My first reaction is to understand where these people I’m meeting are coming from.  They are in the UNwhere they hear the frequent security reports coming out of Kamenge.  They may not even have security clearance to enter Kamenge.  They may work directly with the government or NGOs that advise them to stay away from this community.  They may be Burundians who remember hearing reports of violence coming out Kamenge during the war or were so close to Kamenge that they heard the gun shots and the screaming.  It’s just an accepted fact here in Bujumbura: there’s no good reason to be in Kamenge.

I, on the other hand, visit Kamenge daily.  I take a crowded bus from the center of downtown Bujumbura, ride for about 15-20 minutes, get off, take a tranquil walk around some houses for about 5 minutes, and I’m at the clinic.  I’m never once afraid for my safety, or worried that something catastrophic will happen.  Instead, I am amused by the children shouting and singing “Muzungu BON bon” (white person, we want candy!) at my manager.Seeing some of the scars of war such as bullet holes still etched into buildings, demolished houses, and the haunted look in peoples’ eyes saddens me.  Kamenge was a major site of violence during the war.  It was and still is a stronghold of the major Hutu rebel groups, particularly the FNL.  It is estimated that they can still mobilize anywhere from 7,000-20,000 troops.

This small community of about 35,000 people continues to struggle with trauma, rape, poverty, HIV/AIDS, and hopelessness.  There are very few health services, since besides Friends Women’s Association (FWA) there is only one other health clinic and a very expensive hospital.  The presence of FWA is felt in the immediate proximity to the clinic, where many women come to receive primary care, pre/post natal care, HIV testing, STD testing, and psychosocial counseling.  Additionally, FWA receives patients from other northern communes in Bujumbura and conducts trauma healing workshops in three communities “up country” named Gitega, Nyarurambi, and Mutuho.

Part of my job this year will be to conduct a baseline assessment of Kamenge, since it is only possible to get health and demographic information by province, which in this case, includes all of Bujumbura. When we have an accurate picture of Kamenge, we will continue to adapt FWA’s services to the needs of the community.  We will also be able to report to funders and to the Ministry of Health the impact FWA has on the community.

I don’t feel courageous just because I work in Kamenge.  My coworkers, the people I come into contact with every day at FWA, are the courageous ones for remaining in Kamenge after the horrific things they experienced during the war to ensure equitable health access for women and victims of trauma.  Instead of leaving the community with their education to make more money downtown, at the hospital, or abroad, they are using their skills to provide vital services for people who don’t have those same options.  If I can contribute to the improvement of FWA’s already great work with my public health education and technical background, then I am just doing my job.  No praise or worry necessary.

My plan to try out all the chairs available to me over our two-week training period, however, was foiled.  For the most part, everyone sat in the same ones, in the same location, day after day.

GHC Training 2010. Note that not all of the chairs recline, despite the fact that they are deceptively similar. (Source: http://bcc.stanford.edu/)

It appears that we crave routine, despite the artfully vague and ambitious goals we’ve created.  Not that I’m immune from the trend: I board the same train, see the same conductor, arrive at work at more or less the same time everyday. Yet when I read stories about hardcore development folks, the ones that seem to live for disaster, I never pictured them, say, making a peanut butter and jelly sandwich every morning.  I figured they were too important for the banalities of routine.

I suppose, then, that I expected to emerge from the two-week training transformed.  I envisioned action shots: holding a child’s hand while walking down an earthy clay road, damp from a recent rain. Smiling wistfully while pointing at a blueprint or some other impossibly large piece of paper. Captions describing how important my work is in a blog describing how important I am.

Perhaps at some point through the course of this year, some of these items will actually happen. For now, though, my life is a set of routines, albeit new ones. This may turn out to be a good thing, though. Part of the reason why my students enjoyed success in learning the multiplication tables, for instance, was because they sat in the same unvarnished, pliable, particle board chairs everyday, ate lunch at noon, and invariably knew there would be a math tournament at 12:45. One could have taken a photo of a student pumping his/her fist in the air, the Rocky of Port Houston Elementary for the day, but a more appropriate and nuanced representation would reflect the many iterations it took to ascend the throne.

