with banana leaves in the other. We have not yet even addressed the indoor air pollution as a cause for ill health, so busy are we with infectious diseases. Another challenge!

Here at the village level one thinks how interrelated things are. I suspect if we were able to reduce the level of air pollution /smoke that women and especially children are exposed to in these closed spaces we would see a great reduction in the pneumonia.

I am pleased to see the woman has sent her small child outside, away from the heavy smoke in the room at least for now before the rains come down. I am only able to tolerate the smoke long enough to take a quick photo. But it is a lovely photo even thru the dense smoke.

Photos: man with matooke on bicycle; parish room; windstorm beats matooke trees; VHTs copy down notes; cook with matooke on 3 stones

Rubber Necking in SW Uganda

2010-10-18T10:01:00.000-07:00

Catching up on the Volunteer Health Team VHT training going on in our rural areas has me travelling to distant places in the districts of the South West of Uganda 4 days a week, each day a different set of trainers and a different community. Most of our original CORPs (Community Owned Resource Persons) have been incorporated into the VHT, and our facilitators have been leading the training in our own area, so it is nice to see how well they are doing. There are the usual issues of the training material has not been translated so manuals and teaching aids are not ready for participants and the record books they are to register people in are not yet available.

The great thing about travelling to the field is the wonderful rubber necking one gets to do as many of the villages where we train are deep in the rural countryside. Intensive tea plantations have been built on the road to Queen Elizabeth National Park. We found large groups of workers picking tea. It was also the first time I have seen them do it with mechanical pickers which sheer off the top of the bushes. Groups of workers collect the tea leaves in large plastic rice bags by the road for transport to the kilns for drying.

Uganda tea, even the cheapest kind available, is lovely. I am not clear about what is needed for great tea, but the cool high, fertile land here in Western Ankole seem to be just the ticket.

Near the forests in the same direction last week there were men sawing huge logs on a platform, one man below and the other on top, to hand cut planks. I had never seen this done by hand before except in historical photos of the early felling of the Pacific Rain Forest.

Towards Lake Victoria, high in the hills we come across a couple of children collecting water from a protected source. The enclosure for the pump is made out of a rapidly growing cactus-like plant which will over time weave together to form a barrier to the cattle. There was a younger child, only four or five years old with the two boys. Even he has a small plastic bottle to fill.

Small children often participate actively in the collection of water. These kids seem to be having a good time of it. The smallest child started to cry when he first saw me, perhaps his first time to see a white person, but the others soon reassured him. But he does not appear very happy in the photo. Life in rural areas tends to require the participation of the whole family including small children. But the good thing is that they have access to clean water.

FPHC Begins Reconstruction Activities in Flood Areas

2010-10-09T15:13:00.000-07:00

Sorry for the delay in communicating with you. We have been really overburdened and it continues. even now. The staff is working longer hours than routine, even the office staff.

Because our geographical area is prone to emergencies and we have needed to respond quickly in the past to earthquakes, floods and massive IDP migration, this past January we opened a special bank account to create emergency response fund. This also has helped us to track the emergency funds we received better. We had a small amount in this account when the floods hit that allow ed us to jump right into relief services at the end of July, 2010.

The need for medicine and supplies, even at the beginning, however was very big as whole families and communities had run from their flooded homes with only the clothes on their back. So we were very glad that you were able to raise and send funds to us so quickly.

Our early and effective emergency response was acknowledged by the government authorities, who put us on their official list. This helped as we then received some local donations from philontherapists and organizations. International groups such as UNICEF, WHO and UNHCR also came forward to assist us with supplies. In addition, we had realized some unspent funding in ongoing projects in the tribal areas and got approval from UNICEF for utilization of those savings in flood affected areas.

Along with the donations sent by Society of Rural Physicians of Canada, Hillman Medical Education Fund and Rose Charities we have been able to continue our work since the floods began.

Recently we have been chosen by UNHCR for an emergency grant to set up two static health care centres in government health facilities in Nowshera and Charsadda districts for the flood-affected people. Each of the static centers supports by six mobile teams. The static centre consists of LHV, 1 MCH Assistant and 1 Male Social Mobiliser. . Each of the six mobile teams supporting the static centre consists of 2 Medical Doctors, 1 Medical Technician, 1 Laboratory Technician, 2 LHVs, 2 MCH Assistants, 2 EPI Technicians and support staff. So this totals more than 50 additional staff members as well as the necessary medical and non-medical equipment, rented vehicles and medicine. As part of this UNHCR project we are also rehabilitating 12 health facilities, including several FPHC centers, that have been affected by the heavy rains and floods.

We expect to hear shortly from UNICEF regarding a possible six month Nutrition Project for flood affected people that is planned to start middle of October. Under this project FPHC will be providing Nutrition Services (specifically provision of ready to use micronutrients and nutritional information) to women and children in at least 10 Union Councils . A Union Council is an administrative unit like a big village.

In recognition of our activities, FPHC is now an established part of the the Nutrition Cluster at Country level and coordinate regularly with UN Office for the Coordination of Humanitarian Affairs (UNOCHA) and National Disaster Management Authorities. Thank you to all our generous donors for helping not only flood-affected people in Pakistan but also for assitsting all the staff of Frontier Primary Health care to build capacity in responding to these humanitarian emergencies.

from Dr. Emel Khan and FPHC

Photos: Flood relief 2010

FPHC Continues in Flood Relief in KPK

2010-09-26T13:19:00.000-07:00

Since late July, 2010 more than 10 million children have been affected by the Pakistan floods, including 2.8 million under five-year-olds. 1.2 million people still living in 6300 camps all across the country.

Although progress is being made, many flood-affected families still have limited access to health facilities. In some areas service delivery has been totally disrupted as up to 80% of the homes and facilities were affected. With more than 200 health units destroyed or only partially functional attention has not turned to repairing them.

The majority of private sector health providers have also been disrupted by the floods. Luckily most of Frontier Primary Health Care health units are functional so they have been able to assist in areas where facilities have been destroyed..

Surveillance in the affected flood areas of Pakistan is available on the WHO site. http://www.who.int/hac/crises/pak/en/index.html In the four districts of KPK, Punjab, Sindh and Baluchistan a total of 80 health facilities were affrected, almost half (38) of them in KPK (Northwest Frontier Province). WHO has 20 health partners assisting in the flood relief in KPK including Frontier Primary Health Care, which is active in both nutrition and health in flood affected areas in Mardan district and a refugee camp.

So far it has proved difficult to track activities of FPHC on the WHO website, which better captures activities of large international organizations likely due to better access to the internet. I could not for example, identify any of their health centers on the WHO maps of KPK health facilitiy status following the flood nor was were they mentioned among partners although the number of medical contacts they have daily exceeds that of many of the other organizations and they were in the field earlier.

However, in early Sept, 14 staff from Frontier Primary Health Care (FPHC) mobile health teams were trained on the WHO Disease Early Warning System so hopefully their activities will be better tracked.

The efforts of FPHC continue in assisting provision of emergency health assistance including high impact, critical life-saving services for men, women and children in communities of flood-affected areas of Mardan, Khyber Pakhtunkhwa through strengthening, providing and maintaining essential health services.

Photos: FPHC Flood relief 2010

Responding to the 2010 Floods In Pakistan

2010-09-02T09:03:00.000-07:00

Frontier Primary Health Care is a small, effective Pakistani NGO operating for more than 20 years in the Khyber Pukhtoonkhwa (KPK) region, formerly called Northwest Frontier Province. They provide primary health care to more than 250,000 Afghan refugees and local Pakistanis in 4 rural districts and one of the federally administered tribal areas near the Afghanistan border. They provide the complete range of PHC at a cost of less than $2 USD per person annually. While minimal in terms of cost, this PHC has increased the health status of the populations they serve enormously, with many of the parameters in their communities much higher than elsewhere in the region. They have accomplished this remarkable achievement by using an army of both male and female local volunteers and a committed group of staff paid local wages.

