Archive for March, 2017



Containment

Yesterday we completed our sweep through one of the regions in the western part of Cote d’Ivoire. We sat in on the last session of this round of the workshops in the leadership program at the hospital of Bangolo. We were seated on brightly colored plastic chairs in a small standalone meeting room on the hospital grounds. Here too there were no tables, though some people used another chair for that purpose. This team, which included two women (unlike the previous group), was made up of the hospital director, someone from the ministry of sports and youth, an NGO leader, a midwife and a couple more hospital staff.

There is a way of applauding, all across Francophone West Africa, that starts with a shout ‘clap one,’ at which command people clap once, followed by a ‘clap two,’ and then ‘triplet’ (pronounced the French way). People clap three times in unison and with their hands send the last clap to the person who merits the applause. This person then accepts the clap by bringing his or her hands, full of the clap energy, to his or her heart. In the first group we attended on Wednesday, they even had assigned a focal point for these ‘triplets,’ who periodically shouted out the commands. The second group we observed had little of this and the third group did a triplet just about every five minutes. It can get a little bit stale after hearing dozens of triplets, but no one seems to mind.

I was quite pleased with what I observed the last three days. The facilitators were trained by the people I trained back in 2014, and most had entirely internalized the concepts and tools they were sharing. The three teams are working on the containment of infectious diseases outbreaks to keep them from becoming epidemics; it is small scale and small victory work right now but that is because they are practicing new ways of managing and leading as they go along. The hope is that after we are gone, they will have changed the way they lead and manage and can tackle larger problems.

The team in Guiglo focused on bringing deaths due to meningitis down to zero; the team in Duékoué was looking at neonatal tetanus and the team in Bangolo focused on rabies. I remembered a district in Afghanistan that had followed the same leadership development approach and also focused on rabies. They were able to bring the number of people coming into the hospital with rabies to zero by getting rid of the dogs that carried the virus. They did this by engaging multiple stakeholders to work together on this public health threat. I am sharing their Challenge Model with the group here – as they are not focusing on the dogs themselves, which they probably should. In Afghanistan it was the lack of environmental hygiene in the market and around slaughter houses that had led to the rabies outbreak

We had our last meal at the same place we have eaten every night – grilled carp and atieke and a salad with, every day, less and less tomatoes and more and more onions. We are now buddy-buddy with the waitress, Estelle, who was dressed in long white and gold trimmed gown, an outfit fit for the Oscars. Maybe because it was Friday night and payday just happened a few days ago? In her gown she dragged small tables and plastic chairs to accommodate our wish of not being too close to the disco that we assumed employed her. The playlist was fabulous but better at some distance. She served us our drinks with a smile and entertaining conversations. When we made moves to leave she kneeled before me and extended her arms, a respectful way of saying goodbye to an elder, which I am in this part of the world . She called me  ‘mamie’  (grandma), which I am also.

Student rising

Our new hotel has no restaurant yet. That part of the complex is still under construction. One can have breakfast in a temporary arrangement that consists of a canvas canopy in the middle of the construction site. The table is set with plastic plates and cups for the 5 of us and a few other guests. Right now the finished part of the hotel is where we sleep. There is no reception, only rooms.

We prefered eating elsewhere and went to a local patisserie where we spotted the little Nespresso machine, for which there was electricity and capsules, we were in luck. An espresso cost the same as a stick with powdered Nescafe: 1 dollar each. For two dollars I had an espresso, a half baguette, straight from the oven and a tasty omelet.

Everything in this new town has been better than in the previous one: no centipedes, warm water (that is if you take a shower at 5:30 AM), and electricity (after a while). I now have a cold beer waiting in my private refrigerator for when I get back to the hotel tonight.

Today we are sitting in a tiny room with two rows of chairs facing each other, it looked a bit like contestants facing each other.  Later it turned out the cleaner had arranged the room like that and my colleagues the facilitators, for reasons unknown, did not change the set up.

Outside the conference room, cleaning supplies piled up high give the impression that hygiene is important – a good thing in a hospital. However, our colleagues tell us these supplies have been sitting there for a while, which makes me wonder whether hygiene is a theoretical rather than a practical issue.

A loud boom outside shakes me, activating reflexes from our Lebanon and Afghanistan days. My Ivorian colleagues tell me this is the sound of teargas. I have never been close to teargas and so I don’t recognize the sound. For me a boom is an explosion. We learned earlier that the students are holding a demonstration; we saw them streaming to a central point along the wide sandy paths that serve as secondary roads. Our driver turned into another sandy path strewn with the ubiquitous blue plastic bags to avoid the area where the conflagration seemed to be concentrated.

I learned later that the students are protesting the cancellation of their February vacation. A strike earlier this year of the teachers set them back by 3 weeks. The school administration decided it should cancel the vacation to catch up. Two students were arrested. Today’s demonstration is calling for the release of those two. This is how demonstrations can be self-generating and the administrative forces better pay attention to this, otherwise it will continue to disrupt the lives of many people, including the regional director whose office is right in the center of the demonstration, so that we could not make our courtesy visit.  That part of the town is now off limits and the police is in full riot gear.

Amenities

We observed the first day of the three day workshop that is the second in a series of four. We met in the same meeting hall that had been re-arranged, to my great delight, with a circle of chairs in the middle. I had introduced this notion to others some time ago, as a much better way to meet (one cannot work on a computer or check a cellphone when sitting in a circle without tables). The idea had trickled down to the next generation of facilitators. It was a new combination of faciclitators and participants, and so a bit stiff for the first part. But eventually thaw set in and the conversations became more animated and the learning began.

Having a workshop that is held, quite literally, in the middle of the hospital, is challenging as participants can be called out at any time for an emergency. The facilitators were scratching their heads on what to do about it. I suggested they stop scratching and give the job to the participants. That is after all the team that is supposed to learn about leadership.