The rains have officially begun here in Rwinkwavu, Rwanda, which must be a sign that I should stay indoors today and write a blog post! I’ve just hit the one-month mark here, where I joined Marjorie as a member of Partners in Health Rwanda’s now three-person HR department. It’s an impressive operation, especially when you consider that our tiny group is responsible for hundreds of people distributed across dozens of offices, hospitals, and health centers around the whole country.

When I first arrived, many of my more experienced colleagues advised me to spend the first month observing more than doing, listening more than speaking, and trying to absorb all I could about this new context before jumping into problem-solving mode. So observe I have. And it’s been quite an experience. Since I joined GHC, I’ve found that telling people I’m going to work on internal operations (even for an amazing organization) is not, shall we say, instantly inspiring. It seems to elicit images more along the lines of spreadsheets and flow charts than it does life-saving and community-building. But after this month, I can think of no better way to learn about a culture than sitting in an HR office and listening. It’s where people declare what they find fair and unfair, where they articulate the role work plays in their lives, where professional status is accorded, and where leaders look for direction. I can think of few more culturally-specific and -revealing jobs one could have in this field.

Many of the projects I will be working on are infrastructural, aimed at enabling others to do their jobs more effectively over the long term. This means that those spreadsheets and flow charts do have their place, and a vital one at that. Establishing clear policies, automating data management, strategically building skills, and strengthening systems of accountability will hopefully allow us now, and our successors eventually, to reserve reactive management for the margins and make strategic thinking a more central feature of our work. Ok, this might still sound a little heavy on the business jargon, but getting better at people-related things (teaching skills, paying employees, resolving conflict, etc.) means that the people concerned have more time to do what they do – and here, that often quite literally means saving lives. So in short, there’s lots of exciting work to be done!

Life outside of work has been a smooth adjustment as well. One thing that struck me right away was that simply living the countryside can be as much a new experience as moving to a new country entirely. Things like beginning and ending your day according to the sun, dodging cows on your morning commute, actually seeing stars at night…in many ways, these are the things that truly feel exotic after plugged-in city life. It’s such a luxury to hike in the mountains right outside my office after work and watch the sun set over the patchwork rice fields. The animals rustling around in the bushes along the path always make me jump about a foot or fifteen, but it’s well worth the adventure each day. My Kinyarwanda skills are coming along slowly but surely. Having colleagues translate Rwandan pop songs is proving very helpful, though it doesn’t necessarily give me the most useful vocabulary for daily living. All in all, I’d say the year is off to an excellent start! I think I’ll end on that note.

In the first week, looking at the hospital system so closely, I noted
some things that were not right with me. I was saddened after seeing
an in-patient from his hospital bed escorted by a health worker to get
to the clinicians office for his ART treatment. The patient was
visibly in a very bad shape and could not walk by himself. I also noted another patient who came early to the clinician’s office but missed the flow and was referred to another room he had apparently
missed. He then had to come back at the clinician’s office at the end
of the long line. These plus other irregularities show how much work
still needs to be done to improve the health system. I am very sure that working in the health system and particulary with Dignitas international, will give me a clearer understanding of what the health system is all about. There are things I got used to seeing in the hospital since I was born in Malawi and which I took for granted. Things that seemed normal then, no longer seem to be normal.

Staying true to my work over the next year evaluating and reporting on progress, I have the following to report on my first month’s accomplishments.  First, I am fairly comfortable navigating my way around Kampala, and am proud to say that I can now, almost successfully, give directions to my apartment on “church road.” After a few disastrous attempts, I discovered quickly that this is not really the name of the street, just sometimes labeled so because there is a church on the road.  It is estimated that Christians make up close to 85% of the population, so I am sure you could imagine how many “church roads” there are in Kampala…

I have also discovered the ease of moving around the city fairly cheaply on the back of a motorcycle taxi, called boda boda, and how quickly I has become comfortable with my surroundings because of the Kampala community.  Before I left, I was presented with the comparison of the personalities and temperament of the people in Uganda to Midwesterners in the United States [for those not from the United States, people from the middle of the country are stereotypically friendly, value community…you get the picture].  Being from Wisconsin I may have a small bias, but even the size of Kampala does not inhibit the feeling of community. I was lucky enough to have arrived with a small community, the other two members of Team Uganda!, and am grateful to now have the support of the community at IDI.