Over the past five years they have also responded to four humanitarian crises in their region. The earthquakes on the Kashmiri border; the deluge of Internally Displaced People (IDPs) as a result of violence in Northern Pakistan and floods in Mardan in 2009 and now a Pakistan-wide flood of 2010. Their expertise and efforts have been recognized by UNICEF and they have in the past been contracted to provide medical care and nutrition feeding centers.

In the current crisis more than 20 million people, almost 1/5 of the population of Pakistan, have been displaced and in the area where Frontier Primary Health Care operates, flood waters more than 20 feet deep flow over the roads, destroy homes and inundate the fields.

Nowsherra and Chadsadda districts have been among those worst hit. FPHC is providing assistance to the flood-affected at their health units in those districts. Additionally Frontier has been deploying two mobile medical teams consisting of medical doctors, medical technicians, Lady Health Visitors, social mobilisers, EPI technicians and support staff equipped with ambulance, medicine and equipment daily. The mobile teams focus mainly on emergency services and MCH services. The major diseases reported are water related such as skin infections, diarrhoea and also respiratory infections.

The mobile teams are also distributing food and clothing donated locally; micronutrients and vaccines supplied by UNICEF and occasionally cooked food and utensils. Each morning the mobile teams report to the District Health Officer to be sent to the hardest hit areas. As the need is so great and the resources few, the teams rarely return to the same area. The threat of cholera and dysentery, because of the difficulty in obtaining drinkable water, increases daily with nutrition of the many displaced children and pregnant women an ongoing need.

FPHC has been in contact with UNICEF and UNHCR but so far international organizations have been experiencing difficulty in moving supplies and people in place in the rural areas. I notice that several of the humanitarian sites such as Hesperian and Grassroots International are suggesting donations be sent to appropriate, reliable local Pakistani NGOs to circumnavigate the difficulties the larger international NGOs are experiencing, in the same way SRPC is doing.

The Society of Rural Physicians of Canada has partnered with Frontier Primary Health Care for more than four years. During that time we have worked with FPHC to improve the management of sexually transmitted diseases, trained traditional birth attendants and are currently developing participatory research, conflict resolution and training projects. Money sent to FPHC will be appropriately and well spent. Along with the Hillman Medical Education Fund and Rose Charities Canada, Society of Rural Physicians proudly supports their work and have found secure reliable ways to send funds. Your generous donations have allowed us to send $6000 to date. Rose Charities is a volunteer-based organization with low overhead.

You can donate online at the rose Charities Canada website.

https://www.canadahelps.org/DonationDetails.aspx?cookieCheck=true

Click on Donate Now button.

On the Fund Destination list scroll down to Pakistan Flood Relief.

Tax Deductible receipts are provided for donations over $20. Every bit helps. We can make a difference.

Photos: FPHC in 2010 flood

The Highwayman

2010-08-26T11:49:00.000-07:00

When my Dad offered to read to us as kids, we would run to the yellow bookcase in the den to haul out his tattered school reader with its scuffed and worn cover. Asfor many school texts of those times, previous owner’s names were scrolled across the fly leaf. A fat book without illustrations, its bindings were held together precariously with string, but it’s memory was intact and it would fall open at our favourites, one of which was The Highwayman by Alfred Noyes.

From years of doing readings in one-room schools and rural homes without electricity which came to the prairies in the 1950s, my father’s recitations were polished and mesmerizing, his voice sonorous and mellifluous and the phrases paced and evocative. He had as well a real gift for voices and would read Little Bateese by William Henry Drummond in French Canadian dialect. His readings, a form of performance art before we knew what it even was, created a magic net I can still recall with clarity. Both he and my mother read to us from the Grimms Brothers and Hans Christian Anderson’s Fairy Tales, but it was the poems we really loved.

It was only later when I encountered The Highwayman in school as a teen that I realized how brutal an event it portrays. For me as a child, it was about the magic of the purple moor, the highwayman in his velvet coat with lace at the chin, tlot tlot of the horses hooves, the marching of King George’s men and the landload’s black-eyed daughter plaiting a love knot into her long black hair.

While I think as kids we only take in what we can absorb at the time and make sense of, it seems to me now that kids also absorb the real meaning or true sense of a story rather than the specific details. I find now I have returned back to my original understanding and appreciation of the poem, the repetitions capturing the movement and wonder.

I read The Highwayman as interpretive poetry at Toastmasters and was stuck by how much is involved in reading poetry well, getting the cadence, the rhythm, rhyme, flow and meaning clear. The Toastmaster’s manual has a lot of good suggestions about capturing the skill and it opened my eyes to what a truly wonderful gift my father had. It also served to bring home to me again how important is not only what we say and how we word it but how we say it especially our tone and timbre.

Out of Africa

2010-08-22T15:47:00.000-07:00

For a CUSO volunteer in East Africa in 1965, the Thorn Tree at the New Stanley Hotel in Nairobi was a central gathering place. There was a good bookstore run by an Asian right around the corner. I was able to acquire and read a number of books about the colonial days in East Africa. Among them were Karen Blixen’s Out of Africa, along with Robert Ruark’s Horn of the Hunter, Ernest Hemingway’s Snows of Kilimanjaro and White Mischief by Jamie Fox. These stories of the colonial times captured the excitement and romance of the early settlers in Kenya or at least the well-heeled, aristocratic gentry variety. The world they portrayed was exotic and charmed.

When the movie Out of Africa with Meryl Streep and Robert Redford, came out in the mid eighties, I was working with AMREF. I went to see it in Nairobi with a couple of African physician friends. I had read the movie reviews and convinced my friends with my effusive descriptions of how fascinating the book was. During the movie I was transported by the romance of the story, the setting and the exquisite photography and it took me a while to notice on leaving the film that my friends had gone quiet. I was surprised that they didn't like the movie.

“OK", I said, attempting to see it through their eyes, “The whites used Africa as a playground. They were frivolous, privledged aristocrats and those were different times. Not very politically correct.”
Finally one of my friends opined, “It is more than that. The Africans are portrayed as simple and backward. They were treated as children.”

“Unfortunately, that part is probably an accurate portrayal,” I admitted, “or at least close to the truth.”

“Yes, he agreed, “ and it’s depressing, not only as a way to treat people but also as a way to represent them in a film.”

Since then I have had this love-hate thing about Out of Africa. Well maybe love-hate is too strong but I feel like it as I do about Tom Sawyer being designated as racist. It makes me sad because I really like the book.

So my first thought when I saw that the exhibit of African fabrics I had loaned to the local Fiber Arts Festival in Gibsons this past week had been entitled Out of Africa, was not overly enthusiastic. However, curator had done such a smashing job of displaying the pieces, I was stunned into disbelief.

I had provided piles of old and new articles of clothing, blankets, pieces of tie dye, swabs of cassava print, photos of the process of weaving and dye pots in Kano; Bokolofini cloth, raffia pile mats from Congo and Ethiopian goat hair mats and from this hodge-podge, Tracey Lee Hearst, the curator had created a museum-quality display.

Not all of Africa was represented in my collection, but more than just East Africa, so the title Out of Africa seemed appropriate. It celebrated the complex, artistic, traditional creativity and exuberance of Africa.

An Africa able to fashion so much out of so little. An Africa which celebrated and decorated the simplest articles of daily apparel and furnishings with such beauty and grace. An Africa where artistic, identifiable styles were developed and perfected over generations and then the very best of them adopted by others in specific geographic areas. An Africa where ideas and approaches are shared and exchanged.