The facilitators create a village and the group selects the name of the village, appoints the chief and notables, a ‘conscience horaire’ (time keeper), a treasurer for the fines that late comers have to pay, etc. The norm setting is a well-worn ritual all over Africa and has little to do with the behavior of people. This version, which I have only seen in Cote d’Ivoire, with its village and chief was at least Africanized. But it did have an entire enforcement system that I thought was too much like the way things are here with the emphasis on extrinsic motivation.

And then, like all the other norms I have seen over my career, immediately ignored. The only part that was respected was the role of the village chief, both as arbiter of divergent opinions and to open and close the day.

The leadership work that we do, and which few recognize, is about awareness. I believe that if you are not aware you cannot make choices. And so I pointed out that they had created a new norm, by ignoring the norms they created, and that was that norms don’t matter and that there are no consequences for breaking the norms. And now that they were aware of this they could either throw out the norms or find ways to stick to them.

At 4 PM the session was over and we drove to the next town and a new hotel. This one also had no power and also no water. It may be hard to imagine this, from one’s comfortable vantage point in the US (or Europe, or fancy hotels everywhere) that a hotel could run without water and electricity. It reminded me of my first month in Beirut, in 1976, after the fighting had stopped. We stayed in the Mayflower hotel and ate our peas and rice in the dark.

I was given the royal suite. A comfortable suite of rooms with an enormous bed, and several amenities that were useless because there was no electricity (two aircos, two TVs and a refrigerator). The bathroom was nice but without running water not usable. All would come back in due time we were told.  Insha’llah, I murmured. But water and electricity did indeed return and I slept comfortably and took a hot shower in the morning. The latter had to happen before 6AM because after 6 the water would be gone again until 10PM. One learns to adapt.

We ate with our colleagues on the side of the road, grilled carp, an onion tomato salad and hot salsa and atieke, the local starch, washed away with a cold beer. Life is good.

Coffee

We met for the morning in the city hospital after making a courtesy visit to the hospital director. He is not a medical doctor but someone trained as an administrator. There are not many places I have visited, especially not in Africa, where non-doctors are considered competent to head a hospital. My Ivorian colleague told me that those hospitals headed by an administrator are generally doing better than those that are not. I am not surprised. After all, hospital administrators are trained for the job. Doctors are not.

I once had a fierce conversation with one of the aged notables of public health in West Africa who could not imagine that someone who is not trained as a medical doctor could possibly direct a hospital. It is funny how the same premises (having been trained professionally) can lead to opposite conclusions. Only if you take a closer look at the premise can you see the false reasoning.

In the morning the entire zone was without electricity. Our hotel had a ‘groupe’ (a back up generator) but it was without gas and ‘la direction’ had not responded to the frantic calls from his un-empowered staff. And so we were without electricity until we checked out. We had some fantasy about a small cup of Nespresso. Many hotels now have the little Nespresso machine and for an extra 3 dollars (a Nescafe stick costs 1 dollar) you can have cup of espresso, if, and this is a big if, the electricity works and/or they have the little Nespresso cups to put into the machine.

Although the electricity had not come back, two small cups suddenly appeared and the waitress beamed with pride, happy to bring us what we had asked for. I noticed the absence of foam and tasted the coffee.  It was hot and brown but it was not an espresso. They had simply opened a Nespresso capsule (and went back to the kitchen to show the used capsule to prove that they had not just used powdered coffee), and poured hot water over the content. The result had little to do with what I had hoped to get and tasted pretty much the same as the Nescafe powder that comes in the sticks.  I suppose both kinds of coffee have ‘Nes’ in common. I negotiated the cost down a bit but congratulated them with their inventiveness. With unhappy clients like us and management that is impervious to customer requests or complaints, they are the ones who will ultimately suffer.

More than a thousand feet

On Monday morning there was a further split among the three of us; two heading west to Guiglo, an all-day ride, and the other staying for a few more days before heading out to Niger, on another assignment.

I do dread the long drives, but with someone to talk with in the back it wasn’t that bad. The roads are good except for a long stretch with holes in the asphalt that require a slalom approach. This is fine as long as there are no cars coming from the opposite direction. I avoid looking ahead. I look sideways to my companion or down and read.

We had lunch in a ‘maquis’ (small semi-open air restaurants with limited menus). I had a piece of boiled oily fish in a bitter eggplant sauce, not so great but tying me over until the evening meal.

At hotel Tam-Tam in Guiglo we settled into our rooms, having to step over centipedes that were crawling all over the place. I learned that when they sense danger they roll up in a tight coil that feel and look like a button. I know this because I stepped on one such coil with my bare feet and thought I had lost a button. I had not paid attention to where I put my feet.

The omnipresence of these centipedes explained why the sides of the bedcover were flipped over onto the bed, preventing my bed from crawling with these 2 inch long creatures the size and shape of garden variety worms.

Other than that the room was comfortable, with an airco that worked as long as there was electricity, which was there about half the time, and a comfortable centipede-free bed.

We had a brief meeting with the team of facilitators of the leadership program – some people I had accompanied as they embarked on their new roles, nervous, and confused at times 15 months ago, and others that they themselves had trained or who had been coached by my Ivoirian colleagues. My terms of reference included a ‘refresher’ and then observing the trainings at various hospitals, given feedback, advice and suggestions where needed.

I asked for the men’s input (there is not much of a gender balance here) and realized that I had made some wrong assumptions about the timing and modalities of this training. I revamped the agenda accordingly that night, taking advantage of the electricity being on, and carefully stepping between the bathroom and my bed to avoid the centipedes that came in in droves from the hallway.


March 2017
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