I am sure each day, week, and month will bring more personal and professional accomplishments.  Brenda and I have a very large goal ahead of us.  We will be working together to help IDI improve the trainings for health care professionals in Uganda to ultimately increase the capacity of these individuals to deliver the highest quality of care possible.  Big goal, but I think we can contribute over the next year if we apply one of my few luganda phrases, very useful when riding a boda boda:

Genda mpola, go slow.

Sunrise over Kampala

Almost wrapping up week three, and I’m finally feeling a little bit settled in Zomba, Malawi.  I more or less know my way around town, more or less know my way around the hospital, and more or less know what I’m doing on a day to day basis.  One of the exciting things about working in data management is that there’s data about everything patient related and it requires an actual understanding of what the data means.  My partner Dina and I have been doing a lot of shadowing, watching, listening, and absorbing at Zomba Central Hospital and the surrounding health centers.  A lot of issues that we discussed during our idyllic two week training at Stanford have already surfaced.  We’ve talked to people about the tension between the funding donors provide and the demands they have.  We’ve seen many of the challenges that come with implementing electronic medical records (EMRs).  We’ve seen how powerful technology can be in improving systems, but that without proper training and surrounding infrastructure it is not a magical cure-all.  I hope that in the months and blog posts to follow that I’ll be able to speak/write more eloquently and knowledgably about all the aforementioned issues, but presently I’ve been mulling over my motivations for joining GHC and how it relates to the work that we are doing.

One of our more interesting mornings was during our first week here as we watched the new Baobab touch screens get installed at our Tisungane clinic.  The touch screens allow for medical information to be entered immediately at the point of care which is hugely beneficial for patients, doctors, and Ministry of Health alike.  While a really momentous and important step, in the general disarray and hullabaloo of the transition, we watched as bewildered patients watched confused hospital staff try to figure out the new system.  I was particularly struck by a young-ish man who had just tested positive for HIV the day before and sat watching a very confused clinician who in theory knew where to direct the patient, but was stuck on the logistics of the new touch screens.

There were lots of lessons to take from this example: the importance of proper training, good planning, and emphasizing user-centered design of new technologies.  What struck me most though was what an emotionally trying experience that must have been for the young man—I know I would be a wreck!  I don’t really have a grand conclusion to draw from this, but it’s something that has been sticking with me for the past few weeks.  Poverty forces our patients to be dependent on us for the life-saving services and drugs that we provide for them.  They have very little choice but to endure a rocky morning or long lines and a confusing flow.

I’m so excited to be working at Dignitas International this year, but it reminded me that there’s more to life than just staying alive.  Of course, it is a very very important first step, but dignity and autonomy should not be luxuries that only the privileged can afford.  I hope I don’t ever lose sight of that in the face of the many pressing day-to-day issues that are so much more concrete and measurable.  Providing equitable healthcare is an end to itself, but to me, it is a starting point for equity in all other aspects of life.

On my first day in the field, I was really excited to have  the  introduction to my work. I visited one of many cooperatives that I will have to work with during this coming year. And since that day, I was challenged by how people are really happy to have us in their work activities. I can not forget the speech of a community health worker; He welcomed me saying: ”we  are excited to work with you for a bright future  of our cooperative”. I was at the same time touched but also challenged by this speech. As I have begun my work in the field with cooperatives, I have had this same experience more than once, and it has made me begin to think.