Over the years I lost track of those two friends. Last year I ran into one of them at a workshop in Nairobi. He is now the director of a large clinical and research organization in Africa. The other had recently died of a brain tumor. I think they would have appreciated and enjoyed the Out of Africa exhibit of fabrics and its celebration of Africa and Africans.

Photos: Entrance to Exhibit; Nigerian dress; display of Senegal Cassava print cloth, Indigo tie dye &Hausa blankets;cards depicting aspects of cloth preparation; Ethiopian dress; Dahomey applique

On-The-Job MCH Training

2010-03-30T10:21:00.001-07:00

For many professions, the most important training one gets is the one-to-one mentoring that happens with older colleagues while you are actually doing the work. They can be formally supervising you or they can just assist you in keeping out of trouble. For years in medicine, such apprenticeship training produced excellent physicians. While it may not be sufficient it is certainly necessary. The one aspect of current medical training that seems less than appropriate, is the demise of such hands on coaching from experienced members in the field.

In rural remote areas with few opportunities for formal education and training, skilled health workers can be trained effectively in a form of on-the-job training that not only incorporates such coaching but also allows and in the case of women, actually encourages them, to undertake training. Reasons for its success include that on-the-job training can take place to the homes of potential recruits, thus allowing them to remain at home while they are trained, reducing the cost and the barriers imposed by leaving the community. Also it prepares health workers for work within that specific environment. While portability of training is overall a good thing, it negatively impinges on rural areas with a net loss of those trained. For people who plan to stay in that region, training in and for that region make perfect sense. Providing training in the home environment helps to increase educational levels in that area. A career ladder that allows the best to move ahead ensures gifted and hardworking health workers are rewarded. But perhaps the best recommendation for on-the-job training occurs when outside organizations recruit your trainees as part of their workforce.

This has happened at FPHC, where several of the recently trained volunteers have been offered jobs within the government health system, including one at the hospital. It is akin to getting a giant feather in your cap, to have someone you have trained to be recognized as useful in a formal role in the health system.

It means you are doing something right and providing opportunities for trainees including volunteers to provide for themselves and their families and to move into the regular job market. It is rewarding to hear that the women volunteers trained by FPHC continue to provide their services free to their own communities. The services they provide will also be augmented by what they learn in their new jobs.

Congratulations to them!

Photo: Sterilizer at EmOC

Maternal & Newborn Training in Refugee Camps

2010-03-17T10:19:00.000-07:00

Mero’s sister-in-law was due to deliver shortly after she completed her training with Frontier Primary Health Care as a Female Health Worker. Most of the deliveries in the refugee camp where she lived, were done in rooms set aside for animals or for bathing. This made the cleaning up afterwards easier. Mero had seen how careful the nurses were about hygiene in the labour rooms. Mero had been impressed by the importance her trainers placed on having a delivery done in clean surrounding.

So Mero shared this new information with her sister-in-law and together they began to prepare a room for the delivery and arranged clean clothes, pads, soap and basins. While Mero and her sister-in-law were preparing the room, other women in the camp were watching them and learning. They admired Mero’s efforts. They were glad Mero would be able to assist them to have healthy deliveries.

The baby was born safe and healthy in hygienic conditions with Mero using her new Clean Delivery Kit. Things were already starting to change in the camp .

45 new TBAs were trained in Akora and Akairabad Refugee Camps in Nowsherra district of Northwestern Frontier Province in Oct and Dec, 2009. Training of these female health workers will ensure women in this remote area of Pakistan have ready access to accessible skilled maternal and newborn care. 32 in Akora and 13 in Khairabad.

A comprehensive community selection process ensures that the female health workers are trusted and respected individuals in their own community who will be allowed to visit women and care for them in their homes. The TBAs are provided with three weeks of interactive training in primary health care with an emphasis on maternal and newborn care. They are coached in to recognize and refer pregnancy complications early and to provide health promotion over the three weeks of their training. More than 15 days is spent in health center labour rooms and first level EmOC facilities of Frontier Primary Health Care.Improvements have already been noticed in Ankora within the first three months since the training was done. New registrations of mothers has increased 25% from 88 in Oct to 101 in Dec. while babies weighed within the 72 hours has increase from 92 to 131 in the same periods. The number of women delivered by skilled workers also increased 30%, from 98 to 127.

Successful TBA Training in the Midst of War

2010-02-25T08:25:00.000-08:00

Almost 60-70% of women and their families in the isolated communities of Wardaga and Ismailia prefer and use traditional birth attendants. Over the past ten years, due to illness, old age, insecurity and relocation, the number of Traditional Birth Attendants in Wardaga and Ismailia village in Northwestern Frontier Province has decreased drastically. As the area is conservative and rigorous purdah practiced, women rarely venture outside their own homes. In these areas linking pregnant women up to women within their own community who are knowledgeable about pregnancy and child birth is crucial to reducing deaths from child birth.

4000 was obtained from the Hillman Medical Education Fund and Society of Rural Physician donors to train 30 TBAs. A lengthy consultation with the two communities ensured they were supportive of the plan to improve maternal health services, were willing to have their wives and mothers trained as TBAs and/or visited by the TBAs in their homes and had agreed upon a minimal fee for provision of birth kits and TTBA care. Discussion of the qualities needed for being a TBA lead to development of a set of criteria and identification of suitable candidates for each community. At the end of the process the communities had identified a total of 38 women were needed.

Wardaga’s population is 12,000 while Ismailia’s is 30,000. It was recognized that these female health workers as the only ones in their community would also be important conduits of health information on diarrheal diseases, immunization and nutrition as well as pregnancy and newborn care. Wardaga has a day labour room staffed by two nurses and 3 dais while Ismailia has a basic emergency obstetrical center (EmOC) providing 24 hour coverage with 3 nurses, 1 assistant nurse and 4 dais. So skilled TBAs were an important adjunct to getting services to women and women into the health centers for delivery when needed.

The need for skilled female health workers in the community resulted in the extending the training from four weeks to six weeks. This 50% increase in enrolment and training period were accomplished with cost efficiencies within the original budget with $4000 training 38 TBAs, or approximately $105 per TBA trained. This cost included provision of a supply of individual birth kits containing rubber gloves, soap, razor and tie. The individual kits form a rotating supply that will be sold to pregnant women at cost plus a small amount for the TBA which is agreed in advance by the community, approximately $0.50. In addition each newly trained TBA received a TBA kit with rubber sheet, nail brush, towels, gloves, soap, plastic apron, containers and a supply of oral rehydration packets.

The project did not include an evaluation component and information is available for only 4-6 months following the training but data from the health units show a real impact. Ismailia Health Center, where 38 TBAs were trained, reported a more than thirty percent increase in the number of ANC visits, from 240 to 320 women in the first four months following training of the TBAs and a >200% increase, from 30 to 68 in the number of women delivering at the Health Center. Prior to training. almost half of the women admitted to the obstetric unit did not proceed to delivery prior to training while six months following training less than 10% of the pregnant women who initially admitted were discharged without delivering.

Health Center, where nine new TBAs were trained, ANC visits doubled from 51-106 within six months and the number of delivered women receiving at least two doses of tetanus toxoid rose from 36-51 in three months.

While the follow-up period is short and the data preliminary, these figures suggest that not only do trained TBAs refer more pregnant women to ANC and for delivery but appear to be more appropriate and effective in their referrals. Trained Traditional Birth Attendants in this area are proving to be valuable resources in reaching women in their homes and linking them to appropriate delivery and antenatal care. Their pride and dedication to improving the care to pregnant women.

Photos: TBAs in class; TBAs using models; TBA with certificates

Turner Clegg, My Grandfather

2010-02-08T23:08:00.000-08:00

Recently I was rearranging a bookcase in a attempt to organize books by subject and found an envelope stuffed with curious bits of paper that I didn’t at first recognize. 'the turquoise blue booklet jogged my memory and I recognized my father's handwriting immediately. It was the memorial record of my mother’s funeral. For most of my youth a stash of the memorial records were kept in the cupboard where winter coats, curling sweaters and other out-of-season outer clothes were stored. No one wanted to throw them out.

This one however, had in my father handwriting, a note saying, “Mom, If you would like some more of these, let me know. Les”. So I realize this item must have come from my maternal grandmother.

Among the notes were two penciled letters on thin sheets addressed to "Dear Wife" dated June 26, 1917 and Jan 15, 1918 from my grandfather, Turner Clegg, who served in France during WW I. A cropped sepia photo of two young unidentified children was included as well as a handwritten Xmas letter written during WWII from my mother to her father with details about my father’s difficulty completing his degree if he is still working at the cordite plant and if he isn’t not being able to afford it. Handwriting is like a face as is instantly recognizable. My mother’s handwriting feels familair too, although I she died when I was ten. There is as well a letter of reference for Turner Clegg dated May 23, 1899 in elegant copperplate signed by Herbert Mitchell of Holly Bank, Bradford.

Dear Sir, it states, Turner Clegg worked for me for about 6 weeks to get up some young pedigree Hackneys for sale, from what I known of the man he seems honest, sober, industrious, willing and obliging, he left for no fault, namely because we had no further employment for him. I think he is a steady young man.

This, it would appear, must have been the reference letter that my grandfather brought with him when he immigrated as a young man to Canada.

Slowly I recalled that a number of years ago, when my mother’s sister, Aunt Millie Teskey, whom I had kept in touch usually at Xmas, was moving into a small apartment and was clearing out things, she had sent me these items in a letter. She said her sons weren’t interested in these and I might be since I had asked her for info about my grandparents. My Grandma and Grandpa Clegg had moved from Medicine Hat to stay with her family on their farm in Orillia for their final years. She had also given me the name of relatives in the UK, whom she had kept in contact. She had died within the year but I had followed up and visited the relatives where I collected some more information on my family. .

Letter dated 15/1/18

Dear Wife,
Your parcel dated Nov 20 arrived safely on January 13th. The contents gave me much pleasure. In our cellar there are six men and all have had parcels so you can bet we had some time, real bean feasts. Did I tell you they had your watched fixed for me in England & it is going first class. Hope it keeps on doing so feel lost without it was good of them don’t you think so. I had a letter from my sister Annie making all kinds of inquiries how I spent the rest of my time over there. Have you any of those photos which I had taken over here to spare, if so will you send one to the families. I think you have the address you might drop them a line at the same time it would be a good opening, that is if you don’t mind. Well we are having all kinds of weather just now, front, snow, thaw and today it is raining, just the kind that comes across the prairie. Well I hope yourself and the kiddies are well it is with me. I have not heard from Twyford yet so cannot say anything about there so I will close with much love to you all from
Yours
Turner

552255 Pte. T. Clegg
P.P.C.L.I.
Att. Area Commandant 3rd Can Div
BEF France

Letter dated June 26, 1917

Dear Wife
I received your parcel and the contents were fine, also the small note, wish I could say the exact date but am looking forward to it anxiously, wish it was now. I have enough handkerchiefs, sugar and vaseline for a long time & if you have not sent off the milk I should not trouble, you see where I am there are Y.M.C.A.s and Canteens so I can buy most of the things I want, don’t think you are not wanted to send anything. It is nice to have parcels but useless expenditure, buy something for yourself & the kiddies. I would be much more pleased with it & better for yourself. I have more than a hundred dollars credit so if I get a blightly leave shall be jake. I had letter from Twyford this week and your father is well and about again poor old chap he had a long spell of it this time. Yesterday I had my half day holiday so took a stroll down to the village for a change had tea eggs & milk & finished up with a glass or two of beer on Violet so tell her I shall have to collect when I see her. The Thimble Hall people wrote me and they are all well. Willie is in the Punjab at Rawal Pindi lucky for him & Bob is still in England. Well I don’t know of anything very interesting. The weather is not to bad, rain & sunshine and the country looks pretty nice, as for myself I am well and hoping that you are the same. I will close with much love to yourself and kiddies Yours Turner

552255 Pte. T. Clegg
c/o Major Ramsey
Camp Commandant
Can Div
B.E.F. France

Letter from Vi to her father Turner Clegg dated Saturday,

On the back- Read This First Don’t Open Parcel

Dear Dad,
You aren’t supposed to open your present until Christmas and please see that Mom and Millie keep their mudhooks off theirs too.
I hope you are feeling better now. Les says he is going to get some beer delivered here for Christmas but he never gets time to get a permit. It would keep nice and cold down our cellar. It’s too bad you couldn’t be here to celebrate. Les gets the day off unless anything happens.
We are maybe going to move from here in the Spring. If Les is still working at the plant he won’t be able to go to summer school & if he isn’t, we won’t have the money or else, he’ll be in the army-so his degree will be away off again. Still- it can’t be helped, and if he can stick to this line of work after the war, he’ll be O.K. Defense Industries Ltd is a subsidiary of Canadian Industries Ltd (CIL) and they in turn are supposed to be connected with Vickers. They make all sorts of things so maybe he’ll stand in good with them or the gov’t because the gov’t is interested in (DIL) so perhaps it was a good change.
Well, hope you have a nice time. Wish I could be home or you folks here.

Merry Christmas.
Vi

It moves me to read these handwritten notes from so long ago, some handwriting I recognize and all somehow linked to me with information from so long ago and so far away. To learn about a relative who served in Rawalpindi, so close to the NGO project I work with near Peshawar in North West Frontier Province of what is now known as Pakistan. And the degree my father was unable to complete; the camaraderie between my mother and her father along with antiquated expression which feel somehow familiar, such as mudhooks. As I put the priceless notes into plastic covers to preserve them, I decide to post them on my blog on the internet so the rest of my family and even those still to come, also will know they exist. It is one thing to have a genealogy chart and quite another to have some handwritten notes, some of them more than a hundred years old. Now I must track down the identity of those two kids in the photo. And for those interested, Hackneys are a pedigree horse bred by country gentlemen.

photos: 2 young children; memorial record of Vi; reference letter for Turner Clegg, 1899

I am Here if You are Here

2009-11-21T07:17:00.000-08:00

A tomato plant has somehow found its way out of the concrete ditch that circles our flat. Over the last few weeks it has produced first yellow flowers, then small green tomatoes. Today the first two tomatoes are big and green and more flowers are blooming. It looks like we are going to have a lush tomato harvest soon from our concrete ditch.

I also notice a flowers growing out of cracks in the steps sprouting bright purple heads. Northern and eastern Uganda is in drought but we have plenty of rain here to the west of Lake Victoria. And this fertility in the cracks and crevices, seems a sort of symbol. At the market today one of the final year medical students who did field placements last year with me, recognizes me and wants to talk about a NGO project he is planning for children. We make a date to meet. Sometimes where you think there is little fertile soil, glorious flowers poking out their fine heads.

The colleague sharing the flat with me for the past couple of weeks has gone off to the game park. Lake Mburo is about three quarters of an hour away. To me it makes a wonderful early morning tour followed by a cup of hot tea from a thermos in the early African morning sun. His idea is to spend the whole day, get his money’s worth, he says, so I am glad to have a whole day on my own.

Around two o’clock I decide I need to take a trip into town. Nothing much to do in town other than a need to seek out others. There are of course tomatoes, avocado, onion, garlic, fresh coriander and cumin seed to purchase in anticipation of a visitor arriving on Monday. As well, I remember to pick up a couple of baskets in natural dyes that have been set aside for me by the basket woman in the market. Her stall is being upgraded and the money goes directly from my hand into the carpenter’s.