One of the next days, during a meeting with community health workers, I was surprised to see how they are willing to work hard for a change in their community. They were proposing many ideas and suggestions; they a have a will of upgrading their business by buying a new solar panel, generating electricity. As they were explaining, this will not only be a big step towards a sustainable development, but also a revenue source when charging people’s cell phone for small money. They were convinced to achieve their targets just because they believe in it. Realizing that I will contribute to a such change was really satisfying for me.

Hence, as GHC fellow, we may not realize clearly the impact we can make in a community, within the period we have for this fellowship, but I believe that since our work is improving the living conditions of people, we can ensure that we are making a great contribution to change towards a good life standard.

Ntwali Alain.

I was worried that food might be a problem as I’m an ok baker (but I am without an oven) and a poor cook. But I’m learning.  I was struck by the considerably high prices of most of the larger stores, and have routinely been spending $5-10 daily on lunch rotating between Simba, La Gallete and Nakumatt. This weekend I went to the market and I’ve found my salvation. I left onions, habaneros, green peppers, bananas, mangos, a pineapple, and beans for only $4. They have nearly everything that is not exclusively western and at exceedingly great prices.

Work is interesting. I am working on both a primary school and the final items on the Butaro Hospital. The Girubuntu Primary School is a new facility for a school with a 30% orphaned population.  I will see the school from the beginning of construction through completion in January. The construction phase is extremely exciting. So far no machinery as all of the excavation work has been completed by a large energetic work crew.

I took a quick tour of the existing facilities at the first Girubuntu School. While parts of this school were built after the genocide much of it is in disrepair. The kids were super cute:

The weather here is ideal. The temperature maxes out between 80° and  85° and it has been overcast once in nearly four weeks. The only problem is the dust. Every day ends with some dirt around the collar and the rest down the drain. I’m told that this ends with the beginning of the rains arriving in September. Essentially that’s when spring will begin. And being that this is my first apartment with a yard, I plan on usurping Gerard as GHC’s preeminent agronomist!

It is Monday morning ,a group of women scheduled to undergo operations the following Wednesday have had to come to make prior arrangements such as booking beds or rooms as well as other relevant activities on which I have limited knowledge. Some of these ladies will undergo operations to deliver while others have come to address different illnesses.  My wife was among these ladies; and any one who has been in such situation knows what  it  means to have concerns about the lives of two loved ones; not just wife and baby, so you can see why I call it my experience even if I did not “knife together with her” as folks would put it around this side of the world . Up until Wednesday, the day of the operations, it was not clear if rooms were going to be provided. The person in charge of providing rooms would say that I know that you need rooms don’t come back I will let you know at the appropriate moment. In fact, on  Tuesday the ladies received instructions that they were not supposed to eat anything from 8:00 PM and so they were supposed to spend the night in the hospital, but no rooms or even beds in the common ward were provided. The common ward is the last place you would wish your loved one to go to, due to various reasons, but just to mention a few, the fact that the person attending the sick person ( as is a common practice in our side of the world ) will not get a place to sleep, not to mention parasites that will feast on the body of the sick one. Ladies broke instructions and spent a night home due to lack of beds. In the morning, the ladies had to undergo operations one by one as planned; out of the operations room the ladies had to spend another five hours in the corridor waiting for beds. We were lucky to find a room so we could avoid parasites and the attendee got a place to sleep.

Just to sum up what happened later, one of these ladies had to receive medicine in the middle of the night but it was done 4 hours later. Another one was in too much pain, but the pharmacy was closed. If it  were not that God sent a taxi man who was able to get the medicine in a pharmacy that works 24/7 ( a new idea around here) this lady could have agonized for hours until morning. Getting someone to help in case of a problem is not easy and when you  reach out to ask for anything you should be sure of being answered in a language that is far from being appropriate. When it is time to check out make sure you have at least 3 hours, otherwise you will spend another night in the hospital. Thank God we got a healthy son, since a big percentage of children got sick, I guess due to much dust, as the hospital was undergoing renovations.  As you can see folks, there is a lot to be done especially in the area of public relations and custom care.