“Good thing I dropped by today”, I say amidst much laughter.

I pick up some samosas at the Tumweereza Bakery on High Street but pass on the bread which tends to be dry and crumbly. Then I drop by the pharmacist to get some antihistamines and buy some English Leather soap at Pearl Super Shop for my sister who can’t find it in Canada. At Pearl I meet the staff from the newly constructed Catholic pediatric hospital just outside of town and stop to chat.

Today I have been reading The Dust Diaries by Owen Sheers, about his ancestor who was missionary among the Mashona in Southern Rhodesia, now Zimbabwe. He mentions that the traditional Mashona response to "How are you?" is:

“I am here if you are here”.

To which one replies, “I am here”.

It seems an appropriate greeting for today and for Africa. You have to be here when you are here.

When I arrive back home, I find I am without the newly purchased baskets. I must have set them down at the last stall I visited. So I head back in to town and sure enough find the stall owner waving them gaily over his head when he sees me heading his way.

The boda-boda driver who takes me back into town asks if he can stop enroute for some ensenene, local grasshoppers, which are spread out live on sheets and in clear plastic bags in front of the university. A bag cost 500 UgS/- approximately 25 cents.

For a long time, like many whites, I didn't eat them. But grasshoppers have always been a special treat for Ugandans, especially good for malnourished children because of the fat content. Now, I too appreciate their sweet, crunchy flavour when fried and salted. I am especially pleased to be able to take a picture of them on sale by the roadside as I sit on the back of the driver's motorbike waiting for him to make his purchase. The green branches to the side are supposed to keep flies away.

This is where I have been today. I am here if you are here!

Photos: tomato plant in ditch; flower in crack, Grasshoppers for sale

Team Building in Ruhururu

2009-10-22T02:45:00.000-07:00

Our last workshop on Team Building in Bwezibari is by far the most smoothly run of them all. However it doesn't start off very promising with only one participant on site when we arrive at 9:30 am. Having passed the Health Center ambulance, which serves as a general all-round vehicle for the Health Center, returning after having dropped the trainers off, we were surprised when we arrived that we couldn’t find them. They turned up about 45 minutes later by which time 29 participants have gathered. I guess they were getting their marketing done early when they found no one at the site.

At the last workshop we provided some formal feedback to the trainers who have been facilitating these workshops. They have been doing a wonderful job, are enthusiastic, engaged, active and interested. They have adapted to the changes we have added in and the newer material that includes community development. They have taken turns so all trainers have facilitated all the sessions and have begun to include the volunteers who have also begun to be trained as trainers to facilitate sessions. We also suggested that they all need to concentrate on pre-planning each sessions so they not only have all the material ready to go but have run thru in their heads the lessons they want to pull out of each exercise. Amazingly, they have responded to the suggestion about advance preparation and the material needed for each sessions has been prepared in advance and the lessons to be drawn appear to all be elicited. As well it appears that without prompting they are tying the questions they ask to elicit key points after the lessons to actual behaviour within the groups. I can barely believe it.

One example goes like this. In the Puzzle Pictures exercise, everyone is given a single piece of a puzzle. Five pieces make a picture. Puzzles are unfamiliar to people here. They don’t play with them as children. A Peace Corps volunteer told me she gave a puzzle to the children in a family she stayed with and after counting the pieces they didn’t know what they should do with them. So just making the pieces fit together is something of a challenge. Some people are better at finding other matching pieces than others. But always one or two people wander around, not fitting in any puzzle, until with almost the whole puzzle together, a group goes looking for their missing piece. Some people and their pieces are also sent away from a group because they are the wrong colour.

The lessons that can be drawn from this exercise are many. When you have just one part of the puzzle, it means nothing, but when you have all pieces, you have a picture which means something. You feel bad when you are not included in a group, no matter what the reason, even if it is just because your piece is not needed. Some people are more active in finding matching pieces than others. Some people wait to be found. Even when you have all the right pieces together it takes time to make them into a picture.

Obviously it works best in debriefing people if you select someone who had trouble and ask them how they felt, what happened and what they did or ask the person who found other matches early, what they did that worked best. Our facilitators have finally done this. This is when I figure that I am getting an additional lesson as well, that when one facilitates well in a group, magic happens. I am reminded of this a little later when we do the exercise Build With What You Have. Each of three groups is given a heap of what looks like junk and asked to construct something. In the past they have mostly rearranged it into a store or home. This time we specifically say we want a building made. One group has made a grass hut of a traditional healer. When at the end everyone goes around to the three groups to see what each has constructed, one person is left at each site to explain to others.

At the final site, one of the two men who came to this workshop in a sparkling white shirt and shiny tie, has made himself a corncob pipe and is drumming on a tin can, mumbling loudly, playing, for all it is worth, a traditional healer. As the onlookers say, amidst great laughter and applause, his group has constructed a building but he has made theatre out of it.

When the groups sing the songs they have composed about the work they will do as volunteers, their enthusiasm and conviction carry far beyond this hopeful church in the green hills of Africa. They are silhouetted against the church windows, the male and female voices a counterpoint to each other weaving together in graceful effortless harmony.
About half way thru our workshop in the nave of a partially constructed church, local schools children are let out for recess and we are swamped. At first the participants try to get rid of them, shooing them outside, but finally they give up and tell them to be quiet. Amazingly it works and until the recess drum goes, they sit at the windows and on the floor and quiet as stone statues. Now where else would this happen?

A while later a group of seven women are returning from market, a couple with small children. They come tentatively to the door and look inside at the single group working on the benches at the back of the church. I smile and greet them in Runkankole wondering if they are participants. They answer shyly and then sit down at one side of the church to quietly pray before making their way home. Photos: Puzzle Pictures; Groups Sing; School Children Join US; and Traditional Healer Drums

Team Building Training In Uganda

2009-10-20T10:41:00.000-07:00

We are headed out to the village in Bwezibwera in Southwestern Uganda for a day of Team Building. The Ministry of Health is launching a nation-wide program of Volunteer Health Workers (VHW). In the parishes where our child health training project works, many of our volunteers have been chosen as VHW. As our volunteers have been trained and working for five years and have formed cohesive groups that are proud, self-reliant and active, many are not sure they want to give up this identity and the connection with our NGO project. This is despite the fact that funding has drawn to a close so it looks like our project may be coming to an end. This has resulted in them thinking of themselves as better than and apart from the other government volunteers. We are concerned this may affect team work as VHWs and want them to start to work together as a group, hence the Team Building day.

We are out early in the crepuscular light of early dawn. The red murram village roads take us past milk cans being collected and tied on the backs of bicycles for delivery or waiting by the road for transport to larger centers. Local sales appear to be part of it too. Milk is plentiful here in Ankole. African Tea is almost half milk, my favourite breakfast drink.

We are weaving our way over and around the hills. At one small widening of the road, the driver finds out the trainers we were meant to collect are elsewhere and we trace our way back to the health center. While we are stopped, I am able to photograph people winnowing peanut shells after the peanuts are passed whole thru a grinder. The whole operation is set out on a grass mat by the side of the road, stunning in its simplicity. I have seen such tableaus before but never knew what was being ground. My African colleagues identify it right off, so distinctive the equipment. It makes me aware of how much else I look at but don’t really see.

We arrive at Mirongo at 9:00 am and there are about 30 volunteers already gathered. They trickle in over the next two hours and by 11:00 there are 83. They arrive by foot or bicycle, climbing up over the crest of the hill, many of them delayed by the need to dig in their shambas before the sun gets high in the sky as it is the rainy season and digging must be done in the early hours. About 20 of the group gathered are our volunteers, the rest are newly appointed to the volunteer health worker role by the government.

We use a variety of interactive exercises. The five trainers each take one group and change groups after each exercise. At the end of the day, one of the participants who is new to such training, says in awe, “We didn’t come with pens and paper but we have learned a lot.”

Another says, “I thought we were not getting the same teaching in each group, but I can see from the feedback that we have all learned the same things.”

It is exciting to work with people new to participatory methods. They are so keen and eager and seem to have Eureka moments at every other turn. The Picture Puzzles we have used seem particularly effective. Each person is given one piece of the puzzle and told to find others to make a picture. Some are active, circling the groups, holding their own picture piece up high for all to see. Others hang on to their own piece afaid to let it go,hoping others will find them. The pictures we use are bright and colourful photos of our local area of calender photos of West Africa. Not many of them have worked with puzzle pieces before so even when they find others that seem similar there is time spent in making it fit together.

Our facilitators are skilled, especially at holding the energy and enthusiasm in large groups. Many lessons about how to find a group, how to locate others like you so you can create a picture together and how the overall picture is much more obvious when the pieces are fit together, are readily made in this exercise.

A question in the feedback highlights that someone did not understand a lesson in an exercise and they easily review it for the whole group. It has been a totally successful launch to the Team Building training. In the car on the way back home we hold our facilitators’ meeting and decide we will introduce some community development exercises as well in the next training. And everyone agrees we are off to a good start.

Photos: milk cans ready for pickup; winnowing ground nut shells & putting the puzzle together.

Floods Create Havoc in Mardan & Swabi

2009-08-24T16:34:00.000-07:00

Frontier Primary Health Care has been called again to respond quickly to a humanitarian crisis, this time even closer to home as the recent devastating floods in Mardan and Swabi districts have played havoc in their own communities of Ismailia as well as Kagan and Baghica Afghan refugee camps. This most recent disaster comes just weeks after the Internally Displaced Refugees in camps around Mardan had been repatriated to Swat and the camps officially closes. For several weeks following the closure of The Sheikh Yaseem town camp, where FPHC had beenproviding 24-7 coverage, FPHC staff continued to provide nutritional services to other camps as well as some medical clinics in the camps until all were closed.

On August 16th a heavy deluge of rain resulted in massive damage throughout Swabi and Mardan districts. Approximately 50% of the mud homes in the Kagan refugee camp were fully destroyed and the rest remain in dangerous condition. Ismailia Health Center was also badly hit with flood waters filling the clinics with mud and debris. The home of several staff were also affected including FPHC's hardworking, stalwart administrator, Said Zaman. Luckily he and his family all escaped unscathed.

The homes in the refugee camps were especially badly affected, as they are made of mud and wattle. Many of the injuries and deaths that occurred were a result of collapse of the homes which happened suddenly and catastrophically.
As many as 27 people died in the flash floods with many more injured and thousands now without homes. The EMOC Center in Ismailia as well as the Health Centre there, both busy and active clinical sites suffered serious damage to both medical and non-medical supplies.

FPHC vehicles and staff assisted in Kagan with the evacuation of people from the worst of the flooded area as well as arranging for cooked food for those affected. The health center at Ismailia and the emergency medical team provided emergency medical care to those injured.

There are ongoing concerns about the spread of cholera and typoid in the area. Staff and community are busy rebuilding their homes, cleaning up and shifting the debris and mud that has been left behind.Everyone is busy now cleaning up the damage and putting things right.

Photos: Kagan & Baghica Refugee camps and Ismailia.

Go For It

2009-06-27T11:09:00.001-07:00

My strip of foam stretches out beneath the table. My friend has found a massage table in the hall closet and by lowering the legs as far as they will go, makes her bed against the bookcase that sits perpendicular to my foam. We are visiting our friend, Barbara. We have only the two days together so to optimize our time together, we decided to bunk with her in her small apartment.

We met through our Rosen Method bodywork so we continue with the same kind of activities we began then. We talk about old friends, eat great meals and drink strong coffee. We consult our horoscopes and read Tarot cards. We laugh a lot and discuss our soul work and where we are in our lives. And we cavort in thrift shops.

This is the first time I have seen Barbara since she moved from her childhood home in this same town, with its extensive rose garden to this Leisure Home. Barbara is 90 and remarkably between such visits we manage to keep in touch by internet mostly. Barbara's email handle is Go For It. She says she didn't understand about email addresses when she settled on it--didn't know she would be saddled with it-- but we think it is incredibly appropriate. Her favorite admonisions to us are a) Listen to what the universe is telling you and b) Go For It. Usually in that order. At one of our Rosen workshops during a tour of the local thrift shops, we found a board game appropriately named Go For It and brought it home for her.

Our forays into thrift shops are mainly for the purpose of searching for synchronicity, in as much as one can not really look for synchronicity but stumble upon it. To do this we notice what in the thrift shop (read universe) attacts us and reflect on what lesson it holds.

As Barbara says these days, "When your reach for the glass, the glass comes towards you".

She is currently reading Chilton Peace's The Death of Religion and the Birth of Spirit, along with a large pile of similar books. Years ago he wrote The Crack in the Cosmic Egg and it seems Chilton-Peace has ventured even further afield since then.

On this trip up and down the aisles, my friends locate a picture on glass of an owl. To me it looks like a make-work project as the frame is damaged and will need to be removed to be fixed but they are thrilled with it.

"Owls, says Barbara, "are about wisdom and letting go."

The exquisite Sterling Silver brooch I find of a hare in chase, in the same thrift shop, shines up with a bit of rubbing and I realize I have a real find for am amazing $2.25.

"Rabbit," I note outloud, "better not mean fertility at my age."

"Maybe fertility of ideas," says Barbara, "and clarity of eye and transformation."

It is amazing what our serenidipity approach uncovers.

Barbara is adamant enroute home that we take the car through the car wash. Well, the car is a tad dirty after the drive down to Seattle. She acknowledges later in a light-hearted way, that it was important for her to go thru the car wash. For her, as well as for us, somehow washing all the dirt and grim off prepares us to shine, indeed to trail clouds of glory. It is wonderful and reassuring to be surrounded with such a perception of the world.

Later when I acquire the lovely children's storybook of Pele the Lamplighter, with its exquisite drawings and enchanting story, Barbara reflects how it is an invocation to continue to light lamps as we go. Nothing escapes her eagle eye. We are learning not only about going with the flow from Barbara but to Go For It !

Photos: Barbara with Go For It Game

Frontier Continues Work in IDP Camps

2009-06-08T04:17:00.000-07:00

The health group I work with in Pakistan, Frontier Primary Health Care, is based out of Mardan, North West Frontier Territory. Right now they are in the epicenter of one of the most massive movements of internally displaced persons on the globe as the number of people fleeing from Swat, Bajaur, Lower Dir and Buner, just north of them moves past three million.

The executive director of FPHC, Dr. Emel Khan, came to Canada last year to present the keynote address to the Society of Rural Physicians of Canada in Halifax. He also visited the west coast to initiate links with UBC and Simon Frazer universities. We secured a small grant later in 2008 for his wife, Dr. Wagma, the deputy director of FPHC, to take courses in conflict resolution at the Justice Institute of BC.

As the disaster unfolded in May, FPHC was among the first to respond, providing emergency and maternal care at their 14 health units. This has continued. FPHC now has a formal agreement with UNICEF for provision of health and nutrition services in the camps. The provincial health department has provided an ambulance and driver for use. Local and international organizations wanting to assist are asked by the government to coordinate their services thru FPHC, including specialist physicians from the large government hospitals from outside the area such as Punjab.

They are providing round the clock coverage to the largest camp in Mardan, that near Sheikh Yasin town with a population of 12,000.

To continue this level of support FPHC have hired 90 temporary staff members including physicians, dispensers, lady health visitors (LHVs), assistant LHVs, EPI technicians and nutrition assistants. Until a formal agreement was in place, FPHC was providing care with their own staff who number only 120. In addition to emergencies staff provide general OPDcare, MCH care, immunization, TB control and diarrhoeal disease control.

FPHC have also established nutrition services in six IDP camps that are screening children and pregnant women, providing nutritional supplements and sharing information about preparing healthy balanced diets. Prior to establishing nutritional services, three staff members, including Dr. Wagma received seven days of training on UNICEF’s emergency approach to nutritional support.

The agreement with UNICEF does not include medical supplies so FPHC struggles to provide what they can. More about FPHC can be found here.

Photo: FPHC provide emergency care during Mardan floods.

Vintage Drapery

2009-06-03T16:51:00.001-07:00

I was waiting for my friend at the ferry dock about 5:15pm. It was the computer ferry when hoards of hurrying workers from Vancouver scramble onto the dock and head for the car park.

A fellow came up behind me, someone I didn’t know, and said, “ I like your outfit.”

I had on Capri pants and a short-sleeved top made out of vintage drapery material. The kind called barkcloth, which I have used to make cushion covers and futon covers. Brightly coloured, bold flowers and broad sweeping lines. You’d recognize it if you saw it.

“It’s like 50’s drapery material,” I replied, looking down on the large, lush hibiscus and lilies painted in vibrant colours while I continued to keep an eye out for my friend.

“My mom had one like it,” he said, grinning. His face was open and friendly with a squint in one eye making it slightly eschew. He too seemed to be waiting for someone.

It was a boiling hot day so I added, “Well, I am glad it is an Indonesian knock-off because that thick drapery material would be much too hot today.”

“My mom really liked hers. She died recently” he said, somewhat sadly. "She used to say, Scarlet!”, he exclaimed laughing, throwing one arm out at the side. “You probably know that skit.” He demonstrated again, throwing one arm out at right angles to his body, “Scarlet!”

I looked down at the material. Not much scarlet in it. I smiled at him and said thank you, not at all sure what he meant. But it is not that often that someone you don’t know comes up and tells you they like your outfit. Such happenings can make your day.

Just then my friend walked over with someone in tow and a request that we drive him home as well, so we engaged in making arrangements and introductions. My new friend had slipped away, probably spotting who he was waiting for and I didn’t think about the exchange until later that evening.

Still wearing the Capri pant outfit, I was explaining the interaction to a friend as a typical kind of connection created here on the Sunshine Coast.

She laughed, “He meant Scarlet O’Hara!”

Then she went on to explain, “When Scarlet was destitute and hungry and wanted to seduce Rhett Butler, she decided to go to him to plead for food but she had no dress to wear so she tore down the green satin curtains and made a dress out of them.”

Something stirred in the deeper recesses of my mind.

“Then”, my friend went on, “Carol Burnett used to do this funny skit when she pretended she was Scarlet O’Hara but had left the rod in the curtains so whenever she turned from side to side, she would hit people with the curtain rod. It was hilarious!”

For me it was a glimpse into someone else's very special family stories. We all have them. They are how we make meaning and embrace ritual in our lives. For my new acquaintance, a chance encounter with an outfit sewn from vintage drapery material invoked his mother and her enjoyment of her drapery outfit, as well as Scarlet's and Carol Burnett's take on it. He got me to thinking about my own family stories and the need to savour them.

Photos: vintage barkcloth drapery

Up the Ying Yang

2009-06-03T12:56:00.000-07:00

Jerry Seinfeld might indeed be the originator of “Yada Yada”, but my brother coined the term “Up the Ying Yang”. Without the help of a TV program drawing millions of viewers or a stand up comic, my brother launched a descriptive, evocative phrase at the age of 5 that has since circled the globe!

Do you have family jokes, words and phrases that only your family enjoy? You might be sitting on something that can spruce up the rhetoric of the English language.

When my brother was young, I often read bedtime stories to him in his room in the basement. We had the Grimm’s Brothers Tales and Hans Christian Anderson’s folktales but I frequently read him books that I was interested in. When I was fifteen and he was five, we were reading Pearl Buck’s The Good Earth.

Supper times at our house were a time of conversation. Older kids would be asked about school and my brother, who was not yet in school, would be quizzed about the book being read to him. It was in retrospect excellent preparation for gathering and presenting one’s thoughts. My brother surprised me when he was asked, because he remembered the name of the book, that it was about China and even the trip the characters were making up the river.

“Where were they going?” my dad continued.

My brother struggled. “Yang, Ying, Yat” before he blurted out confidently , “They were going up the Ying Yang” . Then he looked around proudly, sure that he had got it right.

“Up the Ying Ying?” My father asked his eyebrows raised as the rest of us hooted with laughter.

“He’s close”, I opined. "It’s the Yangtze River.”

We laughed long and loud, so my brother, as kids will do, continued to use the phrase. If he couldn’t find a sock or tee shirt-- it was up the Ying Yang. When we were heading off for a car ride to visit my dad’s friend and none of us had ever been there, we were heading up the Ying Yang, accompanied by peals of laughter. Soon the whole family were using the phrase to mean the unknown, the lost or even someone who was confused for any reason.

I was at university when I noticed other people around me were using it. It has an onomatopoeic ring to it which connotates bewilderment and confusion. It is self explanatory, providing a verbal embellishment of a situation. I can’t ever recall anyone needing to ask me what it meant. It is also a very descriptive way of saying someone is off topic.

Later when I was teaching at university, I would occasionally use it and soon I noticed others were using it too.

Now it is out there and it has a life of its own. The other day I heard someone, whom I am sure that my family and I have never spoken to, using it on the radio.

If constitutes a wonderful personal story about something, but I am not sure what. Either it is that we are all connected in vocabulary terms by only six degrees of separation and our unique family joke has made it out to the world. Or it could be related to to the 100 monkeys truth, that when a new skill is learned by 100 monkeys on one isolated island it is not long before monkeys everywhere have acquired the same skill—a sort of collective transfer of consciousness for monkeys. It is also possible that a wonderfully evocative phrase began for similar reasons, about the same time in several widely separate locations around the same time. What do you think? Do you have such a family story?

Photos: Bro and his pumpkin crop, Bro painting in dad's shirt in the bath

Responding to IDPs in Northwest Frontier Province

2009-05-25T00:43:00.000-07:00

While war wages around them, Frontier Primary Health Care (FPHC) struggles to assist in mitigating the impact of the disaster on women and children.

Frontier Primary Health Care is a small Pakistani NGO, working with 200,000 people at 14 separate sites in four districts in Northwest Frontier Province of Pakistan. They have a number of Canadian partners including the Hillman Medical Education Fund, Rose Charities and Society of Rural Physicians of Canada.

FPHC works in ten Afghan refugee camps and the surrounding Pakistani communities providing the full range of primary health care at the cost of $2 per person per year. FPHC have also had some experience in responding to disasters with the recent quakes and floods in the region.

Northwest Frontier Province has been swamped with more than 2 million internally displaced people (IDP), according to the UN. It is one of the most extensive migrations of IDPs on the planet as people take flight from intensive US and Pakistani bombing, drone attacks and fires in Swat, Bajaur, Lower Dir and Buner districts. Fleeing their homes, they are quite literally running for their lives. 80% of the refugees have arrived in Mardan and Charsadda, the target area of Frontier Primary Health Care.

As the disaster has unfolded, FPHC has been providing free medical and maternity services at all 14 of their health centers including the Ahmed Shah Abdali Hospital in Mardan. On May 7th, 2009 Frontier Primary Health Care arranged for emergency health care services for IDPs in one camp and was planning how they could assist with emergency health care and nutrition rehabilitation services in four other camps. In discussions with UNICEF, FPHC indicated that although they have limited resources, their staff is eager to assist. By May 10th, staff had been deputed and health posts established in two IDP camps . Community labour rooms in Mardan and Nowsherra were also taking on deliveries of the IDPs.

Some IDPs are able to go to the homes of relatives but most look for shelter, food and health care where they can find it. The people, especially the pregnant mothers and children, have been arriving in miserable condition as the unrest and violence in their homes has been ongoing for many months. Many women and children have nutritional deficiencies. Civil society groups,government and common people are doing their best to provide relief.

Four main camps have now been established in Mardan district, Jalala, Sheikh Shehzad town, Mazdoorabad and Sheikh Yasin town. Emergency and comprehensive health care at the IDP camp at Sheikh Yasin town was officially delegated to FPHC. FPHC staff have continued to provide round the clock services with their own resources assisted by donations from friends and staff. Working in their regular health centers during the day, many staff take on additional evening and night duties at the IDP camps,extending their working days to 18 hours. FPHC have been using their own meagre drug supplies as supplies have been slow to arrive and 700- 800 patients daily present at the clinics with diarrhea, dysentery, respiratory infections and skin conditions in addition to the pregnant women who present for delivery.

FPHC urgently need funds to continue to provide medical supplies and nutritional support to mothers and children. Check here to find out more about the Hillman Medical Education Fund and Rose Charities. Rose Charities Canada is able to accept and send donations directly to Frontier Primary Health Care and provide tax receipts for Canadians. For a USA tax receipt donate through Rose Charities US

Photos: Lady doctors hold MCH clinic during emergency; field immunization clinics; FPHC responds to Earthquake; FPHC hold emergency clinics during floods.

Dazzled by Gratitude

2008-11-29T10:48:00.000-08:00

Gratitude is handled differently in other cultures. Ugandans seem to have a better take on it than we do. They can dazzle you with their gratitude. I want to be dazzled by gratitutde and to dazzle others with my gratitude.

Uganda, like most of Africa, has been full to overflowing with Obama-mania. It would be hard to imagine if one wasn’t there. When I walk into town, TVs are on in some shops and people crowd around them watching Obama. Unknown people high-five you on the street asking if you are for Obama. The newspapers are full of pictures and stories of Obama.

I meet the only person not for Obama--a surgeon from Dallas who is staying at the same Guest House in Kampala as my friends and I. He’s a staunch Republican who is returning a second time for a stint at Mulago Hospital. Oh, and he is black and originally from Uganda but left when he was a young child.

My friend argues with him over breakfast each morning. One morning he tells us that the reason he likes working in Uganda is because people are grateful for what you do for them. They thank you and mean it. This is something with which we can all agree. We have found at last some common ground.

On the way to the airport later that week, a couple of us are waiting outside a hotel in the van. Julie, our coordinator is standing by the door with Abdul, the driver. Harry has slept in. He comes running out and throws a couple of bags in the back. Then he drops a lumpy plastic bag and a pair of shiny black leather shoes by the door of the van and says quickly, “These are for you, Abdul.”

Julie and George turn to watch him as he races back to the hotel.

”Is he giving these to Abdul?” asks Julie, slowly pulling out two shirts and a pair of jogging pants.

“I think so,” I reply. “He’s a bit flustered because he’s late.”

“And the shoes?” inquires Julie, holding them up.

“Seems so,” I nod, as Julie hands then to Abdul

Abdul holds them close to his chest and says, ‘It feels like Xmas!”

As Harry brings out the last of his bags, Abdul is waiting by the door of the van to thank him and shake his hand. Harry is in a rush as he jumps in the van and doesn’t notice so Abdul just says his thank you.

‘No problem,” responds Harry, snapping in his seat belt.

“Abdul said it feels like Xmas”, I comment.

A huge grin lights up Harry’s face as the warmth of the gratitude dazzles him and we all laugh.

Still what I want in my life is to be willing to be dazzled

To cast aside the weight of facts

And maybe even to float a little above this difficult world

I want to believe I am looking into the white fire of a great mystery

I want to believe imperfections are nothing

That the light is everything

That it is more than the sum of each flawed blossom rising and falling

And I do --Rumi

Photos: Kids at window; Kids with blue cloth; Kids at Kinoni

Men with Young Children

2008-10-15T14:07:00.000-07:00

I started the week seeking photos of men with children under five. There aren’t that many drawings or photos of men caring for young children available so I decided to find my own. Outside the maternity ward I found this father amusing his young daughter as they waited to see their new sister.

Then later in the day I accompanied 4th year medical and nursing students on community visits. Apuli, one of the community volunteers, facilitates community entry for students. This time at the suggestion of the health center in-charge, he took the students not to his own village but to one which is not a recipient of our community program. Ordinarily this could result in resistance and lack of access to homes. But Apuli has a wonderful manner and managed to keep two groups moving from home to home along the hills at the edge of the Ugandan Rift Valley all afternoon. In one yard, just as he was leaving to take the second group of students to their next home, he interceded a wailing child running by and within minutes has her calmed down. I’ve been looking for photos of men with under fives and am pleased to be able to capture Apuli in this role.

It is the time of the long rains and the hills are steep and slippery. Apuli alone of the whole group has come prepared and carries a brightly striped umbrella in addition to wearing gumboots. Sure enough as we head down a particularly slippery slope, I slide a good ten feet on my backside with my knee twisted beneath me so badly that I am surprised when I land in a heap at the bottom of the slope that I can still walk.

Medical students are drawn from the whole country so in this group of nine there are only three who are fluent in the local language. In the group I am with, Frances has an engaging manner and soon has people at ease. I can’t follow much of the interview but the non verbal communication is a delight to observe. One woman stops in the middle of her laundry to invite the whole group into her home. Later Frances tells me she is concerned about whether she can get AIDS from caring for someone who is sick so so he had to reassure her.

The students are on their second last home visit with a man who has two male visitors but still agrees to be interviewed. A number of children are underfoot. Some of them seem to be following us from house to house. There are also a number of curious older youngsters sitting off to the side watching the interview.

A sharp cry in the local language rings out amid some confusion. The father bolts off across the compound followed by a couple of older children.

“What happened?” the rest of us inquire looking around in confusion.

Frances replies, “There is an accident in back”

I head off with the group to investigate. As we arrive, a slack two year old is being hauled dripping wet, by his father, out of a huge drum sunk part way into the ground at the back of the house. The air is suddenly steely cold with shock before the child starts to cough and heave. His father pulls his soaked shirt off and wipes him off with it.

The toddler had leaned over the edge of the drum and toppled into the murky water below. Luckily some older kids saw him and set up a hue and cry. Apuli measures the depth of the drum with a piece of stick. It is about 3½ feet deep. When I ask why a drum would be sunk in the yard, Apuli tells me that such drums are used to cool the distillate for making waragi, local home brew made from banana. I gather this home must to be local brewery as there are in addition, two hand hewn “boats” carved out of huge tree trunks that are used for making local beer on the other side of the house. With the rescue over, the father soothes the naked child in his lap as he continues the interview with the students. It is a lovely picture. I have my third photo of men comforting young children in a single day.

Photos: father with daughter at hospital; Apuli with child; Father comforting child post drowning; Sunken drum in yard; Pombe boats

Trip up the Mountain

2008-07-25T00:20:00.000-07:00

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

Trip to Nathiagali

2008-07-22T09:17:00.001-07:00

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

The Fascinating Art of Truck Back Panels

2008-07-21T02:16:00.000-07:00

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

2008-07-21T01:23:00.001-07:00

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

Alive and Well in Pakistan

2008-07-06T00:20:00.000-07:00

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 because 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.